"Walk Alongside Them": Beacon Health's Efforts to Reduce Maternal and Infant Mortality

Summary

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Advancing Health Podcast: "Walk Alongside Them": Beacon Health's Efforts to Reduce Maternal and Infant Mortality

American Hospital Association | January 19, 2026
Host: Julia Resnik
Guests: Kimberly Green Reeves (VP of Community Impact and Partnerships), Cassie White (Director of Community Impact), Beacon Health System

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Episode Overview

This episode centers on Beacon Health System’s multifaceted approach to reducing maternal and infant mortality in northern Indiana. Host Julia Resnik discusses with Kimberly Green Reeves and Cassie White how Beacon is building a community-first, collaborative “ecosystem of care” to combat alarming disparities in maternal and infant health outcomes, particularly among Black and African American populations. The guests share actionable strategies, lessons learned, and the importance of trust, coordination, and community partnership.

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Key Discussion Points & Insights

1. Beacon Health System & Community Landscape (00:46–02:20)

• Introduction to Beacon Health
  • 11 hospitals across 10 counties (Indiana, Michigan).
  • Urban and rural care; locally governed, allowing customized responses.
  • Partnerships with major universities (e.g., Notre Dame, Western Michigan).
  • Unique local economy (nation’s largest RV industry) shapes population needs.

“We are able to meet people where they are by being locally governed and addressing those needs. ...We bring a really unique perspective.”
— Kimberly Green Reeves (01:04)

2. Addressing Maternal and Infant Health Disparities (02:42–04:17)

• Targeted Problem Areas
  • Focus on 3 Indiana counties; local infant mortality higher than state rate.
  • Disproportionately high rates among Black and African American families (three times higher than other groups; specific zip codes up to 10 times higher).
  • Use of county health data and EHR to identify and verify disparities.

“The infant mortality rate in those three counties exceeds the state rate… for Black and African American population, it’s about three times the rate of other races and ethnicities.”
— Cassie White (02:53)

3. Internal Strategies & Building an Ecosystem of Care (04:24–06:54)

• System-Wide Infrastructure
  • Internal alignment on goals; need for better communication of patient needs and service navigation.
  • Building out case management and home visiting, integrating clinical, mental health, and educational supports.
  • Continual assessment of social drivers of health; reward systems for families’ milestones.
  • Focus on “walking alongside” families for up to 18 months through their obstetric journey.

“We like to celebrate our families…providing additional resources on different milestones that they hit throughout their OB journey.”
— Kimberly Green Reeves (06:31)

4. Holistic, Community-Focused Interventions (06:54–07:39)

• Ecosystem of Care & Social Drivers
  • Slogan: “80% of our health is impacted outside of our clinical walls.”
  • Initiatives include mobile medical units to bring care to underserved communities.

“We’re trying to create an ecosystem of care…understanding those basic, basic needs and how we can support and provide resources.”
— Cassie White (06:58)

5. Building Trust with Patients & Community (07:51–11:04)

• Listening and Collaborative Approach
  • Importance of genuine dialogue: Letting patients define their needs, not presuming as providers.
  • Inclusion of lived experience; all voices matter (“we are all matter experts in our own right”).
  • Example: Nurse using remote monitoring who proactively helped a patient experiencing troubling symptoms, ensuring immediate hospital care.

“Instead of doing something to someone, we’re gonna do it with them… listening is very important… to believe them when you hear that.”
— Kimberly Green Reeves (08:14)

“Sometimes that trust doesn’t come on a scheduled plan… she pulled over to the side of the road to see what she could do to best assist this patient.”
— Kimberly Green Reeves (10:13)

6. Michiana Family Journey Grant: Catalyzing Coordinated Care (11:04–13:52)

• Overview of the $5.4M Grant

  • 5-year federal grant (Office of Health and Human Services) for creating a comprehensive, connected ecosystem.
  • Enables seamless referral processes; dedicated family nurse practitioner supports continuum from prenatal to postpartum care.

• Partnership Expansion

  • Partnering with organizations outside their expertise—e.g., mental health.
  • Secure data-sharing arrangements for efficient, HIPAA-compliant care coordination.

