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

 

Introduction: Preventive Medical Visit

For the Women/Maternal Health domain, Hawaii continues to focus on improving Well-Women visits by promoting reproductive life planning with plans to include men’s health whereby reducing gender inequalities.

 

Hawaii selected NPM 1 Well-Women visits based on the results of the 5-year needs assessment. By July 2020, the state seeks to increase the number of women who have a preventive medical visit to 72.0% this includes preconception and interconception care. The 2018 indicator reports 69.4% of women in Hawaii received a preventive medical visit, which met the state objective of 67%. The rate was similar to the national estimate of 65.6%. There is no comparable Healthy People 2020 national objective.

 

This figure has increased from the proportion of women who received preventive medical visits in 2012 (61.6%). Subgroup analysis of the data showed that non-Hispanic White (62.1%) and Hispanic (68.4%) were less likely to have a visit in the past year compared to non-Hispanic Native Hawaiian/other Pacific Islander (72.8%) and non-Hispanic Asian (75.9%) women.  Additionally, uninsured women (49.4%) were less likely to have had a visit in the past year compared to those with insurance (70.9%). Women with less than high school education (60.3%) were also less likely have had a visit in the past year compared to the high school graduates (76.2%), those with some college (69.1%) or college graduates (65.0%). There were no differences based on the analysis by age, household income, or marital status.

 

The leadership for this issue comes from the Title V Women’s and Reproductive Health Section. The Section supervisor is partially funded by Title V. The programs in this section also participate in the effort and include the Title X Family Planning program, Perinatal Support Services, and the Adolescent Health program (the coordinator is Title V funded). For the Adolescent Health domain, Hawaii also selected adolescent wellness visits so there is opportunity to partner.

 

The strategies for this priority reflect the work of the Hawaii’s Maternal and Infant Health Collaborative (HMIHC) which has provided leadership for perinatal issues in the state over the last 5 years. Title V has been an integral part of the HMIHC leadership and Steering Committee. Updates for the strategies for this NPM are discussed below.

 

Strategy 1: Promoting Women’s Wellness Visits through Systems Building

 

Integrating Women’s Wellness into State Health Plans and Initiatives

The importance of women’s preventive and reproductive health care is reflected in several state health policy/planning documents including:

• The Executive Office of Early Learning Action Strategy plans (specifically the component focused on “Healthy and Welcomed Births”),
• the Hawaii Maternal and Infant Health Collaborative (HMIHC) to improve birth outcomes and reduce infant mortality,
• the state Department of Health Strategic Plan (specifically the component focusing on “Investing in Healthy Babies & Families”), and
• the draft Hawaii Early Childhood State Strategic Plan.

 

The state plans and collaborative working groups all embrace a life course approach that acknowledges the importance of women’s wellness as a foundation for healthier birth outcomes, infants, children and families.

 

Hawaii Maternal and Infant Health Collaborative (HMIHC)

HMIHC was established as a result of a 2013 National Governors Association Learning Network technical assistance (TA) award to improve Birth Outcomes. The application was submitted by the Title V agency in partnership with the Hawaii March of Dimes. The TA supported a series of planning sessions with a broad group of stakeholders including the Executive Office of Early Learning’s (EOEL) Action Strategy Work Group on “Healthy and Welcomed Births.”

 

HMIHC was formed to sustain the plan and implementation activities.  HMIHC completed a strategic plan, The First 1,000 Days, aimed at achieving the outcomes of 8% reduction in preterm births and 4% reduction in infant mortality by 2020.  To date, over 120 participants across Hawaii have been involved in HMIHC including physicians, clinicians, public health professionals, community service providers, insurance representatives and health care administrators.

 

Women’s preventive health is viewed as a critical factor to reduce infant mortality, improve birth outcomes, and sustain healthy families. HMIHC has a Pre- and Interconception Work Group focused on promoting optimal health before and between pregnancies in order to increase the number of births in Hawaii that are healthy and welcomed. The Work Group aims to reduce unintended and mistimed pregnancy by increasing clinical, educational and programmatic supports for pregnancy planning across the state.

 

HMIHC goals for preconception and interconception care are currently:

1. Increase pregnancy intention,
2. increase access to Long Acting Reversible Contraception (LARC), and
3. increase information available on healthy behaviors.

