Introduction to State Action Plans

The following state action plans provide comprehensive information—including objectives, strategies, activities, and performance metrics—on Michigan’s Title V maternal and child health (MCH) priority areas. Per Title V requirements, the state action plans are organized within five population domains: women/maternal health; perinatal/infant health; child health; adolescent health; and children with special health care needs (CSHCN). Within these population domains, the state action plans focus on the following federally-defined National Performance Measures (NPMs) and state-defined State Performance Measures (SPMs):

• NPM 1 (Well-woman Visit)
• NPM 3 (Risk-appropriate Perinatal Care)
• NPM 4 (Breastfeeding)
• NPM 5 (Safe Sleep)
• NPM 10 (Adolescent Well-visit)
• NPM 12 (Transition)
• NPM 13 (Preventive Dental Visit for Women and Children)
• SPM 1 (Childhood Lead Poisoning Prevention)
• SPM 4 (Medical Care and Treatment for CSHCN)
• SPM 5 (Immunizations—Children)
• SPM 6 (Immunizations—Adolescents)

These NPMs and SPMs were chosen based on Michigan’s five-year needs assessment and were refined in 2018 based on changes to the Title V Guidance and ongoing needs assessment activities, as discussed in last year’s application.

Michigan’s Title V program continues to engage in a process of regularly examining goals, objectives, and strategies associated with each NPM and SPM. As a result of this process, some program areas made changes to FY 2020 state action plans and associated objectives and/or strategies, especially to address health disparities and health equity. Therefore, the FY 2018 annual reports (based on previous state action plans) may contain different objectives and strategies than the current plans. Lastly, methodologies for updated NPM annual objectives are included in the Supporting Documents.

Women/Maternal Health Overview

The health of women and mothers is the focus of the Division of Maternal and Infant Health, which oversees the Reproductive Health Unit and Michigan’s Title X program. Title V funds directly support several programs and services designed to improve women’s pre- and inter-conception health. Much of these resources are directed toward family planning. However, Title V funds are also used to understand and address women’s health issues more broadly, especially as they relate to maternal mortality and factors such as race, class, and gender inequity that drive disparities. In order to address non-reproductive health needs of women, Michigan leverages other federal funds, such as the Preventive Health and Health Services Block Grant (CDC), and partners with the chronic disease, cancer prevention, and injury and violence prevention programs within MDHHS. Additional partnerships that impact women’s health include local health departments, Family Planning service providers, and the Michigan Primary Care Association.

Michigan’s approach to women’s health emphasizes improving access to health services for this population, including reproductive and oral health services, based on the concept that access to care can be preventative across a variety of health needs and concerns. While severe maternal morbidity (138.61 per 10,000, HCUP-SID, 2015 Q1-Q3) has been consistently lower in Michigan as compared with the national average, the risk is much higher among non-Hispanic Black women (221.16). Similarly, maternal mortality (19.38 per 100,000, NVSS, 2012-2016) is lower in Michigan than the national average, but the risk among non-Hispanic Black women (38.71) is much higher. These disturbing statistics have led Michigan to place greater focus on understanding and addressing the unjust and unfair conditions that place non-Hispanic Black women at much greater risk for disease and death before and after childbirth.

Although surveillance data tends to focus on indicators of a healthy pregnancy and healthy infant, wellness in pregnancy and at birth reflect women’s health status prior to conception. While 8.53% of infants (NVSS) reported in 2016 were born with a low birth weight, 14.55% of babies born to non-Hispanic Black mothers had a low birth weight. Similarly, while 10.14% of infants (NVSS) reported in 2016 were born preterm, the percentage was much higher among non-Hispanic Black mothers (14.39). These data also suggest that Michigan is far from achieving equity in health among women in our population and improving women’s health status must focus on addressing the conditions that lead to unjust outcomes for Black women. Oral health is also a concern In Michigan where 10.36% of children, including 7.44% of children under five years of age, have tooth decay or cavities (NSCH, 2016).  Another trend that Michigan is attending to closely is the dramatic rise in rates of infants born with neonatal abstinence syndrome, which increased from 2.0 per 1,000 in 2008 to 8.3 per 1,000 in 2015. Partners at the state and local level are designing and implementing strategies to understand and address this crisis.