“With these additional resources, we are able to ensure that everything is connected… a seamless referral process... a family nurse practitioner that can see families all the way prenatally to postpartum.”
— Kimberly Green Reeves (12:19)

“We’ve brought [partners] into our system where they … log in and see the necessary information our community health workers are collecting … kind of creating more of that care coordination across multiple disciplinaries.”
— Cassie White (13:20)

7. Lessons in Building Collaboration (13:52–15:34)

• Persistence Amidst Complexity
  • Integration is complex; expect obstacles.
  • Continuous improvement (“stop and start” mentality); importance of operations and foundational work.
  • Data collection is challenging but vital for telling the story and driving ownership among staff.

“Just keep going. We’re going to hit roadblocks… we are determined to create this seamless process so that families can go through their OB journey without feeling the burden…”
— Kimberly Green Reeves (14:08)

“Every statistic, every number represents a person and represents a story.”
— Cassie White (15:16)

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Notable Quotes & Memorable Moments

• “Instead of doing something to someone, we’re gonna do it with them.” — Kimberly Green Reeves (08:14)
• “We know that 80% of our health is impacted outside of our clinical walls.” — Cassie White (06:58)
• “Every statistic, every number represents a person and represents a story.” — Cassie White (15:16)
• “We are determined to create this seamless process so that families can go through their OB journey without feeling the burden…” — Kimberly Green Reeves (14:08)
• “Sometimes that trust doesn’t come on a scheduled plan.” — Kimberly Green Reeves (10:13)

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Important Segment Timestamps

• 00:46 – Beacon Health System and Community Background
• 02:42 – Key Maternal and Infant Health Gaps and Target Populations
• 04:24 – Internal Strategic Responses and Ecosystem Building
• 06:54 – Whole-Person Care and Mobile Outreach
• 07:51 – Building Trust: Partnership and Patient Empowerment Story
• 11:04 – Michiana Family Journey Grant: Scope and Partnerships
• 13:52 – Challenges and Lessons in Collaboration
• 15:16 – Data’s Role in Storytelling and Ownership

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Tone & Language

The episode is characterized by warmth, openness to learning, and a deep sense of community responsibility. Kimberly and Cassie’s language frequently returns to inclusivity (“do it with them”), persistent optimism (“just keep going”), and determination to innovate for patients and families.

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Summary Takeaway

Beacon Health’s work shows that reducing maternal and infant mortality requires a coordinated ecosystem: one where health care is integrated with community voices, social needs are as important as clinical ones, and trust is the foundation for all partnerships. Their experience offers both hope and practical guidance for any community tackling health inequity.

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Transcript

[A]

Welcome to Advancing Health. In today's episode, learn how Indiana based Beacon Health System is creating an ecosystem of care to support moms and babies in their community.

[B]

Hi, everyone. I'm Julia Resnik, Senior Director of Health Outcomes and Care Transformation here at the aha this week we observe Maternal Health Awareness Day. And I'm so privileged to be here with two leaders from Beacon Health System in Indiana to talk about their work in this space, I'm joined by Kimberly Green Reeves, Vice President of Community Impact and Partnerships, and Cassie White, Director of Community Impact. So for those who aren't familiar with Beacon Health System in the area you serve, can you tell us some more about your hospital and your community? Kimberly, I'll start with you.

[C]

Absolutely. So we are fortunate to be a locally owned healthcare organization right now with 11 hospitals across 10 counties in two states in the state of Indiana and Michigan that also includes our Beacon Medical Group offices. And so we have over 35 specialties in health care that we're providing, both urban and a rural perspective. And what really makes this community unique is again, that we are able to meet people where they are by being locally governed and addressing those needs. And I think also we have a great community that's surrounded by colleges and universities, one of them being the University of Notre Dame. And so we're working collaboratively with the university there right now, really establishing our partnerships with the University of Western Michigan as well as the medical school there. And lastly, we come from a manufacturing community as well. And so we have the largest RV industry in our country. And so we're able to work very closely with those organizations and then also with our community support agencies as well, and our non for profits. So it's a really unique perspective that we bring in terms of being able to work collaboratively with those organizations, colleges and universities, in order to improve healthcare outcomes. But that's really exciting for us and our work.

[B]

Absolutely. And every time I drive through northwest Indiana, I'm always struck by how many RVs there are. So I love that local flavor. We're really here to talk about maternal health, though. So can you talk more about the emerging needs or gaps that you're seeing in maternal and infant care in your community and if there are any populations that you're particularly concerned about or focusing on. Cassie, let's turn to you specifically looking.