The Title V agency and State Medicaid office are co-convenors for the workgroup that includes the March of Dimes; Hawaii American Congress of Obstetricians and Gynecologists, Hawaii Section (Hawaii ACOG); the University of Hawaii School of Medicine (SOM) Department of Obstetricians, Gynecology, and Women’s Health; the Queen’s Physicians Network; Healthy Mothers, Healthy Babies; Planned Parenthood; and the Federally Qualified Health Centers. Participation of Medicaid and the FQHCs has been critical to assure services are targeted toward low-income, high-risk women of reproductive age.

 

The work group meets bi-monthly to share information, network, collaborate on implementation and planning to improve systems building efforts. An annual HMIHC meeting is held to provide updates and secure statewide input from agency/program stakeholders for the year’s action plans.

 

Two evidence based/informed strategies were selected from the federal MCH Bureau Collaborative Improvement and Innovation Network on Infant Mortality (IM CoIIN) targeting women of reproductive age: Long Acting Reversible Contraception (LARC) and the One Key Question® (OKQ) pregnancy intention screening tool. A Hawaii team attended the February 2017 IM CoIIN Learning Session in Houston, Texas, sharing information on partnership building through HMIHC and other state planning efforts targeting women of reproductive age.

 

Early Childhood Action Strategies

Hawaii’s Early Childhood Action Strategy initiative is a research-based, public-private collaborative comprised of over 100 professionals focused on supporting children’s health, safety, development and learning. http://hawaiiactionstrategy.org/ Originally, launched under the former Governor’s Executive Office on Early Learning the work is divided into 6 cross-disciplinary focus areas:

• Healthy and Welcomed Births
• Safe and Nurturing Families
• On-Track Health and Development
• Equitable Access to Programs and Services
• High-Quality Early Learning Programs
• School Readiness for Successful Transitions

The project coordination is now privately funded. HMIHC leads the Action Strategy’s Healthy & Welcomed Births Work Group.

 

Department of Health Strategic Plan: Investing in Healthy Babies & Families

One of the three pillars of the current DOH Strategic Plan is a focus on Investing in Healthy Babies and Families. Women’s reproductive health planning and health during pregnancy are an important focus in the plan. Strategies include promotion of the One Key Question® screening tool to decrease unplanned pregnancies and screening pregnant women for substance use to optimize the health of mothers’ and assure healthy birth outcomes. The plan is available on the DOH website: https://health.hawaii.gov/opppd/files/2013/04/Hawaii-Department-of-Health-Strategic-Plan-2015-2018-081616.pdf

 

State Early Childhood Strategic Plan

The State’s Executive Office on Early Learning is completing the Early Childhood State Plan 2019-2024, a strategic plan for early childhood to help coordinate and guide all state early childhood efforts. The plan will provide a comprehensive vision that reflects the state’s commitment to the children and families of Hawaii with specific measures to monitor and track progress. Key women’s health priorities include: promoting preventive screenings for risk factors and assuring access to a medical home.

 

Strategy 2: Promote pre/interconception health care visits

 

One Key Question® (OKQ)

Hawaii adopted OKQ as an evidence informed intervention from the federal MCH Bureau IM CoIIN. The OKQ screening protocol encourages providers to routinely ask women about their reproductive health needs to ensure pregnancies are wanted, planned, and healthy by asking "Would you like to become pregnant in the next year?"  Developed by the Oregon Foundation for Reproductive Health (OFRH), OKQ assists women in identifying and clarifying their reproductive desires and goals, with a specific emphasis on promoting highly effective birth control methods for women who do not desire pregnancy. OKQ is also a method to address underlying maternal health conditions and risky health behaviors that may have a detrimental impact on both mother and baby's health before, during, and after pregnancy. This strategy focuses on a women’s intent rather than what she plans since the concept of pregnancy planning does not always resonate with all ages, cultures, and backgrounds. OKQ developers advocate for screening in every healthcare encounter to address a woman's changing desires and goals. Regardless of the reason for a women’s visit, the use of OKQ provides opportunities for a broad array of service providers to engage women in planning for their reproductive and general health needs.

 

In January 2016, HMIHC launched the One Key Question® initiative at its annual statewide meeting with keynote speaker Michele Stranger Hunter, Executive Director of the OFRF.  Ms. Hunter also conducted OKQ training sessions for providers on implementation of the screening tool into their practices. OKQ was widely accepted at participating health care facilities and service programs forming a group of pilot sites for Hawaii implementation. Three Title V programs integrated OKQ into their service delivery: WIC, family planning, and the Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV). By September 2018, there were over 199 providers trained and 4,956 individuals reached with OKQ; and, over 150 individuals provided with information on birth spacing via “How long should I wait before getting pregnant again?” brochure (March of Dimes).