Well-Woman Visit (FY 2018 Annual Report)

In 2018, MDHHS focused on strategies to improve the quality of family planning counseling and access to long-acting reversible contraceptives (LARC) through quality improvement efforts and provider professional development. MDHHS’s Family Planning Program facilitated a Contraceptive Access Learning Collaborative with six local agencies to measure contraceptive performance and conduct quality improvement efforts. Local agencies averaged an 85% increase in LARC use from baseline to end point. The Family Planning Program (within the Division of Maternal and Infant Health) participated in Medicaid policy discussions that led to the unbundling of LARC devices from the maternity Diagnosis Related Group payment allowing for separate reimbursement, effective October 1, 2018. Family Planning promoted its Contraceptive Counseling Module Series garnering 61 completions with 58 individuals requesting continuation education credits. In FY 2019, Medicaid Health Plans will receive pay-for-performance credit in their contracts for completing the series. During FY 2018, MDHHS held two clinical practicums on the insertion and removal of LARC training 24 local providers, 13 of which resided in the Upper Peninsula, a low LARC access region.

MDHHS also worked to increase quality of services and access to women in need, with a focus on family planning services. Family Planning’s Medical Advisory Committee promoted and disseminated the Before, Between, and Beyond Pregnancy educational modules and the National Preconception-Interconception Care Clinical Toolkit to local agencies and other health care providers. Suzanne Woodard, University of North Carolina Center for Maternal & Infant Health and Janis Bierman, March of Dimes, presented a keynote and breakout session at the annual Family Planning Conference on preconception health and community messaging. Family Planning collaborated with Behavioral Health to equip case managers with the knowledge and skills to effectively asses substance misuse clients’ pregnancy intentions, counsel on contraceptive options, and provide referrals for pregnancy prevention services. During the FY 2018 Open Enrollment Period, local Family Planning agencies assisted and enrolled clients in Medicaid or Medicaid Health Plans or the Marketplace and referred clients to an entity with the capacity for enrollment assistance. Local agencies continued to connect Family Planning clients to primary care providers within the community, as needed. MDHHS continued to find opportunities for local Family Planning agencies to foster relationships with Medicaid Health Plans.

Objective A: By 2020, maintain 84% of females aged 15-44 who use a most effective or moderately effective contraceptive method.

Having access to a full range of effective contraceptive methods allows each woman the opportunity to choose the method that is right for her to successfully delay or prevent pregnancy. In 2018, 78% of female Family Planning clients aged 15 to 44 years old chose a most (i.e., sterilization, vasectomy, or LARC) or moderately effective (i.e., pills, patch, ring, cervical cap, or diaphragm) method, with 16% choosing LARC. Most or moderately effective (MME) method use peaked at 86% for Family Planning in 2016 and has declined approximately two percentage points each year while LARC use (12%, 2016) has increased by the same amount each year for this age group. To increase contraceptive access to individuals at greater risk of unintended pregnancy, a number of local agencies have integrated their Family Planning and STD clinics, which has resulted in more comprehensive services for men and women. At the same time, this has also resulted in an increase of females aged 15 to 44 who report male condoms as their primary method of contraception. In FY 2018, MDHHS worked toward increasing access to MME methods while balancing individuals’ contraceptive needs and preferences.

