The Title V program strives to assure that women have access to and utilize integrated, holistic, patient-centered care before during and after pregnancy. Within the context of this priority, we strive for integrated care and alignment and coordination among systems and providers serving women, such as between Title V/MCH and Title X/Family Planning services, public health/primary care/OB-GYN, physical and behavioral health, and others. Title V is also focused on holistic care through assuring access to preventive services, screenings for early identification/intervention, addressing disparities and social determinants of health, and connecting to collaborative communities to address all needs of the women served, while meeting them where they are and with what they need. Work within this domain was affected by staff related changes. The Woman/Maternal role was officially filled in July of 2022 and further strategies to update and implement work in this domain is anticipated for the upcoming grant year. Systemic barriers and state policy related to Medicaid expansion, limited number of providers, lack of access to quality childcare, pandemic related restrictions to the number of appointment attendees, no consistent state-wide, nation-wide, or employer policy paid-time-off available to attend medical appointments, as well as cultural impacts of well-woman care in Kansas in relation to the 2022 Supreme Court decisions impacting women’s reproductive health are all considerations for upcoming work in this domain.

 

NPM 1:  Well-woman visit (Percent of women, ages 18-44, with a past year preventive visit)

ESM:  Percent of women program participants (18‐44 years) with a preventive medical visit in the past year

 

SPM 1: Postpartum depression (Percent of women who have recently given birth who reported experiencing postpartum depression following a live birth)

ESM:  Percent of MCH program participants screened for depression and anxiety during pregnancy and/or the postpartum period using the Edinburgh Postnatal Depression Scale (EPDS)

ESM:  Percent of pregnant/postpartum MCH program participants who received a referral in response to a positive screen for depression or anxiety through the Edinburgh Postnatal Depression Scale (EPDS)

 

National Performance Measure 1: Well-Woman Visits

 

Annual routine medical checkups are important for preventive care. The American College of Obstetricians and Gynecologists recommends that the well-women visit specifically include “screening, evaluation and counseling, and immunizations based on age and risk factors.”1 In 2021, an estimated 72.4% of Kansas women aged 18-44 years reported having a routine medical checkup within the past year (95% confidence interval [CI]: 70.3%-74.4%). This was significantly higher than the U.S. estimate of 69.7% (95% CI: 69.0%-70.5%).

 

Utilization of a routine medical checkup within the past year varied by household income and health insurance status. The percentage of women reporting having a routine checkup within the last year was highest among women with a household income of at least $75,000 (76.4%; 95% CI: 70.9%-81.2%), followed by at least $50,000 but less than $75,000 (74.7%; 95% CI: 69.2%-79.5%), at least $25,000 but less than $50,000 (68.6%; 95% CI: 64.1%-72.8%), and finally, less than $25,000 (68.0%; 95% CI: 61.6%-73.7%). A significantly lower percentage of women without health insurance coverage (41.2%; 95% CI: 34.1%-48.6%) reported having had a routine checkup within the past year compared to those with health insurance coverage (76.3%; 95% CI: 74.2%-78.3%). The estimated percentage of Kansas women aged 18-44 years who reported having a routine medical checkup in the past year increased significantly from 2018 to 2021, with an estimated annual percent change (APC) of 0.5% (95% CI: 0.3%-0.7%).

 

Weighted Percent of Kansas Women, Ages 18-44, Reporting a Routine Medical Checkup within the Past Year, 2018-2021

* The Annual Percent Change (APC) was found to be significantly different from zero at the alpha = 0.05 level.

Source: Centers for Disease Control and Prevention (CDC), Behavioral Risk Factor Surveillance System (BRFSS), 2018-2021

 

State Performance Measure 1: PMADs

Data on postpartum depression have been collected through the Pregnancy Risk Assessment Monitoring System (PRAMS). Kansas-specific PRAMS data have been collected by the Kansas Department of Health and Environment since 2017, in partnership with the Centers for Disease Control and Prevention. Through PRAMS, Kansas residents who have recently given birth in Kansas to a live infant are asked about their health and experiences before, during, and in the months following pregnancy.

 

From 2017 to 2021, no statistically significant change was observed in the prevalence of postpartum depressive symptoms, despite an increasing trend.

 

Prevalence of Self-Reported Postpartum Depressive Symptoms Among Kansas Residents with a Recent Live Birth, 2017-2021

The Annual Percent Change (APC) was not found to be significantly different from zero at the alpha = 0.05 level.

