2019 Annual Report

NPM 1 - Percent of women, ages 18 through 44, with a preventive medical visit in the past year

Objectives:

• Increase prenatal care utilization by 10% among women in the targeted impact area(s) (Border Region of the State) through the development of place-based improvement strategies that address the social determinants of health by October 2020
• Prevent the onset of the Type II diabetes for women with a history of Gestational Diabetes Mellitus (GDM). Increase the percentage of women in UNM hospital’s Maternal and Family Planning (MFP) clinics completing a postpartum visit and appropriate testing to 80% by June 2019
• Percentage of primary care providers who receive education and support for assessing and treating clients with mental health disorders. By June 2020, 25% of primary care providers within the reach of the dedicated programs receive education

Strategies

• Design and implement a prenatal care resource app (web-based application) that will be used with women at three community-based sites in border area, who have a positive pregnancy test
• Work in a collaborative partnership to address the prevention of Type II diabetes by addressing barriers to postpartum visit completion for women with Gestational Diabetes
• Provide training opportunities on the assessment referral and/or treatment of women perinatal mental health disorders to primary care providers in rural areas of the state

Progress Report on 2019 Activities

Work in the 2019 reporting period shifted significantly from web-based resource development to curriculum development for certification of community health workers/promotoras de salud. NM PRAMS data point to two primary barriers to timely care in Dona Ana County, the first being late recognition of pregnancy and the second, challenges getting prenatal appointments when needed. To address the need for better and more timely care, Title V staff and Project Concern International (PCI) worked together in the Fall of 2019 to assure a transition from Healthy Start- La Clinica de Familia staff involvement to leadership by the University of New Mexico Health Extension Rural Officer (UNM HERO) in Las Cruces and rural communities of Anthony, Berino, Chaparral, including trans-border and floating populations.

Infant Mortality Collaboration Improvement and Innovation Network (IM CoIIN), a network of US-Mexico border states working to improve prenatal care entry in the first trimester. The project went through major staffing and leadership changes, so the FY20 plan was framed to work through important scope of work negotiations and transition to new leadership.

Women in these border communities still need support in their access and utilization of timely prenatal care. Brief statistics presented in the FY20 Plan showed:

• 56.4% of women residing in the communities of Anthony, Berino or Chaparral (small rural colonias) had prenatal care within the first trimester (2012-2016 births). This compares to 59.8% of all women in Dona Ana County, and 63.9% in NM, overall.
• Excluding women delivering a very low birthweight baby (<1500 grams), just 48.7% of those with a low birthweight infant (1500-2499 grams) had prenatal care in the first trimester (NMVR, NM-IBIS).

The scope of work and focus changed from being a marketing campaign/web application promoting first trimester prenatal care to developing, piloting and delivering CEU approved Community Health Worker (CHW) training modules focusing on preconception and prenatal care. As promoted by PCI, the backbone organization involved in the Border CoIIN project, the new scope of work also employed human centered design principles. The design included discussion opportunities with community member input on community-based needs. and partner input to shape and modify project design to create the most informed product for end users​. 

Timeline

July-Sept 2019: Started work with the University of New Mexico (UNM) HERO and re-established a team charter with revised process and outcome measures. Discontinued the development of a web-based resource application and instead focused on a project to develop a curriculum in perinatal health for the community health workers that exists in the Dona Ana County and border region.

Oct 2019-Jan 2020: Curriculum development by the UNM HERO with input on evaluation measures for measuring the success and impact of the curriculum. The UNM HERO officer met several times over this period for technical assistance from PCI and the TA advisor provided by PCI. Project measures included:

1. % of certified CHWs who have gone through any formal training (with CEUs) in prenatal care
2. % of certified CHWs who have gone through any formal training (with CEUs) in preconception care
3. % increase in test scores from pre-/post-test on preconception care curriculum 
4. % increase in test scores from pre-/post-test on prenatal care curriculum 

Feb 2020-present: Curriculum has been introduced in the CHW programming available to this workforce via Dona Ana County Community College (DACC). The first class was held in Feb 2020 over a two-day period with twelve participants. Data from this recent class is currently being processed and evaluated with PCI staff. The team will complete a technical brief in September 2020.

The Border CoIIN ends its 3-year project phase in Oct 2020. It is expected that 2-4 CHW classes will be held between Feb and Oct2020. Feedback will be collected from participants and there is a plan for longer range measurement of impact with the CHWs who participate in the class. Process and balancing measures also being tracked:

• Process: # CHWs trained in new curriculum
• Process: Diversity of CHWs trained in new curriculum
• Balancing: Funding for CHW workforce does not increase thereby leaving  skilled workers without employment or under employed
• Balancing: Increased demand by CHW students for women’s health focused CEU approved training modules are not developed/available and/or lack cultural sensitivity/awareness of the NM border region

Members of the “GDM Project”: the NMDOH Diabetes Control and Prevention Program, the UNM Maternity and Family Planning Clinic(s) (UNM M&FP) and Title V staff have worked together on the improvement of services for clients at risk of gestational diabetes mellitus (GDM) at a UNM-run urban clinic located in Albuquerque. The collaborative work started in March 2018 with members of the DOH team and the UNM M&FP staff team attending and participating in an MCH Workforce Center Learning Collaborative. Project members are full-time employees in their respective professional settings and devote in-kind hours to this project.