From April 2018 to September 2018, MDHHS facilitated a Contraceptive Access Learning Collaborative (CALC) with six local agencies to measure performance and conduct quality improvement (QI) on two contraceptive care measures (i.e., most or moderately effective methods and LARCs) endorsed by the National Quality Forum. The goals were to 1) support local agency performance on two contraceptive measures; 2) increase local agency capacity to conduct QI; and 3) foster collaboration between MDHHS and local agencies. CALC participants received resources on contraceptive access best practices; shared improvement strategies, challenges, and successes with peers; collected and used performance measurement data for QI; and received one-on-one technical assistance from MDHHS. An in-person kick-off meeting was held April 20, 2018 to introduce the Contraceptive Access Change Package, review baseline contraceptive performance data, foster peer collaboration, and develop sub-recipient performance improvement plans. From May 2018 to September 2018, CALC participants and MDHHS met virtually each month to discuss QI project progress and have an in-depth discussion on a contraceptive best practice. CALC participants also submitted their performance improvement plans on a monthly basis which documented their project progress and tracked contraceptive performance. Improvements in LARC access occurred as a result of this project. At baseline (January-December 2017) CALC participants averaged 6% LARC use among females aged 15-44 years old, and at end point (January-December 2018), sub-recipients averaged 8% LARC use, an 85% increase. MDHHS is in the process of developing a CALC infographic to share best practices, lessons learned, and next steps with its network and partners.

During FY 2018, MDHHS’s Family Planning Program explored the feasibility of a Contraceptive Access Workgroup with state and local stakeholders. In doing so, it determined an existing group of state and local partners and stakeholders was pursuing the goal of increasing access to immediate post-partum LARC insertion through Medicaid policy changes. Given the work that was already underway, the Family Planning Program participated in existing Medicaid policy discussions, as appropriate. After several months of negotiations, this workgroup was successful in unbundling LARC devices from the maternity Diagnosis Related Group payment, allowing for separate reimbursement for LARC devices when provided immediately post-partum in an in-patient hospital setting prior to discharge. Medicaid issued the notice of policy change on August 31, 2018 with an effective date of October 1, 2018. This workgroup has since transformed into the Michigan Collaborative for Contraceptive Access (MICCA), a partnership between MDHHS, the University of Michigan, and the Institute for Health Policy at Michigan State University. In FY 2019, MICCA will focus on expanding access to immediate post-partum LARC in Michigan hospitals. MDHHS’s Family Planning Program provides staff support to the project. The MDHHS Family Planning Advisory Council also meets regularly to discuss contraceptive access issues. As a result of these two groups already existing, the idea of an additional Contraceptive Access Workgroup was put on hold.   

MDHHS continued to promote its Contraceptive Counseling modules to providers from Medicaid and Medicaid Health Plans, Maternal and Infant Health, Home Visiting, and Adolescent Health programs. During FY 2018, 61 users completed the Contraceptive Counseling modules, with 46 participants requesting social work or nursing continuing education credits and 12 requesting certified or master certified health education specialist continuing education credits. Of those who completed the modules during FY 2018, 58 completed the course evaluation. Most respondents felt the stated course objectives were met, found the course easy to use and well organized, and thought the course was interesting, helpful, and relevant to their job. MDHHS continues to promote the Contraceptive Counseling modules to new providers including Medicaid and Medicaid Health Plans. With a variety of online ways to access continuing education content, it is a challenge to get non-Family Planning providers, like primary care providers, to complete the course. In FY 2019, MDHHS is partnering with Medicaid Managed Care to offer the modules to the Medicaid Health Plans for pay-for-performance credit in contracts. MDHHS plans to review the modules annually to assess if updates are needed.