Source: Kansas Department of Health and Environment, Kansas Pregnancy Risk Assessment Monitoring System (PRAMS), 2017-2021

 

Among Kansas residents with a recent live birth in 2021, whose deliveries were indicated on the birth certificate as being paid for by Medicaid, 26.6% were indicated as having postpartum depressive symptoms. This was significantly higher than among those with a non-Medicaid payment source for the delivery (10.4%).

 

Some Kansas residents with a recent live birth in 2020-2021 (two years combined) had a significantly higher prevalence of postpartum depressive symptoms, including:

• Those who were under 20 years old* (30.7%*) or 20-24 years old (20.6%), compared to those who were 25-34 years old (12.7%) or 35 years old or older (8.9%)
• Those whose highest level of education was a high school diploma/GED (20.9%), compared to those with at least some college education (12.0%)
• Those who had received WIC food during pregnancy (21.2%), compared to those who were not WIC recipients during pregnancy (12.7%)
• Those who lived in rural counties (17.7%), compared to those living in urban counties (13.2%)
• Those whose deliveries had been indicated as being paid for by Medicaid (22.7%), compared to those whose deliveries had been indicated as having a non-Medicaid payment source (11.4%)
• Those who had not gone for a postpartum checkup for themselves since the birth (22.8%), compared to those who had (13.8%)

 

There was not enough evidence to show that the prevalence of self-reported postpartum depressive symptoms differed significantly between racial and ethnic groups.

Prevalence of Self-Reported Postpartum Depressive Symptoms, by Selected Characteristics, Among Kansas Residents with a Recent Live Birth, 2020-2021

* Note: Indicator has a confidence interval width >20% points or >1.2 times the estimate or a Relative Standard Error > 30% or a denominator < 60 respondents and should be interpreted with caution.

† As indicated on the infant’s birth certificate.

Two hyphens (i.e., --) indicate suppressed data due to insufficient sample size (numerator < 6 or denominator < 30) or Relative Standard Error > 50%.

Source: Kansas Department of Health and Environment, Kansas Pregnancy Risk Assessment Monitoring System (PRAMS), 2020-2021

 

Local MCH Reach: Based on SFY2023 MCH Aid-to-Local applications received: 54 of 61 grantees selected to work on Women/Maternal Health objectives. Some of the grantees who reached their goals are highlighted in this report. Those who didn’t reach their goals, cited the following barriers:

• Lack of community partners’ willingness to participate in the IRIS referral system which would allow for better tracking of referral completion and follow up.
• Vacant social worker positions
• Clients reported barriers to care for Perinatal Mood and Anxiety Disorders (PMADs) included not feeling connected to therapy and hesitancy to see a new provider, not being able to get in to see the medication provider at the local mental health facility, availability of coverage after losing the medical card and persistent stigma around accessing treatment for PMADs, particularly among Hispanic clients.

 

Well-Woman Visit Initiatives

Objective 1.1: Increase the proportion of women program participants receiving a high-quality, comprehensive preventive medical visit.

 

Well-Woman Visit Integration Toolkits: This toolkit supplement was developed by the Kansas Department of Health and Environment (KDHE) for communities to utilize as a guide to expand access and care for women across the lifespan through the well-woman visit. It is important to acknowledge that a single provider alone cannot address all medical and social care needs of individuals, yet a substantial percentage of women consider their OB/GYN to be their primary care provider. Through the utilization of toolkits, providers can find evidence-based best practices, resources, and guides to maximizing preconception visits. This is a critical opportunity to receive recommended clinical preventive services, including screening, counseling, and immunizations, which can lead to appropriate identification, treatment, and prevention of disease to optimize the health of women before, between, and beyond potential pregnancies. During the report period, 1,382 women ages 13-44 received a well visit from an MCH grantee. 

 

Integration Toolkits Website Redesign: Title V Consultants intended to work with KDHE Communications staff to redesign and expand the content and format of the MCH Integration Toolkits website to make resources more accessible to partners. The project goal was to add search options by domain and topic, as well as type of resource (e.g., toolkit, awareness materials, trainings, etc.). This project was to occur as a “phase 2” of the overall KDHE website redesign work. When the redesigned KDHE website launched in January 2022, a significant number of resources included on the old site were lost or moved to different pages. Opposed to forging ahead with phase 2, Consultants shifted to identifying lost pages, resources, information, etc., while ensuring information was correctly labeled and included in the right section of the website. Efforts then transitioned to updating all materials to include the new URLs, as all URLs changed when the new site launched. Consultants continued development work on new MCH Toolkits but have not yet initiated the toolkit webpage redesign project.

