Priority Need: Well Woman Care
NPM 1: Percent of women, ages 18-44, with a preventive medical visit in the past year.
Population Domain: Women/Maternal Health
Women’s Health Program Objectives
The Arkansas Department of Health’s (ADH) Women’s Health program continues to:
1) Provide direct health care, referral services, pre- and inter-conception counseling, and preventive screenings for women of reproductive age in all 75 counties;
2) Provide education and referrals for smoking cessation to women of childbearing age;
3) Work with the University of Arkansas for Medical Science’s Antenatal Guidelines, Education, and Learning System program to increase screening of and consultation to high-risk women in ADH’s maternity clinics;
4) Develop campaigns to increase uptake of influenza and Tdap shots in pregnant women; and
5) Work to reduce smoking in pregnant women, including screening during the last three months of pregnancy.
According to the most recent federally available data, the percentage of women in Arkansas with a past year preventive medical visit increased from 55.1% in 2011 to 63.7% in 2015, after which the state saw a slight decrease to 58.2% in 2017.
The ADH has at least one local health unit in each of the state’s 75 counties. The health units serve the state’s vulnerable and hard-to-reach populations, especially those in rural areas where access to medical care is limited. The ADH’s Women’s Health program supports the provision of direct health care and referral services to address the perinatal, reproductive health, well woman, and other preventive service needs for women across the state.
The ADH currently offers maternity services in 57 local health units covering 53 counties. Maternity services include:
- Case management
- Prenatal assessments (risk assessment, health history, physical assessment, laboratory tests, gestational age assessment, and fetal assessment)
- Management of abnormal prenatal findings
- Prenatal counseling and education
- Women, Infants and Children program
- Vitamin/Mineral Supplements
The implementation of the Patient Protection and Affordable Care Act negatively impacted the number of Arkansas women who access family planning and maternity services at LHUs. The Affordable Care Act gives women the opportunity to choose a private health care provider and also allows teens to stay covered on their parent’s insurance until age 26.
Current Activities Related to Well Woman Care
Objective 1
Increase the percentage of women, ages 18-44, receiving an annual preventive medical visit in an ADH.
Strategies to support this objective are:
1.1 Review medical record data reports for rates of preventive health services for women ages 18-44 provided in local health units.
1.2 Request Medicaid data reports on preventive health visits for women ages 18-44 provided by private providers.
1.3 Provide fact sheets on risk factors identified to women.
1.4 Provide referrals to community resources for identified risk factors or medical procedures unavailable at the local health unit.
Strategy 1.1: Review medical record data reports for rates of preventive health services for women ages 18-44 provided in local health units.
In 2018, 39,593 women ages 18-44 received a preventive health visit at ADH’s local health units.
Strategy 1.2: Request Medicaid data reports on preventive health visits for women ages 18-44 provided by private providers.
Arkansas Medicaid requires that a woman have a referral from a primary care physician in order for ADH to be reimbursed. This is a barrier.
Strategy 1.3: Provide fact sheets on risk factors identified to women.
Family Planning and Well Woman patients at the local health units receive education and counseling on the recommended preventive screenings that optimize health. Information on height, weight, body mass index, and blood pressure is gathered at each of these visits. After interviewing the client, further education, testing, and/or referrals are provided based on identified needs. Educational topics include sexually transmitted infection screening, pap tests, mammogram referral, hemoglobin testing, sickle cell screening, total cholesterol or cholesterol screening referral, wet mount, pregnancy testing, and fecal occult blood testing. The client is also screened for immunization status, smoking, alcohol, illicit drug use or abuse, human trafficking, and intimate partner violence. The ADH provides written materials on a wide variety of topics at the local health units.
There are many statewide resources aimed at primary prevention and smoking cessation among women. Many anti-tobacco programs and curriculum are based in schools, particularly in Coordinated School Health schools that receive Tobacco Prevention and Cessation program funds. The Coordinated School Health program collaborates with schools and communities to deliver programs that include tobacco prevention education, comprehensive school-based tobacco policies, and promotion of tobacco cessation for staff and students.
The ADH’s Tobacco Prevention and Cessation program continues to support coalitions, colleges, community-based organizations, corporations, health care providers, hospitals, law enforcement agencies, local health units, media companies, non-profits, and other state agencies in efforts focused on tobacco prevention and cessation.
