DOMAIN – Women and Maternal Health
National Performance Measure (#1)
Percent of women with a past year preventive visit.
Oregon’s rate of women attending an annual well-woman visit continues to remain below the national average. There has been a slight decrease in the percent of women attending an annual well visit between 2014 and 2017, from 59.1% to 56.5% respectively.
Strategy #1: Case-management to improve utilization of well-woman care
Accomplishments
State Level
- The program manual for Oregon’s MCH Nurse Home Visiting Program (Babies First!) was updated in January 2019. The updated manual includes a revised protocol on Reproductive Life Planning that has been implemented by programs statewide. Reproductive life planning has been identified as a key program outcome for the Babies First! Program.
- State staff supported training and technical assistance, data collection, and quality improvement activities for the MCH Nurse Home Visiting and MIECHV-funded Home Visiting programs. A key activity of the home visiting programs is to provide case management to assist women in establishing a medical home and accessing preventive care.
Local Level
- Coos County collaborated with Maternal Child Health home visiting programs and WIC to implement a strategy for increasing awareness of the importance of and supporting access to appropriate well-women and pre/inter-conception care among clients.
- Coos County was able to add the One Key Question to the workflows of Reproductive Health Clinic, WIC, and home visiting activities. 100% of eligible clients were screened in both the clinic and home visits, while WIC had 76% of the eligible clients screened, averaging to above the goal of 50%.
- Crook County increased access to the Nurse Practitioner from three times a month to four days a week, increasing utilization of care.
- Deschutes County mandated the One Key Question to be asked of all female home visiting clients yearly.
- Klamath Tribes utilized check-off lists that required participants to see an OB at least four times during their pregnancy, testing for health and wellness of mother and child, taking prenatal vitamins, at least one visit to the dentist, regular phone calls to patients to ensure adequate resources, and a six-week postpartum visit.
- Klamath Tribes report having had increase utilization of the MCH program, which facilitated the clients making well woman appointments and follow ups with their providers.
- Malheur County successfully implemented a plan to educate 100% of MCH home visiting adult female clients on the importance of well women and preconception care and provide referrals as needed.
- Malheur County originally planned to educate MCH home visiting clients on the importance of well woman and preconception care and was able to expand to all Healthy Families home visiting clients. They coordinated with insurance assisters to educate on the well woman care being covered by CCOs or insurance providers.
- Washington County, working in conjunction with Washington County Public Health Division’s reproductive health program educator, developed a plan to implement a pregnancy screening process by the Washington County Maternal Child Health home-visiting team.
Challenges/emerging issues
- Deschutes County noted difficulty motivating staff to ask the One Key Question of non-pregnant or postpartum clients and they were unable to separate the data to just pregnant and post-partum clients.
- Klamath Tribes reported having issues with the mothers completing the checklists and losing them.
- Washington County had difficulties separating out the target population precisely. Also, they had planned on engaging with One Key Question in the pregnancy intention screening, but it was cost prohibitive.
Strategy #2: Use traditional and social marketing to educate the population and promote well woman care.
ESM (1.2): Number of women reached using traditional and social marketing campaigns such as CDC Show Your Love brochures, social media including Facebook and Twitter, attendance at health fairs and community meetings, and public service announcements. (Objective: 700)
Accomplishments
State Level
- Supported shared learning of best practices and lessons learned through Well Woman Care learning collaborative meetings that included Title V grantees and partners.
- Established a committee to plan for outreach activities including a Governor’s proclamation for Women’s Health Week 2020.
Local Level
- The Confederated Tribes of Umatilla Indian Reservation developed an all-encompassing, culturally appropriate women’s health brochure to be distributed throughout Yellowhawk Tribal Health Center.
- The Confederated Tribes of Umatilla Indian Reservation developed a women’s health event that promoted the woman’s traditional role historically within CTUIR and tied it to the importance of the health and wellbeing within the community, which reached 2,000 people.
- The Confederated Tribes of Umatilla Indian Reservation developed a digital story focused on traditional/medicinal plants that women historically gathered to incorporate into modern-day preventative care.
- The Confederated Tribes of Umatilla Indian Reservation – Yellowhawk, in October 2018, successfully implemented an Indigenous Pink Breast Cancer Awareness campaign, including Breast Cancer Walks weekly and an event “Light Up the Night” walk with 75 participants. They promoted American Indian/Alaska Natives breast cancer statistics in the local newspaper and social media outlets and encourage patients to participate in the Yellowhawk mammogram screening. In October the local tribal radio station, KCUW, promoted “Turn Up the Pink” music to rally against breast cancer. Yellowhawk also developed a breastfeeding campaign with breastfeeding statistics, health benefits, and local resources, including offering four breastfeeding classes, with photos of mothers breastfeeding to normalize breastfeeding in the community.