[D]

At our Indiana counties. So we have three counties that we have hospitals in in the state of Indiana. And part of why we have an emphasis in infant and maternal mortality in our Indiana counties is because the infant mortality rate in those three counties exceeds the state rate even more. So we received a grant specifically to focus on eliminating disparities in St. Joseph County, Indiana and Elkhart County, Indiana. And a large part of that is because we see a disparity in our infant mortality rates for the black and African American population. So in total for the whole county, it's about three times the rate of any of other races and ethnicities. And then we can actually look at it geographically as well. And we have a couple zip codes that have a infant mortality rate 10 times higher in those zip codes.

[B]

Kimberly, anything you wanted to add?

[C]

Actually, I will add something. I will say that we also look at our electronic health record data as well. And what we're seeing in the community we are also seeing within our healthcare system as well. So it provided us a wonderful opportunity again to align this work from a strategic perspective as well. So this now is a goal across our health system, which is to address infant and maternal health, which I think is fantastic. Whenever you need to do anything in the community, because it takes all of us, this is not just something that we can do on our own. It's going to take all of us looking at leveraging some of our resources and our collective assets across our region.

[B]

All right, so you diagnosed the issue. You have the data to show it's a problem. Talk to me about what those strategies are that you're implementing.

[C]

So it starts with us internally really looking to see what we need to do differently as a healthcare system to address the issues and the disparities that Cassie has shared in the previous question there. And so we, what that takes is us really taking a look at where we can align our internal resources and where those gaps are. So for us, it really started with creating or building an infrastructure that didn't exist in terms of communicating regarding patients needs, the services that we can provide for our families, as well as understanding what other controls were in place to be able to navigate our system. Once we were able to identify that it really is, then looking at our community partners to really understand where they plug in. And so some of this work looks like standing up case management and home visiting internally, but also looking at where are those other services being offered throughout our community. We also focused on clinical supports As a healthcare system, that is absolutely a place where we need to be. But we understood that we actually needed to hire someone to be able to provide that additional support whose sole focus was on supporting families. And then that mental health piece is also important. So we're looking at the whole person if you will, ensuring that we can address any mental health needs that they may have as well. And then I don't want to lose sight on the educational component. I think that there's a lot to do with education and what we can do to prevent or mitigate risk, but also walk alongside our families throughout their journey, ensuring that they have the supports that they need. And then lastly, we also see a really huge value in providing them the necessary resources. And so social drivers of health are important for us, and we're identifying where those exist and how we can be beneficial. And then we like to celebrate our families. And so we are providing them additional resources on different milestones that they hit throughout their OB journey and providing babe essential items in that way that helps keep them encouraged on this journey with us for about 18 months.

[B]

I love it and love that you're adding joy to that holistic patient care and trying to connect what's happening in the clinic and in the community. Cassie, was there anything else you wanted to add about the work that you're doing?

[D]

Kimberly covered it really well. I think I'm actually going to steal some of her words that she has shared before is that we're trying to create an ecosystem of care. Part of that, too, as she mentioned about social drivers of health, we know that 80% of our health is impacted outside of our clinical walls. And that's a large part of what we're trying to address, is understanding those basic, basic needs and how we can support and provide resources to meet those needs. Also, Kimberly's leadership has brought, she mentioned in the RV industry of this country and working on a mobile medical unit to also try to bring the care to our neighbors and community members. So really exciting work in that regard, too.

[B]

Kimberly, earlier you were talking about walking beside patients on their journey, and trust is such a huge part of that. So how are you all thinking about building trust with your patients and your community members?

[C]

So it does start with having conversations to understand why that trust is diminishing in the first place. We certainly do not want to go into a situation assuming that we have all the answers. In fact, early on in my career when we had a program focused on trauma informed care support, we went in as a health care system saying, this is what we believe you need. And we were told very politely that we know what's best for us. And so that's just been a lesson that I have carried with me, that instead of doing something to someone, we're gonna do it with them. And so very much allowing a process or creating a process in a safe place for families to come in and be able to provide insight and educate us on the ways that we need to show up for them. And so part of this work has a consortium component, which is someone coming in with lived experience. And we know that that lived experience can look differently depending on who you are and depending on what you've actually encountered. I often say that we are all matter experts in our own right. It doesn't matter what degrees you have. It doesn't matter what certifications you might have or what education you might have. We can all lean in on this together. And so that's how we're starting to build trust and rapport with our patients. Also, listening is very important when someone says that they feel right or they've experienced certain elements around their health, to believe them when you hear that. And so one of the programs that we have is our remote patient monitoring program, where we have two RNs working very closely with patients monitoring their blood pressure readings on a regular basis. I think we get up to three readings during the day. And when they see something that's abnormal or when their patient reaches out to them, they're on the phone with them and finding out how we can best assist them. And sometimes that trust doesn't come on a scheduled plan. What I mean by that is we can't wait until the patient's appointment to be able to be there for that patient. One of our nurses was on our way home and got an alert from a patient that she wasn't feeling well. And so she pulled over to the side of the road to see what she can do to best assist this patient. And she was in a safe space and felt comfortable reaching out to the patient. And she says, I'm starting to see stars and dots. This isn't right. And so the nurse at the time said, why don't you go ahead and get yourself over to the ED at our hospital and I'll make sure that we have a provider there waiting for you. And we were able to do just that, where the provider was there waiting for this patient in triage to ensure that she received that timely care and could deliver a healthy baby. And so that's what I mean by making sure that we can walk alongside them in their journey. And that's how we're gonna continue to build trust with our patients.