 

Medicaid Policy Improvements: Significant progress has been made in improvements to Kansas Medicaid, KanCare, and maternal and child health policies. Information on the improvements can be found below.

 

KanCare Postpartum Medicaid Extension: In collaboration between Title V and Kansas Medicaid, an impact paper was drafted in support of a KanCare Postpartum Medicaid Extension policy, expanding coverage from 60-days to 12-months post-delivery. The recommendation was included in the Governor’s SFY2023 budget.

 

Simultaneously, there was a 2021 Special Legislative Committee on Kansas Mental Health Modernization and Reform convening, which included representation from Title V and Kansas Medicaid, to address systemic mental health and substance use concerns. A KanCare Postpartum Medicaid Extension recommendation was put forth outlining the prevalence of maternal mental health conditions, adverse impacts of perinatal mood and anxiety disorders on positive child development, and barriers to accessing treatment for maternal mental health concerns. While the Special Committee supported the recommendation, they believed the optimal approach for impact was through a Medicaid Postpartum Care Extension policy change, which fell under the purview of the Bob Bethell Joint Committee on Home and Community Based Services and KanCare (Kansas Medicaid) Oversight.

 

Within the same timeframe, Kansas’ Perinatal Psychiatric Access Program, Kansas Connecting Communities (KCC), a HRSA-funded Maternal Depression and Related Behavioral Disorders (MDRBD) program, presented a program and maternal mental health overview to the Bob Bethell Joint Committee. Following the December 13-14, 2021 two-day Bob Bethell Joint Committee meeting, the Committee issued a recommendation to expand postpartum coverage to 12-months for new mothers enrolled in KanCare. Without objection, the recommendation was approved.

 

The recommendations and Governor’s budget were approved by the 2022 Kansas Legislature and Senate Bill 267 was signed into law May 2022, extending the state’s Medicaid postpartum care coverage from 60-days to 12-months post-delivery. The Medicaid State Plan Amendment was approved and was retroactively applied with a coverage effective date of April 1, 2022. Title V and Kansas Medicaid continue working together to assure the expansion coverage includes all crucial care and services during the 12-months postpartum timeframe.

 

Maternal Depression Screening: The KanCare Maternal Depression Screening (MDS) policy became effective January 1, 2021 to reimburse for up to three screenings during the prenatal period under the mother’s Medicaid ID and for up to five screenings during the 12-months postpartum period under the child’s Medicaid ID. The policy was updated thereafter allowing reimbursement to occur when non-licensed professionals, like home visitors and community health workers, administer screenings under the supervision of a licensed professional. With the KanCare Postpartum Medicaid Extension, the MDS policy was reviewed, and the limitations on number of screenings was lifted effective July 2022. Title V updated the MDS Medicaid Billing and Policy Guidance, as well as the MDS Medicaid Billing and Policy Guidance for Part C Programs, as part of the Perinatal Mental Health Toolkit. The guides are intended for healthcare providers treating perinatal women and for pediatric providers who administer MDS during the postpartum period. It outlines allowable screening tools, approved provider types, approved places of service, the procedure codes, and documentation requirements for MDS service reimbursement, as well as training opportunities and case consultation support available to providers through the KCC program.

 

Through the KCC program, several handouts were created to promote and increase awareness on the importance of universal screening practices, the KanCare MDS policy, and availability of psychiatric case consultations made available through the program’s toll-free provider consultation line.

 

 

Maternal Depression Screening Billing Quality Improvement: In partnership with KDHE Division of Health Care Finance (Kansas Medicaid), Title V completed an analysis of MDS claims submitted in the first year of the policy change. In summary, 8,845 claims were submitted by 64 providers/clinics and were associated with 4,399 Kansas Medicaid beneficiaries ID, indicating that perinatal individuals were screened twice on average in 2021. Further, the 8,845 claims were submitted by 64 providers/clinics, and about 86% of claims were MDS services were provided by pediatricians.