During FY 2018, MDHHS held two clinical practicums on the insertion and removal of LARC, training 24 local providers. In June 2018, MDHHS collaborated with the University of Michigan to conduct a regional LARC clinical practicum and lecture series in Michigan’s Upper Peninsula, a low access LARC area. The practicum and lecture series were offered in Marquette, with 13 local providers in attendance. During the practicum, providers were trained on the insertion and removal of LARC methods such as intrauterine devices (IUD) and implants to support greater access to these methods with the aim of improving provider skills and comfort. The lecture series was designed to increase provider knowledge of contraceptive best practices and clinical special topics. The practicum and lecture series supported continuing education credits, with 100% of attendees indicating the content was relevant to their learning needs. Attendees reported increased knowledge on all contraceptive methods, improved LARC insertion skills, and increased comfort with LARC. When attendees were asked how this training would change their daily practice, several indicated it enhanced their ability to provide client-centered contraceptive counseling and enabled them to offer LARC on-site rather than by referral. Prior to the regional LARC clinical practicum, only two of the six Upper Peninsula Family Planning providers in attendance offered a LARC on-site (hormonal implants). Following the practicum, three providers now offer all LARC on-site (i.e., hormonal implants and IUDs, non-hormonal IUDs). A fourth provider is in-process and plans to offer all LARC on-site. Most importantly, three of the six UP Family Planning providers in attendance now offer same-day LARC insertion. To increase provider professional development surrounding LARC, a clinical practicum was offered at the annual Family Planning Conference; 11 Family Planning providers were trained on the insertion and removal of Kyleena® by Brent Davidson, MD, Vice Chair, Women’s Health Henry Ford Medical Group and MDHHS Family Planning Program Medical Director. All attendees agreed the information was relevant, and that Dr. Davidson was knowledgeable and effective.

During FY 2018, Family Planning staff met with staff from the Maternal Infant Health Program (MIHP) to discuss areas for improvement within MIHP’s Family Planning module and opportunities to revise module content so that it aligned with national standards of care and contraceptive best practices. Based on conversations between staff, MIHP’s Family Planning Plan of Care was updated to assess pregnancy intention, discuss future goals (e.g., school, career, lifestyle), and include client-friendly contraceptive resources. MIHP also updated contraceptive resources on their website for their provider network as a result of contraceptive resources shared by the Family Planning Program. The Family Planning Program tabled at the 2018 Home Visiting Conference where over 500 home visitors were in attendance, including MIHP. Educational materials on contraceptive methods, preconception health, sexually transmitted infections, and healthy relationships were made available, along with MDHHS’s Family Planning clinic directory.

Objective B: By 2020, increase by 5% the proportion of Michigan women who report ever having discussed reproductive life planning during a visit with a doctor, nurse, or other health professional.

This objective is also Michigan’s ESM for the well-woman visit performance measure. Based on data from the Behavioral Risk Factor Surveillance System (BRFSS), Michigan’s FY 2018 reporting data indicates that 66.2% of women discussed reproductive life planning during a visit with a doctor, nurse, or other health professional. This was an increase over the previous reporting year, which was 64.3%. To continue to make progress on this objective, the Family Planning Program invited Suzanne Woodard, University of North Carolina Center for Maternal & Infant Health and Janis Bierman, March of Dimes, to present at the annual Family Planning Conference on preconception health and community messaging. During their morning keynote, Preconception Health & Health Care Initiative: “Show Your Love Today” Program – Nationally Elevating Local Work, the Before, Between, and Beyond Pregnancy educational modules and the National Preconception-Interconception Care Clinical Toolkit were promoted. This keynote was attended by approximately 110 conference participants. Session evaluations indicated an overwhelming majority of participants “strongly agreed” or “agreed” the presenters were knowledgeable, organized, and effective. Dr. Davidson, MDHHS Family Planning Medical Director, presented a lunch keynote on Creating a Reproductive Life Plan (RLP) and Contraceptive Options for the Plan, which sought to increase knowledge on the key components of an RLP, discuss the connection between RLP and preconception health care, and enhance providers’ RLP counseling knowledge. This keynote was attended by approximately 105 participants. Session evaluations indicated an overwhelming majority of participants “strongly agreed” or “agreed” the presenters were knowledgeable, organized, and effective. In addition, Family Planning’s Medical Advisory Committee promoted and disseminated the Before, Between, and Beyond Pregnancy educational modules and Preconception-Interconception Care Clinical Toolkit to local agencies. The MDHHS Family Planning program disseminated these resources to key contacts within Medicaid, clinical Home Visiting Programs, and healthcare organizations.