- Malheur County developed informational slides on the well woman care that were shared on the TV in the waiting room for clinic services and WIC.
- Marion County built a well woman social media campaign using the hashtag wellwomanwednesday#. They were able to grow their followers from 1500 to 2300.
- Marion County participated in a health fair at the local Teen Parent Program. Thirty-five teens stopped by the booth and received educational materials about Well Woman Care and Reproductive Life Planning.
Challenges/emerging issues
The resources and expertise it takes to build a robust and meaningful public awareness campaign remains a challenge. It is also difficult to measure the impact of public awareness campaigns. Some local grantees described difficulty engaging clinical providers in their efforts.
Progress on ESMs
At least 2085 women were reached using traditional and social marketing campaigns such as CDC Show Your Love brochures, social media including Facebook and Twitter, attendance at health fairs and community meetings, and public service announcements. ESM will remain in place. We were able to track outreach in some areas but need to work on improved methods for tracking reach for social media campaigns.
Strategy #3: Provide education/training on preconception/ interconception and well woman care for health care providers.
ESM (1.3): Percent of local health departments receiving technical assistance to support implementation of the well woman care priority area. (Objective: 100)
Accomplishments
State Level
- Facilitated well woman care learning collaborative meetings for grantees and partners.
- Technical assistance offered to all grantees.
Local Level
- Crook County sent 4 WIC/Family Planning staff to training update for One Key Question /Power to Decide and then were able to train all MCH home visiting workers.
- Marion County provided leadership to a local Maternal Child Health Coalition that selected reproductive life planning as one of four priority areas. They worked on creating and planning for a survey for local providers/agencies that will be used to drive messaging and campaigns moving forward.
- Marion County completed four different education-based trainings, 2 for providers and 2 for the community. At each training Well Woman Care messaging and Reproductive Life Planning materials were shared.
- All local grantees were given the opportunity for technical assistance and shared learning through learning collaborative meetings. Local grantees were able to train their staff and engage in training and community efforts with other providers of MCH services.
Challenges/emerging issues
- Family Building Block home visitors shared that reproductive health messaging would be difficult for them to deliver because they do not give medical advice.
- It is difficult to measure the impact of reproductive health messaging on behavior change.
- Transitioning away from use of the One Key Question due to training cost concerns.
- Crook County had challenges with staff turnover impacting ability to collect data on utilization of the One Key Question/Power to Decide metric and providers who did not like the One Key Question and felt it was insensitive for some groups.
Progress on ESMs
100% of local health departments received some amount of technical assistance. ESM will continue next year.
Strategy #4: Support access to well woman care through Family Planning Clinics.
ESM (1.5): Number of state and local partners engaged to improve access to and quality of well-woman care and reproductive health services. (Objective: 15)
Accomplishments
State Level
- Coordinated and collaborated with state Reproductive Health Program to integrate support for well woman care in family planning clinics.
Local Level
- Baker County utilized EHR recall to remind women that they are due for an annual exam and outreach to the Hispanic population through collaboration with school district.
- Baker County engaged with the Baker 5J School District Hispanic Interpreter to increase and improve outreach to the Hispanic population. Through this partnership, Baker County was able to provide a mother-daughter education class at the high school that included Spanish interpretation. Participants were given gift bags with hygiene products, and outreach materials promoting well woman exams at the Baker County Health Department.
- Union County developed a plan to implement pregnancy intention screening via the One Key Question among women of reproductive age who were clients of the STD clinic. This included educating clients on the importance of well-woman visits, pre/interconception care and providing appropriate referrals.
- Washington County in conjunction with Washington County Public Health Division’s reproductive health program educator, established the Reproductive Health Coalition of Washington County, to determine collective goals and strategies to promote reproductive health and well woman care within the community.
- Washington County through the newly established Reproductive Health Coalition of Washington County, successfully brought the three reproductive health service providers in the county together to work collectively on improving access to reproductive health services. They planned and implemented a “Youth Access Ambassadors” event, which focused on training youth to share information about accessing reproductive health services with their friends, families, and community; reaching over 50 youth. Also, they presented information to the Washington County Board of Commissioners on reproductive health issues and concerns.
Challenges/emerging issues
- Effective contraceptive use will no longer be an incentive measure for Oregon’s Coordinated Care Organizations.