The project had 4 phases at its inception:

Phase I: Improve the scheduling, completion and appropriate testing for women with GDM history at their postpartum visit

Phase II: Introduce an evidence-based, tailored counseling and education approach for managing diabetes risk for women with history of gestational diabetes that starts at their postpartum visit

Phase III and: Disseminate the education and methods to a wider-net of providers Phase IV:  Attempt to create incentive-based initiatives to assure sustainability as well as reach this population in clinics and other settings across the state.

This project has had many challenges, two of its greatest being access to data either to assess baseline activity such as current post-partum visit (PPV) completion rate, or consistent access to measure improvements in PPV attendance over time. A 2019 evaluation final recommendation was to direct the focus of the project on creating an educational module for pregnant clients who were awaiting the 3-hr glucose tolerance test at the M&FP Clinic. The evaluators also recommended measures to evaluate the effectiveness of the module. The work team planned to present the education via a video format and some funding was found to create the video. Over the past 4 months, the work team has drafted a script and gathered feedback from a vendor who will create the video. The script has also been reviewed by a health education team at UNM for its cultural appropriateness and reading level presentation. The start of video creation has been delayed by the COVID situation. The video will cover both the education on gestational diabetes, as well as orient clients (in a “warm handoff” approach) to the specialty clinic that follows these clients in the latter part of the pregnancy for their GDM care.

Another arm of the project is work with administrators of the UNM Hospital and Clinic electronic scheduling systems to introduce reminder steps to providers in the post-partum scheduling process. This arm has met with many challenges as the team members do not have supervisory authority over the staff who work on system improvements. One recent development has been the designation of a UNM perinatologist to improve the system of care for GDM clients seen in the UNM clinics.

The perinatologist plans to utilize the services and staff, including medical students and fellows, to gather data directly from the electronic medical system on client services offered and completed from initial diagnosis to follow-up testing at the PPV. The plan is to fix gaps in the system of appointment scheduling, reminders and tracking completed PPV appts. This specialist also wants to standardize the testing of GDM clients at the PPV so that diabetes risk and/or status is accurately and consistently assessed, and the appropriate counseling and teaching is set up for future visits on high-risk clients. The GDM project team has offered support in these endeavors but recognizes that the UNM specialist involvement may be the needed catalyst to make improvements in the system of care to GDM clients in the perinatal period.

The remaining goal is to finish the educational video and plan for some form of evaluation of its impact on GDM patient knowledge and its contribution to improved compliance with PPV attendance.

The Maternal Health Program Manager worked with a committee of Human Services Department staff (Behavioral Health Division), Children, Youth and Families Department (CYFD) staff and other stakeholders to address the introduction of a new diagnostic coding (DC) system for infants and toddlers with mental health diagnoses. Resources in Infant Mental Health are available but the work to introduce DC 0-5 usage in the state continues now under the State’s Infant Mental Health Association.

To address provider training needs, Project ECHO (Extension for Community Healthcare Outcomes) sessions launched in July 2019. “Child Behavioral Health ECHO Clinic” sessions did initially cover the assessment and appropriate care of infants and toddlers with mental health/developmental challenges. The Maternal Health manager attended these sessions from July to September but had to step away from attendance due to other duties related to Maternal Mortality grant coordination. Recent communication with the coordinator of the Project ECHO sessions revealed that the sessions continue. Content has largely focused on infant and child domains, however there is a plan to introduce perinatal and postnatal topics to promote the assessment and appropriate care to the mother-child dyad. The sessions have also covered substance using populations. The work will help address behavioral and mental health training needs in the new Title V cycle (2021-2026).

Several pediatric providers expressed a need to facilitate assessment and support for caregivers, especially during the pediatric visit. Future topics in this series will cover assessment of post-partum mental health and how it affects children. The sessions will provide case-based clinical discussions and brief didactics to support treatment or referral.  The goal is to reach 100 healthcare professionals (doctors, advanced practice clinicians, nurses, counselors, home visiting staff, etc.) by May 2020.

Another development in perinatal and postpartum depression services is that NM birth providers from the midwife and doula sectors formed a New Mexico chapter of Postpartum International in the fall of 2019. The chapter’s goals are:

• to provide resource directory information to birth and prenatal providers in the state,
• provide training to health care providers in perinatal mental health assessment and treatment, and
• provide education to prenatal and postpartum women on the recognition of perinatal depression and mood disorders.

This chapter has formed partnership with a community-based advocacy organization, called Kassy’s Kause, based in Albuquerque that provides direct support and advocacy to pregnant and postpartum women experiencing perinatal mental health challenges.

The existing barriers to insurance coverage for women of child-bearing can be exacerbated when families should seek prenatal care, given delays in pregnancy recognition, distance to care, and health professional shortage areas. These challenges disproportionately impact women of color residing in border counties and in other rural/frontier areas of the state.