During FY 2018, the Family Planning Program started collaborating with the MDHHS Behavioral Health Program with the goal to equip case managers with the knowledge and skills to effectively asses substance misuse clients’ pregnancy intentions and counsel on contraceptive options, in addition to facilitating the appropriate contraceptive care referral for pregnancy prevention. Family Planning presented to case managers during their October 2018 staff meeting. The presentation covered all FDA-approved contraceptive methods, medical condition considerations for contraception, and the shared decision-making model for contraceptive counseling. Case manager and client-friendly resources were also included within the presentation. Family Planning staff are creating and/or locating a job aid for case managers to improve confidence in assisting substance misuse clients in identifying a method of contraception that best fits their life and needs. Family Planning’s clinic directory has been shared with Behavioral Health case managers and local clinics were notified that substance misuse clients may be referred for contraception. In FY 2019, Family Planning will continue working with the Behavioral Health Program, as well as explore opportunities for collaboration with Michigan’s Adolescent Pregnant and Parenting Program, WIC, and local breastfeeding support groups.

Objective C: By 2020, increase by 5% the proportion of Michigan women who report having a routine check-up within the past year.

This objective is Michigan’s National Performance Measure for the Women/Maternal Health domain. Based on the Behavioral Risk Factor Surveillance System (BRFSS), Michigan’s FY 2018 reporting data indicates that 69.0% of women aged 18-44 years old had a preventive visit in the past year. This was an increase over the previous reporting year, which was 68.2%. To continue making progress on this objective, in FY 2018 Medicaid outreach opportunities were promoted among local Family Planning agencies. During the Open Enrollment Period, local Family Planning agencies assisted and enrolled clients in Medicaid or Medicaid Health Plans, the Marketplace, and other health insurance plans. For agencies without on-site enrollment, clients were referred to appropriate organizations in the community. Local agencies also participated in enrollment events by distributing health insurance brochures and related educational materials. Medicaid outreach training and technical assistance opportunities were curtailed late in FY 2018 due to the restructuring of the Medicaid Outreach Consultant position and policy changes to Medicaid outreach reimbursement. In FY 2019, Medicaid plans to offer regional training opportunities to local health departments on outreach reimbursement policy changes. During 2018, 32% (n=62,707) of Family Planning clients reported utilizing public health insurance such as Medicaid or Healthy Michigan Plans (i.e., Medicaid Expansion).

Local Family Planning agencies were reviewed and monitored on the development of medical and social service referral agreements and collaboration at the local level, as well as their assessment of client needs for primary care or other services. Primary care providers are included as a minimum program requirement for client encounters and established medical referral agreements. Of the agencies reviewed during FY 2018, 100% had incorporated asking clients whether they were in need of primary care services into their Electronic Health Record systems and had current referral agreements with primary care providers within their community. Referrals to primary care providers were promoted on an as-needed basis.

During FY 2018, MDHHS used several tactics to assist local Family Planning providers in fostering relationships with Medicaid Health Plans. Local agencies are encouraged to establish formal arrangements with Health Plans. If that is not possible, then agencies are encouraged to foster informal relationships. MDHHS also focused efforts on receiving regular Medicaid updates, providing input on Medicaid’s common formulary, and providing 340B prices on medications (i.e., antibiotics and contraceptives) to set reimbursements. In FY 2018, regular Medicaid updates were received during Family Planning’s statewide Advisory Council. Local Family Planning agencies had the opportunity to provide input on the common formulary on a quarterly basis, and 340B medications prices were provided to Medicaid on a quarterly basis. Lastly, a Partnering with Medicaid breakout session was provided at the annual Family Planning Conference. MDHHS and Institute for Health Policy staff described Medicaid Health Plan population health and quality improvement initiatives, provided an overview of required performance measures, and identified opportunities for collaboration. Approximately 30 attendees participated in this session. Session evaluations indicated the majority of attendees “strongly agreed” or “agreed” the presenters were knowledgeable, organized, and effective.