- Baker County had difficulties with provider illness which inhibited its ability to provide family planning appointments, during June 2018 – June 2019, which made providing well woman exams difficult.
- Union County did not reach their goal of 100% but made gains. There is difficulty in documenting that the One Key Question is asked so that it is recorded on the reports. The question is asked on the intake form but there is a recording /reporting issue.
- Washington County had difficulty keeping community partners engagement up. Most meetings were well attended but a couple had low turnout.
Progress on ESMs
38 local partners were identified. Number of state and local partners engaged to improve access to and quality of well-woman care and reproductive health services. (Objective: 15)
Strategy #5: Use of the postpartum health care visit to increase utilization of well-woman visits.
Accomplishments
State Level
- Partnered with the OHA Transformation Center to develop a guidance document and host a 6-part Postpartum Care online learning series for Oregon’s Coordinated Care Organizations (CCOs). Postpartum Care became a CCO incentive metric beginning in 2019. The learning series and other supports provided were intended to assist CCOs in meeting their metric targets while enhancing engagement of women in postpartum and perinatal care through strategies that can be applied at the system and clinic levels, and which support collaboration and partnership between various entities serving pregnant and postpartum women.
- Continued to build relationships with Oregon’s CCOs.
- Supported MCH Nurse Home Visiting programs in quality improvement activities to improve attendance at postpartum care visits.
Local Level
- The Confederated Tribes of Warm Springs implemented a plan for the MCH nurse to facilitate scheduling a postpartum check with a provider during the postpartum home visit.
- The Confederate Tribes of Warm Springs reported that their postpartum mothers were very receptive to the MCH nursing making appointments for them. This also allowed the nurse to follow up on the appointment to remind clients and facilitate rides or assist with other issues. MCH worked with WIC to try to schedule appoints on the same day as postpartum appointments to decrease the number of trips to the clinic.
Challenges/emerging issues
- The postpartum metric for the CCOs doesn’t align with the 2018 guidance from ACOG on post-partum care.
- The Confederated Tribes of Warm Springs had challenges with staff turnover, specifically the Director of Nursing position was vacant, and the interim staff were reluctant to make changes to how postpartum appointments were scheduled. The MCH nurse position was vacant for five months.
Oral Health (Women) 2019 Report
National Performance Measure (#13)
Percent of women who had a dental visit during pregnancy.
The percent of women who had a dental visit has been consistently higher in Oregon than the national average since 2012. The state has mirrored the national decrease in this outcome between 2012 and 2015, with Oregon dropping from 56.1% to 53.5% over that time frame. Nationally, there has been a slight increase in dental visits during pregnancy from 2016 to 2017.
Strategy #1: Integrate oral health into state Maternal and Child Health (MCH), Health Promotion, and Chronic Disease Prevention Programs.
ESM (13.1.1): Number of materials developed on the common risk factors and associations between chronic diseases and poor oral health such as cavities and periodontal disease.
- Developed monthly oral health messages that were posted on the MCH and Public Health Division’s Twitter and Facebook accounts.
- Developed presentation and fact sheets for the Oregon MothersCare Program and 211 Info to assist their staff in educating clients on the importance of oral health and making dental referrals.
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Hosted a site visit with Tim Ricks, DMD, MPH, Rear Admiral, Assistant Surgeon General on September 23, 2019. Activities included:
- Dr. Ricks met with senior leadership where oral health integration efforts into Oregon’s system of care were highlighted.
- Live streamed a presentation where the public could learn about the upcoming Surgeon General’s Report on Oral Health, and successes and challenges of oral health integration nationally and in Oregon.
- Toured Multnomah County Health Department’s Northeast Dental Clinic as an example of successful oral health integration and reducing opioid prescriptions by dental providers.
- The Oral Health Unit presented posters and exhibited at the 2018 Oregon Rural Health Conference in October 2018, Oregon Oral Health Coalition’s (OrOHC) 2018 Fall Conference in November 2018, and the WIC Statewide Meeting in May 2019. The posters utilized described the link between oral health and chronic diseases and how oral health can be integrated into chronic disease systems of care. Oral health educational materials were disseminated at the conferences.
Challenges/emerging issues
The Oral Health Unit intended to collaborate with the Health Promotion and Chronic Disease Prevention Section but did not have enough capacity to establish this relationship. Funding outside of Title V is necessary to support their grantees, and no grant opportunities were available during the grant period.
Progress on ESMs
Two fact sheets, three posters, and three presentations were developed.