 

Policy. The November 2016 enactment of the state Medicaid Memo No. QI-1613 One Key Question and Contraceptive Coverage https://www.acog.org/-/media/Departments/LARC/HawaiiMedicaidLARCnotice20161110.pdf continues to increase access to contraceptive care by eliminating prior authorization for Medicaid reimbursement and allows health plans to reimburse for dispensing up to 12-months of oral contraceptive supplies. The policy was developed in partnership with the HMIHC.

 

To increase access to contraception, the 2017 the legislature passed Act 067 which authorizes pharmacists to prescribe and dispense self-administered hormonal contraceptive supplies to patients, regardless of a previous prescription from an authorized prescriber.  The law does require pharmacists to refer patients to their primary care provider upon prescribing and dispensing the contraceptive supplies. If the patient does not have a primary care provider, the pharmacist shall advise the patient to consult a licensed physician, advanced practice registered nurse, or other primary care provider of the patient's choice. In 2018, the Oregon State College of Pharmacy, in partnership with the University of Hawaii at Hilo, Daniel K. Inouye College of Pharmacy, offered the Comprehensive Contraceptive Education and Certification for the Hawaii Pharmacist to fulfill the requirements of HRS 461-11.6.  As of September 2018, eighteen pharmacists are certified to prescribe and administer FDA approved contraceptives.

 

Promotion. The 2018 annual HMIHC statewide conference featured updates to implementation of OKQ, increased access to LARC, and review of data collection efforts.  Breakout sessions included OKQ.  The Pre-Interconception Work Group collected important stakeholder input that was used to update/revise the work plan and training. This included development of a locally-produced OKQ video to promote the initiative and engage more providers. An initial 5,000 OKQ informational brochures were printed by the Title V agency Family Planning program and distributed to providers interested in the initiative. An additional 1,400 were distributed this period.

 

OKQ Trainings. Based on the rapid success of the OKQ provider trainings and the lessons learned from implementation, the Pre-Interconception Work Group focused on developing local training capacity to sustain (and broaden) the effort.  The Work Group identified several Hawaii OKQ trainers that have served as future resources. The Work Group also expanded access to OKQ trainings through use of webinars based on statewide interest.

 

OKQ trainings were hosted by HMIHC as well as integrated into the annual Home Visiting and Early Childhood Conference.  The Healthy Mothers Healthy Babies Coalition of Hawaii, through a March of Dimes Hawaii Chapter grant, completed eight statewide OKQ trainings for ten community health centers and other community partners. OKQ information was also provided through other public health initiatives including provider trainings sponsored by Title V programs: Zika Prevention and Family Planning Care for Non-Pregnant Women and Men of Reproductive Age. By December 2017, a total of 339 providers were trained.

The trainings have evolved based on the experience and feedback from OKQ providers. Additionally, many non-clinical providers requested further training/information on contraceptive options, referral resources, and assistance to address challenging situations including working with adolescents.

 

The One Key Question® training curriculum was expanded to include an overview of reproductive life planning and contraception, dealing with challenging client scenarios, and community resources. Participants are now given the knowledge required to effectively and sensitively introduce the concept of family planning, birth spacing, and setting family planning goals, information to dispel common myths about pregnancy and safe sex (a substantial problem among adolescents), and ways to create a client-centered focus that allows for ambivalence, uncertainty, and individualized approaches. An OKQ comprehensive information packet was developed and integrated into OKQ trainings to assist providers. The Title V Family Planning program assisted with packet development, printing and distribution.

 

Messaging: SafeSex808

Social media has been employed to promote OKQ and help women (teens) to access reliable healthcare information and services. The University of Hawaii School of Medicine Department of Obstetricians, Gynecology, and Women’s Health created Safe Sex 808 (https://safesex808.org/ or https://www.instagram.com/safesex808/), a Hawaii based, online resource to find sexual health resources and locate a nearby reproductive health provider. The online resource has been promoted by HMIHC and Title V programs, including the DOH’s Adolescent Health program.

 

Long Acting Reversible Contraception (LARC)

LARC is the most effective form of reversible contraception and has the highest continuation rates among reversible methods. A single visit or encounter is required for placement and continuing use does not require additional medication or regular follow-up. The immediate postpartum period has several potential benefits for implant insertion or IUD placement because many women are motivated to avoid short-interval pregnancy and the physician and women are together, eliminating the need for an additional visit and potential loss of insurance coverage postpartum. Placing LARC in the immediate postpartum period is additionally effective because many women at highest risk of short interpregnancy intervals, may have low postpartum visit follow-up rates.