Oral Health – Women/Maternal Health (FY 2018 Annual Report)

The MDHHS Oral Health Program (OHP) provides population-based oral health prevention efforts and effective utilization of the dental workforce in implementing and improving oral health access. With the increased awareness of the impact of oral health to overall health, the OHP has increased its collaborations with community partners to improve oral health through prevention activities and direct access programs. This remains evident in the activities of NPM 13 in FY 2018. In the original Title V Guidance, this two-part NPM was originally in the Cross-cutting/Life Course population domain. Starting in 2018, the two parts of the measure were separated between the Women/Maternal Health and the Child Health population domains. Therefore, the original objectives related to Women/Maternal Health (which are now integrated into the NPM 13.1 state action plan) are reported here.

Objective A: Increase the number of medical and dental providers trained to treat, screen, and refer pregnant women and infants to oral health care services.

During FY 2018, the Perinatal Oral Health Action Plan continued to be implemented to support better health status for women and girls. A main strategy continued to be the training and education of Michigan health professionals, particularly those who practice in and serve communities and women adversely impacted by health disparities. The number of medical and dental professionals who receive perinatal oral health education through MDHHS is the ESM for this NPM. In FY 2018, the Perinatal Oral Health Program trained 648 health professionals in the medical and dental fields through lectures, webinars, conference calls and other training events. This number does not include the hundreds of additional professionals trained by partners, coalitions, and other Michigan entities. Michigan-specific Perinatal Oral Health Guidelines continue to be promoted, along with other educational materials. A partnership to teach a lecture on perinatal oral health to Nurse Midwifery and Nurse Practitioner students has continued with the university of Michigan School of Nursing, with lectures occurring each semester as part of the curriculum. This course contains a hands-on component as well as practical application in how to integrate oral health within your future practice. In addition, an interactive piece called “Why is Grace in the Emergency Room” helps initiate discussion on the social determinants of health and health equity. Positive student feedback continues to be measured at 99% with over 250 advanced practice nurses trained to date.

Objective B: Increase the number of pregnant women receiving oral health care services.

In FY 2017, MDHHS awarded grant funds to the University of Detroit Mercy (UDM) School of Dentistry to implement a dynamic medical dental integration program. The project officially launched in FY 2018. This partnership with the University of Detroit Mercy School of Dentistry, the Michigan Primary Care Association (MPCA) and the OHP identified a current successful pilot program in a Michigan FQHC. That model of care, which placed a dental hygienist directly within an OBGYN unit in an FQHC, was expanded to six participating FQHC sites in Michigan communities. In FY 2018, this nationally recognized project led to several thousand educational encounters, over a thousand referrals for needed treatment, and hundreds of cleanings for pregnant women. In addition, the model was proven to be financially sustainable within an FQHC setting and will be further expanded in coming years.

In FY 2018, the wichealth.org module was utilized not only in Michigan but other states that participate with wichealth.org. Wichealth.org provides stage-based, client-centered, WIC nutrition education and an anticipatory guidance model in which WIC clients could complete educational lessons in English or Spanish to receive their WIC benefits. Including Michigan, 15 states have selected the module for use at the end of FY 2018.  Nearly 20,000 lessons were completed nationally since its inception. During the FY 2018 reporting period, over 11,000 lessons were completed nationally, with nearly 3,000 of those completed in Michigan. WIC serves a diverse population and targets those within a lower social economic demographic. By developing education in partnership with WIC, the Oral Health Program has been able to reach populations that may have the most need and may experience the most health disparities. The module has also been developed in Spanish to better serve WIC clients and continues to be utilized, with over 1,000 Spanish language lessons completions documented.

The Perinatal Oral Health Initiative has a Perinatal Oral Health Advisory Committee that continued to meet in FY 2018 to review current program practices as well as guide future priority areas. The committee is comprised of payers, MCH organizations and representatives, clinicians, and oral and maternal health focused organizations. This committee contributes to the promotion of perinatal oral health as well as program planning and evaluation, targeting Michigan’s most underserved areas.