Supporting Transitions to Primary Care Among Under-resourced, Postpartum Women (STEP-UP)

STEP-UP will promote linkage to primary care and ongoing chronic disease evaluation for postpartum women with prior gestational diabetes mellitus (GDM) and/or hypertensive disorders of pregnancy (HDP) by promoting: 1. counseling and referral to primary care, during OB visits, via electronic health record (EHR)-based clinical decision support (CDS) 2. dysglycemia testing for women with prior GDM, prompted via CDS during both OB and primary care visits 3. dissemination of understandable information on future risk and the need for ongoing evaluation generated automatically via the EHR and printed for patients with after-visit summaries (AVS) 4. motivational messaging and reminders supporting transitions of care delivered directly to patients via short message service (SMS) text messages 5. individualized outreach and support for those who need additional help arranging a primary care visit We will utilize a stepped wedge design to achieve the study's specific aims, which are to: Aim 1 Test the effectiveness of STEP-UP, compared with usual care, to improve patient: 1) knowledge of reproductive risks associated with T2DM and recommended self-care activities; 2) engage in self-care behaviors, including diet, physical activity, adherence to diabetes medications, and use of folic acid and most or moderately effective contraception, when indicated; and 3) clinical measures, including hemoglobin A1c, blood pressure, and LDL cholesterol. Aim 2 Investigate the heterogeneity of STEP-UP intervention effects by patients' race, ethnicity, and language. Aim 3 Assess the reach, adoption, implementation, maintenance and costs of STEP-UP components.