 

HMIHC’s Pre-Interconception Work Group activities focused on clarifying policies for LARC insurance reimbursement: 1) immediately postpartum prior to hospital discharge, and 2) for outpatient visits for women of reproductive age.  In addition, denied claims for LARC insurance reimbursement are reviewed to work out processing issues for various hospital and medical providers. A chart with reimbursement codes for LARC continues and to be distributed by HMIHC and through provider partnerships such as Hawaii ACOG.

 

LARC Provider Training. The Title V Family Planning program in partnership with the University of Hawaii School of Medicine Department of Obstetricians, Gynecology, and Women’s Health conducts regular training for obstetrician–gynecologists and other obstetric care providers on LARC insertion as well as counseling protocols to improve access to LARC for immediate postpartum initiation.

 

Policy. As a result of the HMIHC partnership, the state Medicaid program provider memorandum supporting OKQ and Contraception Use also clarified Medicaid reimbursement of inpatient LARC, unbundled reimbursement from the global fee for inpatient services, and supported stocking of the contraceptives (particularly LARC devices) in the hospitals listing billing codes for providers. Also, the memo promotes increased access to contraceptive care by eliminating prior authorization for preventive contraceptive procedures, methods or devices in a plan’s formulary including reimbursement for dispensing of up to a 12-month supply of oral contraceptives. The memo was sent to all Hawaii Medicaid health plans, hospitals, pharmacies, physicians, physician assistants, midwives, and advanced practice nurses in addition to being posted on the Hawaii ACOG website and distributed through HMIHC.  The OKQ and Contraceptives memo mainly focused on using pregnancy intention screening to access contraceptive, inpatient LARC reimbursement for inpatient facilities, and outpatient dispensing of 12-month oral contraceptives (consistent with Act 205 of 2016).

 

Evaluation. This Medicaid policy impacted Oahu birthing hospitals. Several hospitals are now establishing protocols for stocking LARC in their inpatient pharmacies. HMIHC is working to evaluate its LARC promotion efforts. HMIHC recently received a grant from the National Institute for Reproductive Health to assess whether the 13 birthing hospitals in Hawaii are stocking and receiving reimbursements for LARC inpatient insertion postpartum and to address any barriers. The evaluation to identify administrative barriers to LARC at the state’s two largest hospitals is in progress. The grant hopes to identify and partner with provider champions in each hospital to become advocates and early adopters of inpatient insertion of LARC. Lastly, the grant will be used to generate similar LARC policy changes among private health insurers in Hawaii. HMIHC is also in the process of requesting Medicaid billing data for LARC ordering and insertion.

 

Strategy 3: Promote reproductive life planning

 

In FY2018, the DOH Title X Family Planning Services program, provided comprehensive statewide family planning services to 16,002 clients in 24,435 visits.  Services include client-centered education and counseling, pregnancy testing and counseling, basic infertility services, preconception health, sexually transmitted disease/human immunodeficiency virus testing, and other related preventive health services including referrals (i.e. blood pressure screening, weight management and domestic violence and intimate partner violence screenings, tobacco cessation, cervical and breast cancer screening).  Over 80% of the Hawaii Title X clients leave with their chosen contraceptive method.  Of these, 66% leave with a moderately to highly effective method. Family participation in services is encouraged for all clients.  All clients are also encouraged to return for their annual exams to ensure continued coordinated compliance with their family planning method and assessment of other health needs. As noted earlier, most of the Family Planning providers integrated One Key Question® (OKQ®) in family planning and primary care services.

 

In April 2018, the Family Planning program participated in discussions with First Circuit Family Court Judge Bode Uale (Lead for the Juvenile Division), his colleagues, and other juvenile justice stakeholders on the topics of pregnancy prevention, adolescent sexual and reproductive health. The Family Planning program provided resource materials on reproductive health (including OKQ information) which helped to integrate the topic into court-related youth programs that serve teens at high risk for unplanned pregnancy and sexually transmitted infections.

 

ESM 1.1 - Percent of births with less than 18 months spacing between birth and next conception.

The Evidence Based/Informed Strategy Measure (ESM) selected for women’s preventive medical visits is the percent of births with less than 18 months spacing out of total births.  The measure is related to one of HIMHC goals for preconception and interconception care (women’s preventive health) to improve birth spacing through reproductive life planning education and counseling. The FFY 2018 indicator is 31.9% of births met the recommended birth spacing criteria. The data is provisional. The 2018 objective (31%) was met.