A new project to provide tobacco cessation to pregnant mothers began in February 2019 and is called Community Pharmacists – Coaching Arkansas to Nicotine Independence pilot program. The program provides tobacco cessation training to pharmacists in rural areas. The grant allows pharmacists to provide evidence-based tobacco cessation counseling in areas that are usually neglected in tobacco cessation efforts. Patients can receive up to five in-person counseling sessions and two weeks of nicotine replacement therapy free of charge. The pharmacists also work with patient’s insurance provider to allow more nicotine replacement therapy when needed. Pregnant women have the option of an additional five counseling sessions.
Act 959 (2019) was created to increase coverage for medications approved by the U.S. Food and Drug Administration for tobacco cessation in the Arkansas Medicaid program http://www.arkleg.state.ar.us/assembly/2019/2019R/Acts/Act959.pdf. The Medicaid program coverage will include nicotine replacement therapy patches, gum, lozenges, nasal spray, and inhalers. Medicaid coverage will also include the medications Bupropion and Varenicline. Prior authorization shall not be required for coverage of the medication.
The ADH also continues to support strong enforcement of laws regarding Arkansas tobacco manufacturers, wholesalers, and retailers. The ADH’s Hometown Health Improvement initiative encourages communities and coalitions to focus on tobacco prevention and cessation. The ADH’s electronic health record incorporates the meaningful use indicator in all programs (family planning; maternity; Women, Infants and Children; sexually transmitted infection; and BreastCare) to screen patients for tobacco use as well as to provide counseling, education, and referrals to the tobacco quit line. In addition, between October 2018 and March 2019, at least one nurse from each county attended a four-day instructional program to become Certified Tobacco Treatment Specialists. The specialists are able to provide up to four counseling sessions and prescriptions for nicotine replacement products.
Strategy 1.4: Provide referrals to community resources for identified risk factors or medical procedures unavailable at the local health unit.
In calendar year 2018, the Family Planning and Well Woman programs referred patients for a total of 7,678 health related services. The services include laboratory tests, radiology, mammography, colposcopy, social services, dental, tobacco cessation, and referrals to other medical providers. The Family Planning program also made 4,211 referrals to the Special Supplemental Nutrition Program for the Women, Infants and Children (WIC) program. Additionally, 62 referrals were made to the ADH Be Well program (https://www.healthy.arkansas.gov/programs-services/topics/be-well-arkansas). Beginning in November 2018, the ADH launched Be Well Arkansas to provide Arkansans with resources to improve their health and well-being. With Be Well Arkansas, Tobacco Prevention and Cessation Program staff are operating a call center to connect callers to tobacco and nicotine cessation services and wellness counseling for diabetes and blood pressure control. These wellness services are accessible by calling the 833-283-WELL phone number, or online at the Be Well Arkansas website. In addition, the number 1-800-QUIT-NOW for tobacco cessation will route callers to the Be Well Call Center.
The maternity program referred patients for 5,578 services including laboratory tests, ultrasound, genetics counseling, telemedicine, high risk maternity provider, and nutrition counseling. The maternity program made 2,579 referrals for WIC program services, including prenatal education classes.
On June 30, 2017, grant funding to support the University of Arkansas for Medical Sciences’ Antenatal Guidelines, Education, and Learning System colposcopy clinics in performing cervical cancer tests at local health units ended. To ensure that all women continue to have access to colposcopy services, the ADH assists women with application to the BreastCare program, which provides coverage for colposcopy for eligible women, refers patients to community providers where available, and refers to University of Arkansas for Medical Sciences.
In July 2017, the ADH began pilot testing a new training program in order to be able to provide colposcopy services for patients in May 2018. The UAMS ANGELS Program once provided this gap-filling service using telemedicine equipment available in the ADH’s local health units. The ANGELS Program discontinued this service due to funding reductions. As a result, the ADH is training its nurse practitioners to perform this procedure. The nurse practitioners receive hands-on training from the medical directors from the agency’s Family Health Branch and Women’s Health Section. Once that training is complete, nurses continue training using the telemedicine equipment in the local health units. The telemedicine service is being pilot tested in local health units in Hempstead (Southwest Region) and Crittenden (Northeast) Counties. The ADH plans to expand colposcopy services to multiple sites around the state to fill gaps in service. An evaluation is underway to determine unmet need and project sustainability. The ADH plans to train additional staff as needed
Objective 2
Increase the percentage of women, ages 18-44, receiving preconception counseling prior to pregnancy in an ADH Family Planning clinic.
The strategy to support this objective is:
Strategy 2.1: Provide preconception counseling prior pregnancy to woman attending an ADH Family Planning clinic.
Preconception counseling is a focus of an ADH visit where the patient identifies the desire for pregnancy. However, preventive health screening services and referrals are offered at all Family Planning and Well Woman visits for identified health problems.