Strategy #2: Provide technical assistance to school oral health programs and Title V grantees.
ESM (13.2.1): Number of school oral health programs and Title V local grantees provided with technical assistance to enhance the quality of oral health services and increase oral health visits.
Accomplishments
- Eleven grantees – ten local health agencies and one tribe – were provided with individualized technical assistance throughout the grant year.
- Held the training, “Introduction to Health Literacy, Plan Language and Design”, on March 19, 2019 for Title V MCH grantees and school dental sealant programs. Participants learned how to better communicate with the communities we serve. The examples used during the training were oral health related.
- The Oral Health Unit collaborated with the Oregon Oral Health Coalition to promote the Maternity: Teeth for Two training program with grantees. The Maternity: Teeth for Two curriculum informs pregnant women and medical professionals, such as public health nurses, on the importance of oral health during pregnancy. It trains health professionals on how to integrate oral health education and referrals into primary and prenatal care.
Challenges/emerging issues
No challenges to report
Progress on ESMs
Eleven Title V local grantees were provided with technical assistance to promote dental visits for pregnant women.
Strategy #3: Increase oral health surveillance in Oregon.
ESM (13.1.2): Number of data sets in the Oregon Oral Health Surveillance System (OOHSS) that can be analyzed for oral health disparities.
Accomplishments
- Seven data sources were identified within the Oregon Oral Health Surveillance System (OOHSS) can be analyzed by race, ethnicity, language, and disability (REALD).
Challenges/emerging issues
The Oral Health Unit would like to increase its capacity to decrease oral health racial and ethnic disparities in Oregon. In 2018, the Unit applied for a 2018 Dental Trade Alliance (DTA) Foundation grant titled, “Understanding Barriers to Optimal Oral Health in Oregon’s Minority Communities,” but did not receive funding. The grant would have supported conducting a panel survey with Hispanic/Latino, Black/African American, and American Indian/Alaska Native racial and ethnic groups. The findings would have been used to develop a health equity communications plan; test oral health messages with partners in the specific racial and ethnic communities; and develop social media content and materials targeted to each specific racial/ethnic population.
Progress on ESMs
Seven data sets in the OOHSS can be analyzed for oral health disparities.
Strategy #4: (Local) Provide oral health preventive services or education and referral/case management services through Oregon's Home Visiting System.
Accomplishments
- Benton, Linn, and Lincoln Counties provided oral health education and referrals for dental care in their home visiting programs (Babies First! and Maternity Case Management). They also provided First Tooth and Maternity: Teeth for Two trainings for home visiting staff.
- Morrow County provided oral health education and referral case management for their home visiting clients in the CaCoon and NFP programs.
Challenges/emerging issues
Some public health nurses are hesitant to apply fluoride varnish during home visits. Counties intend to provide regular oral health and fluoride varnish training so that staff become more comfortable.
Strategy #5: (Local) Educate pregnant women, parents/caregivers of children, and children 0-17 about oral health and the importance of dental visits.
Accomplishments
- Benton, Linn, and Lincoln Counties provided culturally appropriate oral health education to all clients (e.g. WIC, home visiting, etc.).
- Clackamas County incorporated oral health education and referral services into all programs administered such as WIC, school-based health centers and the federally qualified health center (FQHC).
- Douglas County collaborated with Advantage Dental to provide oral health education and preventive services at two community baby showers, a well-child clinic hosted by a local family practice, and the Douglas County fair. They also worked with the WIC program to provide xylitol kits and oral health education to 125 pregnant and postpartum women as part of an “Oral Health for Pregnant Women Project”.
- Hood River County provided oral health education and referrals to dental care for home visit and WIC clients.
- Klamath County facilitated the Klamath Basin Oral Health Coalition and developed a three-year strategic plan, which included specific strategies for pregnant and postpartum women.
Challenges/emerging issues
Counties have done a good job in referring clients for dental care, but it is difficult to track whether those clients followed through on the referral. It is challenging to build a system that tracks closed-loop dental referrals.
Strategy #6: (Local) Collaborate with primary care providers to follow the American Congress of Obstetricians and Gynecologists (ACOG) oral health recommendations for pregnant women.
Accomplishments
- Jackson County developed a training and outreach plan to incorporate ACOG oral health recommendations for pregnant women into the medical community.
- Jackson County attended an OB/GYN Section meeting for Joint Medical OB Staff Providers (Asante and Providence Medford Medical Center) and gained providers support to provide oral health education in their offices and through home visitors.