 

Hawaii recognizes the need to revise the ESM from a population-based health outcome to a process measure to monitor progress on the specific strategies and activities. However, this process was delayed until the hiring of a new Women’s Health Section Supervisor. The Supervisor, who co-chair the HMIHC Pre-Interconception Work Group, will revise the ESM in next year’s report after consultation with the HMIHC to integrate/align goals, performance and evaluation measures.

 

Review of the Action Plan

A logic model was developed for NPM 1 to review the alignment between the strategies, activities, measures and desired outcomes. By working on these three strategy areas, Hawaii plans to increase the percentage of women ages 18 through 44 who had a preventive medical visit. The activities for this measure have changed slightly to reflect the program focus of the HMIHC Pre-Interconception Work Group. The Work Group partnership has been critical to the success of engaging a broad array of agencies and community organizations to promote women’s reproductive health including preventive health visits. Thus, a systems building strategy was added last year. Sustaining the HMIHC has been challenging and does take dedicated resources/staffing.

 

The importance of women’s wellness visits does not start at age 18 but is an important practice for adolescents particularly females since reproductive health concerns are often more critical for sexually inexperienced and maturing teens. Hawaii’s efforts to promote women’s wellness visits have coordinated well with efforts to also promote adolescent wellness visits. Thus, NPM 10 is integrated into the logic model.

 

Hawaii decided to focus on use of the two-evidence based/informed strategies: OKQ and LARC. Health messaging and education efforts for both providers and consumers focus on OKQ, LARC as well as contraceptive options. Short-term outcomes include increased awareness of pregnancy intention, capacity to address reproductive health for women, increased empowerment around reproductive life planning, accessing and speaking to providers. For providers, short term outcomes include: increased knowledge, capacity, and efficacy to counsel clients on reproductive health and refer to community resources. Systems changes include elimination of barriers to services, building of sustainable practices, and collection/analysis of data for evaluation. The ESM on birth spacing, although population based, is expected to show improvements as progress continues.

 

 

Longer term outcomes include the Title V NPM to increase preventive medical care and the national outcome measures. Additional long-term outcomes expected include increased birth intention, increased access to family planning services, improved healthcare practices, prevention and chronic disease; which will lead to improve birth outcomes and infant health; and strengthened services and systems, and more integration among disciplines and collaboratives.

 

Challenges, Barriers

Some of the ongoing challenges to implementing activities include

• Establishing, coordinating and implementing linkages to ensure timely data for monitoring OKQ and LARC benchmarks
• Staffing to oversee activities for the OKQ implementation and related follow-up
• Potential hospital barriers to LARC such as pharmacy stocking of LARC, private insurance coverage of the device, and streamlining administrative processes for reimbursements.

 

Overall Impact

The Title V agency capitalized on key state and national resources to advance activities to improve women’s health that directly impact birth outcomes and reduce infant mortality. These resources include:

• Strong partnerships with the Department of Human Services Medicaid program resulting in policy changes to promote and support evidence-based strategies to promote women’s health
• The former Executive Office of Early Learning’s Action Strategy Planning process which was supported by the Governor’s Office in conjunction with substantial funding commitment from the Hawaii Community Foundation/Omidyar Foundation
• Selection and engagement in the 2013 National Governor’s Association (NGA) Learning Network to improve Birth Outcomes
• Participation in the national MCH Bureau Infant Mortality CoIIN
• Willingness of Title V and other programs to integrate OKQ into service delivery for women.

 

Additionally, Title V used the resources of key partners to provide leadership, staffing and funding to sustain these collaborative efforts over the past five years.  These resources are crucial since the MCH Branch recently experienced significant staff turnover, retirements and funding cuts. An example of the collaborative efforts include the funding for the state HMIHC Coordinator through the Preventive Health and Health Services Block Grant (PHHSBG), administered by the DOH Office of Planning, Policy and Program Development. The grant funding is critical to sustaining the momentum and work of the HMIHC including the OKQ and LARC activities as well as workforce training.

 

Although funding is available, HMIHC is now challenged with seeking a qualified candidate for the Coordinator position charged with supporting the Collaborative work groups and Steering Committee.

 

The Title V Women’s Health Section Supervisor, who also co-chaired the Pre-Interconception Work Group, was vacated in 2018 and was filled recently in the current federal fiscal year by the former PRAMS program coordinator.