Women at risk of unintended pregnancy are a high priority population for the Women’s Health program. This population includes teens, minorities, low income women, women without insurance, and unmarried women. The ADH’s Health Statistics Branch created the Family Planning Needs Index, which is used to measure and rank the needs of Family Planning services at the county level. In this model, a score is calculated for each county by employing a weighted combination of several different health indicators. The specific indicators used in this model are: general fertility rate; fertility rate for younger teens age 10-14 years; fertility rate for teens age 15-19 years; percent births to unmarried women; percent unmarried teen births; lack of prenatal care in the first trimester; percent low birth weight births; fetal death rate; neonatal death rate; and post-neonatal deaths. The most recent needs index (2013-2017) indicated that the highest priority areas are the counties in eastern and southern Arkansas.
Family Planning patients are charged based on a sliding fee scale, with no fee for families whose incomes are at or below 100% of the federal poverty level. The ADH does not deny services due to inability to pay and the agency bills third party payers for family planning services.
Objective 3
Increase the percentage of women receiving prenatal care in the first trimester.
The strategy to support this objective is:
Strategy 3.1: Monitor medical record data reports for entry into prenatal care at local health units.
The ADH began using the revised birth certificate standard (2003) in 2014. The 2014 data is considered Arkansas’s new baseline. In the state overall, the percentage of live births with first trimester prenatal care increased slightly from 68.4% in 2016 to 70.2% in 2017 (National Vital Statistics System, federally available data). First trimester prenatal care was lowest among mothers with the following demographics:
Low Use of First Trimester Prenatal Care |
|
Category |
Use of Prenatal Care |
Minority (Pacific Islander) |
11.8% |
Uninsured |
49.0% |
Born outside U.S. |
53.3% |
Didn’t graduate from high school |
50.7% |
Minority (Hispanic) |
55.7% |
Young mothers (<20 years old) |
57.2% |
On Medicaid |
59.5% |
Unmarried |
60.1% |
Maternity patients are not charged for services. As noted above, ADH does not deny services due to inability to pay and the agency bills third party payers for maternity services. Maternity patients can complete applications for Medicaid through the Arkansas Department of Human Services and non-citizens or undocumented women may apply for “unborn child” Medicaid for pregnancy coverage. Although there is variability across the state in the length of time a client receives prenatal services from the ADH, the agency is able to provide care until the patient is approved for Medicaid. Once approved, staff in the local health units work with clients to identify a local prenatal care provider. The women’s health services that ADH provides, particularly maternity services, are vital given the rural nature of the state combined with high poverty levels and the disproportionate availability of obstetric providers.
In 2018, the ADH’s maternity program began utilizing an enhanced depression screening tool as part of the routine maternity clinic intake and postpartum visit. The multipurpose questions are for screening, diagnosing, monitoring, and measuring severity of depression. An advanced practice registered nurse reviews the intake information and discusses any areas of concern with the patient. Ultimately, the nurse assigns the patient a score based on her responses and makes a final diagnosis.
Other Programmatic Activities Related to Women’s Health
The ADH implemented an appointment reminder program for patients using the Vital Interaction software with Greenway PrimeSUITE patient data in March 2017. The patient receives three reminders. The first reminder is sent five days prior to the appointment, the second at 72 hours prior, and the third at 24 hours prior to the appointment. The reminder appointment system features include:
- Reminders in English or Spanish, based on the patient’s language preference in the Greenway electronic health record system. The ADH serves a large Marshallese population in the northwest region of the state. The vendor does not offer that language and is working with ADH to find a solution so this population can be adequately served.
- Patients receive a combination of text messages and automated recorded calls for each appointment.
- If the patient is marked with a “CONFIDENTIAL” flag, they are excluded from receiving reminders.
- If the patient is a child, the reminder goes to the parental “Associated Party” on their record.
- Patients are allowed to “opt out” of appointment reminders by texting “STOP”.
- Patients are given the local health unit’s phone number to cancel/reschedule.
- The system is capable of producing reports that give detail on reminders sent (e.g. actions taken, if phone numbers provided are not working) so the Greenway data system can be updated.
- “Recalls” for patients who did not keep their appointment;
- “Annual Appointment Reminders” for patients who had a Family Planning annual visit in the prior year, but do not have an appointment for the current year;
- At 11 months after their last annual Family Planning visit, patients receive an annual appointment reminder to encourage them to make an appointment. Once the appointment is scheduled, the patient rolls over to the regular appointment reminder process.
- Depo-Provera® injections appointment recalls to help patients maintain the quarterly injection schedule recommended for this birth control method.