Challenges/emerging issues
Jackson County had difficulties gaining access to specific OBGYN offices in their area. They plan to work with their Coordinated Care Organization (Medicaid) on future partnerships.
National Performance Measure (#14A)
Percent of women who smoke during pregnancy
The rate of smoking during pregnancy has steadily decreased in Oregon, from 11.3% in 2010 to 9.3% in 2017. This has mirrored a steady decline nationally, although Oregon values in this performance measure are consistently higher than the national average.
Strategy #1: 5As Intervention and Quit Line Referral (or other customized Evidence-Informed Program) within MCH Programs including Home Visiting, Oregon MothersCare, Family Planning, and WIC (if applicable).
ESM (14.1.1): Percent of local Title V grantees who have selected smoking as a priority area who are implementing the 5A’s with their clients.
ESM (14.1.2): Percent of local Title V grantees who have selected smoking as a priority area who have at least two technical assistance contacts.
Accomplishments
Local Level
- In Columbia County, 84% of home visiting clients who smoke received a 5As intervention and 84% also received a referral to the Quit Line, provider, or local tobacco cessation specialist. This process was made easier by incorporating smoking cessation resources into home visiting handouts.
- The Confederated Tribes of the Umatilla Indian Reservation provided 5As intervention during visits at the Yellowhawk clinic for 20% of women ages 13-44 who smoke tobacco.
- The Coquille Indian Tribe worked with multiple partners to improve the tribal clinic’s policies and procedures related to commercial tobacco screening and intervention. Updates were made to the clinic’s EHR to enable providers to document tobacco use, intervention and follow-up at each visit.
- Harney County worked to develop a policy agenda to decrease youth exposure to tobacco products and decrease the likelihood of initiation and use. As part of this effort, staff provided presentations at local schools, reaching over 380 youth. Staff also continued work to make all county properties tobacco free, including the county fairgrounds.
- In Lane County, 53% of home visiting clients who smoke received a 5As intervention and 100% received education on tobacco cessation benefits. Oregon MothersCare (OMC) clients also received information on tobacco cessation benefits. The local Quit Tobacco In Pregnancy (QTIP) program provides support and incentives to quit tobacco.
- Tillamook County’s home visiting program worked to use 5As screening, education and referral for pregnant clients who smoke, referred clients to the Quit Line, and enrolled pregnant people in the tobacco cessation incentive program with Columbia Pacific Coordinated Care Organization. As a result of the incentive program, 10 clients quit tobacco completely and 5 cut down on their tobacco use during pregnancy.
- Yamhill County implemented the Healthy Futures smoking cessation program in partnership with a Behaviorist at Valley Women’s Health prenatal care practice. Thirty percent of pregnant clients continued to be tobacco free at their 3-month postpartum visit.
Challenges/emerging issues
Local Level
- The MCH Program has a focus on home visiting and is therefore not able to see all pregnant people who smoke. The result is that not all clients receive referrals to providers and may miss getting interventions. Grantees have reported challenges getting pregnant clients to accept referrals either because they are resistant or because they have already received a referral from their primary care provider. Training in motivational interviewing and trauma-informed practices may support grantees to provide these services to pregnant clients.
- Several local grantees also reported challenges with staff turnover, which hindered implementation of smoking cessation efforts.
State Level
The lead for the Smoking priority at the State Maternal & Child Health program retired in spring 2019. Her replacement was not hired until mid-October 2019. Unfortunately, this gap in coverage impacted our ability to complete some of the State level activities we had planned for this grant cycle.
Progress on ESMs
Five out of seven (71%) Title V grantees who selected smoking as a priority implemented 5As with their clients.
All Title V grantees who selected smoking as a priority area (100%) received at least two technical assistance contacts with the State Title V program.
Strategy #2: Promote health insurance coverage benefits for pregnant and postpartum women and promote their utilization.
Accomplishments
Local Level
- The Title V-funded MCH Program, Oregon MothersCare (OMC), a patient navigation program for pregnant people, is conducted at the local level by Smoking Priority county programs as well as those who have not chosen the Smoking Priority. Some Smoking Priority Counties have incorporated OMC into their Title V work plans. However, all OMC Programs are required to provide screening and intervention for their pregnant clients who smoke. Nearly 350 pregnant people received smoking cessation education and referral from an OMC site during the reporting period.
Challenges/emerging issues
The lead for the Smoking priority at the State Maternal & Child Health program retired in spring 2019. Her replacement was not hired until mid-October 2019. Unfortunately, this gap in coverage impacted our ability to complete some of the State level activities we had planned for this grant cycle.
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