[B]

Fantastic. And that's a really powerful story. So I know that you all have a fairly new and fairly large grant with Michiana Family Journey. Can you tell me about what that is. And what you're hoping to accomplish and what those community partnerships are.

[C]

Yes. So this Grant, it's a $5.4 million grant through the Office of Health and Human Services. This particular grant is a five year grant for us, and one of a kind that allows us to create that ecosystem of care that Cassie referenced earlier. What's most valuable from this is this grant's been around for a very long time, probably 30 plus years. And so we're coming into this. And while we all approach how we're going to address health disparities differently for families, it is very much a program where you can rely on meeting people that are doing some of the same work and you can leverage some of their best practices. And so that's what this grant is affording us to do. Much of what you've heard us speak about today, we were able to do kind of in a siloed way, not as, as coordinated as we're able to do now, but with these additional resources, we are able to ensure that everything is connected, that we are speaking together, that we have a seamless referral process or system in place to be able to deliver the care that we need. And that additional support around clinical services has also helped us. This particular grant requires a medical provider that's accessible to the patients, solely dedicated to this patient population. And so we're grateful that we have a family nurse practitioner that can see families all the way prenatally to postpartum and even providing those, well, child visits for families as well.

[D]

I think even to the partnership piece has been really cool. That's not necessarily a requirement of the grant. It's more so around ensuring we meet our case management numbers and connect people to different resources. But we taken that to the next level by bringing on community partners that address areas that we don't have the expertise in, such as mental health. And so we have a partnership, for example, that we've brought them into our system where they can actually, through HIPAA compliancy and data sharing, they're able to log in and see the necessary information that our community health workers are collecting during the onboarding process. And then when a referral is made, they're able to be notified and provide that care right then and there, kind of creating more of that care coordination across multiple disciplinaries. But not that we're trying to do it in house and saying, let's bring on those other community organizations to address those needs together.

[B]

I love that. And collaborating with all these community partners, especially ones that are in different sectors can be really challenging. So what have you learned from bringing all these people together and trying to create this functional ecosystem?

[C]

Just keep going. We're going to hit Roblox, right? We all have our own goals and there are expectations that we have to meet. And so we have stopped and started and stopped and started again just to ensure that we get this right. We are determined to create this seamless process so that families can go through their OB journey without feeling the burden of all of the logistical things that it takes in order to have all of these partners at the table. I know no one likes additional meetings, but I think I keep telling the team we're just getting set up. Like we have to create this system in order for the system to work in the way that it's supposed to.

[B]

Any final thoughts, Cassie?

[D]

I think it's really cool to see the ownership come into play with the community health worker team specifically. My background's in epidemiology, and so I always say, start out with the team saying, I know data collection and data reporting is such a drag, but at the same time it provides us an opportunity because every statistic, every number represents a person and represents a story. And so help us tell that story because we want that ownership to also be of the people that are a part of our programs and that they have pride in their story and being a piece of this whole journey.

[B]

And I think you're both speaking to something really important that, like the operations in the building might not be the most exciting part, but if you're going to create something, it needs to have a really strong foundation. And I'm really excited to see what you're building and what you're going to continue to build over the years. And for all of you listening on Maternal Health Awareness Day or Maternal Health Awareness Week, we appreciate you. Please join this movement. We have a lot of resources at the AHA on Maternal and Child Health, which you can [e-mail]. thank you again to Kimberly and Cassie and looking forward to hearing more in the future.

[A]

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