The appointment reminders application has the capability to notify patients as the need arises (e.g. special events, birthdays, age-based programs, new procedures and/or programs offered in the health unit, celebrations, back-to-school, birthdays, recommended actions). These notifications can be developed and delivered quickly across the entire data base or to a target population as defined by the request.
The appointment show rate for the year prior to the implementation of appointment recalls (March 2016 - February 2017) was 65.6%. The show rate for March 2017 – February 2018 is 68.8%, an increase of 3.2%. From March 2018 - February 2019 the show rate was69.7%, an increase of 4.1% since implementation in March 2017.
The Become and HPV Hero Summit for medical and dental professionals was held on March 1, 2019. The meeting content highlighted the connection between HPV and cancer, included provider tools to talk to patients about the benefits of the HPV vaccine and shared best practices about ways to increase HPV immunization rates. The Women’s Health section supported eighteen maternal and child health nurse participants from all regions of the state.
Through collaboration with the University of Arkansas for Medical Sciences, ADH’s local health units are equipped with video and peripheral equipment for real-time telemedicine consults with maternal fetal medicine providers from the Antenatal Guidelines, Education, and Learning System team (http://angels.uams.edu/). The use of telemedicine services allows patients to save both time (travel and away-from-work) and transportation costs. In addition, the system’s call center serves as an after-hours option for emergency triage consultations with ADH’s maternity patients.
The ADH Women’s Health section has a professional services contract with the University of Arkansas for Medical Sciences’ Department of Obstetrics and Gynecology to facilitate the delivery of comprehensive and risk-appropriate maternity care to low-income women throughout Arkansas. It also supports the department in its efforts to continue to provide outpatient services to ADH’s high-risk maternity patients. In addition to telemedicine, the contract supports the provision of clinical services and the liaison/consultation services of a certified nurse midwife for ADH’s Lay Midwife Program. Funding for a 0.5 full-time equivalent OB/GYN physician supports the position as ADH’s Family Health Medical Director.
The ADH partners with Arkansas POWER (Perinatal Outcomes Workgroup Education and Research) to develop strategies to improve perinatal outcomes in the state. In 2018, the workgroup continued its focus on safety bundle implementation for postpartum hemorrhage and hypertensive emergencies throughout Arkansas birthing hospitals. The ADH Family Health Medical Director and Family Health Branch Chief provide public health information and perspective to the workgroup.
The ADH partners with Arkansas Medicaid, Arkansas Foundation for Medical Care, and Arkansas Department of Higher Education to implement strategies and distribute educational materials designed to address unintended pregnancies. Together, these partners developed a toolkit for hospitals and health care providers to use as they discuss health, sexual history, and birth control options with their patients. The toolkit, TAKE CONTROL of Your Life: The choice about if or when you become pregnant is YOURS!, includes a patient education flip chart (https://afmc.org/product/larc-patient-education-flip-chart-providers/) as well as a patient education guide (https://afmc.org/product/larc-patient-education-interactive-e-book-english-download/) that reviews the different options for family planning. The toolkit is available in English, Spanish, and Marshallese. It was distributed to campus health centers/programs at all public 2-year and 4-year colleges in the state. It was also distributed to by the Arkansas Foundation for Medical Care’s staff to ADH’s central office and 73 local health units in 63 counties. Additional information for health care providers and individuals is available on the Foundation’s website: https://afmc.org/larc/ and https://afmc.org/?s=larc. The site also provides links to the YouTube videos developed by the Arkansas Campaign to Prevent Unplanned Pregnancy called Preventing Unplanned Pregnancy (https://www.youtube.com/watch?v=FaCyQMrSUg8) and Your Action Plan (http://youractionplanar.com/).
The Arkansas Foundation for Medical Care developed educational materials on maternal mortality and post-delivery warning signs as part of the initiative to decrease maternal mortality and morbidity. The materials include algorithms to help clinicians recognize urgent warning signs for women up to a year after delivery. Materials for patients include information on urgent post birth warnings signs and information about when a pregnant or post-partum woman should seek treatment with a medical provider.
The materials have been distributed to Medicaid providers at the hospital and clinic practice level across the state. The materials can be downloaded from: https://afmc.org/quality/maternal-mortality/ or https://afmc.org/quality/maternal-mortality/.
According to the Centers for Disease Control and Prevention’s Pregnancy Mortality Surveillance System, the maternal mortality ratio for Arkansas for 2011-2015 is 25.0:
- Non-Hispanic White: 18.6
- Non-Hispanic Black: 54.6
- Hispanic: 15.4
The maternal mortality ratio is the number of maternal deaths per 100,000 live births. A maternal death is a death during or within 42 days of the end of pregnancy due to pregnancy or its complications. Arkansas is ranked 44th in maternal mortality out of the 48 states where data is available for ranking (Health of Women and Children Report, 2018). This is possibly related to the fact that Arkansans often face disparities regarding poor socioeconomic status and rurality, and maternal mortality rates are significantly higher among these groups.
In 2017, the Arkansas Legislature passed an interim study proposal requesting a review of maternal mortality in the state and recommendations for solutions to lower maternal mortality. Leadership for the ADH (Maternal and Child Health Director, Women’s Health Section Chief, and Epidemiology Section Chief) partnered with staff from the University of Arkansas for Medical Sciences (College of Medicine, Obstetrics & Gynecology; Antenatal Guidelines, Education, and Learning System; Center for Distance Health; and Anesthesiology) to form a workgroup to develop the Arkansas Maternal Mortality Interim Study Proposed Plan. The proposed plan was developed using information and resources on a maternal mortality review provided by the Centers for Disease Control and Prevention Foundation; Association of Maternal and Child Health Programs; and the Centers for Disease Control and Prevention’s Division of Reproductive Health (http://reviewtoaction.org/.
In March 2019, the Arkansas Legislature passed ACT 829 to establish a maternal mortality review committee to decrease the amount of maternal deaths in the state.
Leadership from the ADH’s Family Health Branch was instrumental in formulating the final legislation and the ADH is charged with establishing the committee, which will be developed and facilitated within the Family Health Branch.
The Arkansas Campaign to Prevent Unplanned Pregnancy is a not-for-profit organization made up of a group of Arkansans working together to educate young adults about the importance of birth control in preventing unplanned pregnancies. The Campaign was organized in response to Arkansas Act 943 of 2015: An Act to Require the Arkansas Higher Education Coordinating Board to Develop an Action Plan to Address the Prevention of Unplanned Pregnancy. The state’s Title V Director has been instrumental in developing the Campaign’s action plan.
The Campaign launched a website in early 2017 (http://youractionplanar.com/ and http://youractionplanar.com/about-us/our-story/documentation/) and is active on social media. The site includes information on services available at local health units in each of the state’s 75 counties as well as information on birth control options and Guys’ Guide, which is targeted toward educating men about birth control options (http://youractionplanar.com/resources/guys-guide/). National Public Radio featured the work in August of 2016 on its All Things Considered program (http://www.npr.org/sections/health-shots/2016/08/26/491240645/a-new-course-at-arkansas-colleges-how-to-not-get-pregnant).
The Arkansas Tobacco Prevention and Cessation program conducted an evaluation of the Arkansas Tobacco Quitline. The evaluation revealed that females accounted for 64.5% (n=5,310) of the registrants who received intervention services through the Quitline. Approximately 1.0% (n=65, 1.2%) of all who registered for cessation intervention services were pregnant, compared to 1.8% of registrants in 2010.
Arkansas Tobacco Quitline Evaluation Results |
||||
|
FY18 Count |
FY18 Percent* |
FY10 Percent |
|
Gender |
Female |
5310 |
64.5% |
62% |
Male |
2904 |
35.3% |
38% |
|
Female |
Pregnant |
65 |
1.2% |
1.8% |
*Note: Percent numbers for gender do not sum to 100% due to missing and refused information.
According to Behavioral Risk Factor Surveillance System survey data for Arkansas, 21.6% of women aged 18-44 reported being current smokers in 2017. The number marks a decline of 5.4% percentage points since 2011 (27.0%). Data from the 2017 Pregnancy Risk Assessment Monitoring System revealed that 14.5% of pregnant women reported smoking during the last three months of their pregnancy, a 7.9% decrease from the previous year’s rate (15.7%) and a 27.4% decrease from 2011 (19.1%).
In 2018, the Arkansas teen birth rate was 30.7 births per 1,000 females ages 15-19 years (provisional data, ADH Health Statistics Branch). In 2017, the Arkansas teen birth rate for ages 15-19 was 32,8 births per 1,000 compared to the U.S. rate of 18.8 per 1,000 (National Vital Statistics System). Although Arkansas’s rate has dropped 6.5% from the year before, it is still almost 75% higher than the national rate. In 2017, Arkansas had the highest teen birth rate in the nation. The ADH’s staff work with other organizations to pool resources in an effort to educate the public about the issues of teen birth. The ADH provides reproductive health counseling and services in most local health units across the state. These services are available to all and teens are encouraged to include their family in decisions regarding reproductive health. Teens represent 19.7% of all ADH Family Planning program patients.
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