 

 

An analysis of approved and denied claims by procedure code (96160 and 96161) revealed that 25.5% of claims coded as 96161 (caregiver assessment billed under the Child’s Medicaid ID) were denied. A review of approved and denied claims was also analyzed based the Managed Care Organization (MCO) payor.

 

 

Based on finding, the Behavioral Health Consultant notified UnitedHealth Care of Kansas (UHC) than an aggregated summary of MDS utilization revealed that over 40% of UHC’s claims were denied in 2021. This was significant as only 8-10% of the other MCO’s claims were denied. Further, the summary indicated that 42.9% of claims submitted to UHC coded as 96161 were denied. UHC completed an internal review of the denied claims and found two opportunities for quality improvement: 1) there was a configuration error in how their system was built resulting in 15 claims being incorrectly denied; these claims were corrected and reprocessed; and, 2) one provider continually used the wrong modifier when submitting their claims resulting in 580 claims being denied; UHC reached out to this provider, shared the MDS Billing and Coding Guidance, and offered education on how to correctly code MDS. UHC suggested the provider resubmit the claims for payment processing. UHC continues to promote the guidance document across their provider network. The Behavioral Health Consultant will continue partnering with Kansas Medicaid to complete an annual analysis of MDS claims and identify additional quality improvement opportunities.

 

Behavioral Health Integration: Identifying needs is a critical first step to connecting individuals and families with appropriate services. Universal screening is the optimal approach to identifying individuals who are experiencing, or at risk of experiencing, a behavioral health condition. In support of best practice recommendations, Title V strives to assure women are screened for anxiety, depression, and substance use annually, as part of the comprehensive well-woman visit.

 

Effective July 2022, Title V added three evidence-based behavioral health pre-screening questions into the DAISEY KDHE Program Visit Form ensuring that all individuals served by Kansas MCH ATL programs are screened for anxiety, depression and substance use. The Visit Form is completed at every ATL program (e.g., Title V, Pregnancy Maintenance Initiative, Teen Pregnancy Targeted Case Management, Title X) service visit. Title V updated the Behavioral Health Screening Guidance for Kansas MCH Programs to reflect the changes as a resource for ATL providers.

 

The Guidance includes an overview of the DAISEY form changes, outlining suggested protocols for positive responses to the pre-screening questions. All protocols include a recommendation to administer a full screen that is validated for the population group and health risk topic. For example, a woman responds to the Generalized Anxiety Disorder - 2 (GAD-2) prescreening questions as part of her well-woman visit. Following the protocol, the provider would administer the GAD-7 to help determine if further support, intervention, or treatment might be needed. Several behavioral health full screening tools were integrated into DAISEY in July 2021. As part of this integration, a Plan of Action form is populated in DAISEY for moderate or high-risk screening results. This form allows for local MCH staff to document that a brief intervention was conducted, the type of brief intervention provided, indicate referral(s) made, and summarize any emergency or support services initiated for a client experiencing a crisis.

 

The Guidance also includes a 1-page overview of each of the screening tools available in DAISEY, scripts for introducing the tool to a client, tips for administering the screening, details on scoring the screen, information on determining risk-level and appropriate interventions. With the 2022 updates, the Guidance resource was expanded to include universal screening framework, behavioral health screening workflow, virtual screening considerations, and crisis information. The Behavioral Health Consultant also provides technical assistance to ATL programs to help improve internal program workflows and referral processes, as needed.

 

Local MCH Agencies:

• Barton County Health Department recorded 155 instances of one-on-one client education on the importance of well woman visits. They provided education in conjunction with exit counseling for postpartum WIC clients and during MCH home visits. Clients were referred internally to the Family Planning Program and provided a list of providers in the community that provide well woman exams. Well-woman education was provided to attendees of the Women's Expo during an outreach event.
• Community Health Center of Southeast Kansas (CHC-SEK) increased the percent of women in their clinics with a well woman exam completed in the past year. In 2020, 77% of eligible MCH clients had a well woman exam. In 2022, it increased to 81%. Their staff worked closely with all MCOs to utilize the incentive programs to maximize services available to the target population. MCH case managers incorporated completion of a well woman exam in each participant's individual goals, assisted in scheduling the appointments and provided transportation services when needed. County health departments and private practitioners referred their clients to CHC-SEK for well woman services.
• Johnson County Department of Health and Environment used incentives and their established model of care to encourage prenatal patients to return for their postpartum visit. These visits resulted in 63 postpartum well woman exams through MCH and 290 well woman exams through the Title X clinic for those who were eligible.
• Kearny County Hospital recorded 63 well woman visits and 100 instances of well woman education for the reporting period. They saw the number of visits increase as the spread of COVID-19 decreased in the community. During this time, their Women’s Health APRN retired but the other providers were able to take on the well woman visits until a new provider was hired.
• Riley County Health Department educated 100% of clients on the importance of having an annual well visit. 95% of those clients reported having a well woman visit in the last 12 months. All well woman referrals made to the physician/OBGYN were sent via fax. All MCH staff referred women to their primary care physician/OBGYN or internally to Title X Family Planning for birth control. Challenges for Riley County included serving a diverse, transient population from Fort Riley and Kansas State University, and MCH clients choosing natural family planning over more reliable birth control options.
• Saline County Health Department updated their Newborn and Maternal Assessment Form to include specific assessment/documentation regarding well women examinations. Mothers who received a MCH home visit were assessed regarding their compliance with a well woman exam within the 12 months prior to the MCH visit. Depending upon if mother indicated yes or no, an additional assessment was provided to include the last date of the well woman exam and if mom experienced any barriers to scheduling/attending the exam. There were 112 mothers assessed during the reporting period for their well woman exam compliance.

 

Perinatal Mood and Anxiety Disorder Initiatives

Objective 1.2: Increase the proportion of women receiving education or screening about perinatal mood and anxiety disorders (PMADs) during pregnancy and the postpartum period.

 

Kansas Connecting Communities (KCC): Kansas’ Perinatal Psychiatric Access Program, KCC, a HRSA-funded Maternal Depression and Related Behavioral Disorders (MDRBD) program (awarded in October 2018) is managed by the Behavioral Health Consultant. KCC strives to increase health care providers’ capacity to screen, assess, treat, and refer pregnant and postpartum individuals for depression, anxiety, and substance use disorders. In October 2020, KCC expanded from a regional implementation approach and launched statewide. KCC services include resource and referral support, psychiatric consultations, and training/technical assistance for any perinatal provider in Kansas.

 

To bring awareness and utilization of KCC capacity-building trainings, a Perinatal Behavioral Health Survey was developed with goals to pilot with KPCCs, Pregnancy Maintenance Initiative, Teen Pregnancy Targeted Case Management, and MCH ATL grantees. The survey was designed to support the KCC team in tailoring resources to meet program needs. The survey was conducted across these programs in a phased approach, beginning with the KPCC sites in May 2021 to support the implementation of a KCC/KPCC training plan focusing on implementing perinatal substance use screening and interventions and implementation/availability of perinatal peer support groups. See the “Peer & Social Networks” subsection within this report for more information about the perinatal peer support group component of the established KCC/KPCC training plan.

 

A 3-session Perinatal Substance Use Screening Implementation Training Series and Learning Collaborative was offered virtually to KPCC sites in November and December 2021. The first session focused on utilizing and administering the ASSIST substance use screening tool. The second session focused on developing and/or adapting a universal perinatal behavioral health screening policy, and the third session was on motivational interviewing and other behavioral health intervention skills.

 

The training series was held in preparation of the NIDA Quick Screen, a substance use pre-screening tool, being integrated into the Becoming a Mom (BaM) participant initial survey effective January 2022 to ensure all BaM prenatal education programs, a vital component of the KPCC model, were universally screening pregnant women for risk of substance use. The Behavioral Health Consultant presented an overview of perinatal substance use, examples of screening workflows, and response protocols for positive screening results as part of the January 2021 KPCC Quarterly Meeting. BaM programs continue to conduct screening and will provide feedback on effectiveness of including the pre-screen on the BaM Initial Survey Form during the KPCC/BaM Conference in November 2022. Based on provider feedback, changes would become effective in January 2023.

 

For more information about perinatal behavioral health training opportunities made available through KCC, see the Perinatal/Infant and Cross Cutting Reports.

 

Maternal Mental Health Treatment Pilot Project: To further increase the identification of postpartum women experiencing PMADs and improve access to mental health treatment (counseling/therapy), Title V partnered with Russell Child Development Center (RCDC) on a Maternal Mental Health Treatment Pilot Project. RCDC provides a number of early childhood programs and services in 19 rural/frontier counties in Southwest Kansas including Part C, Kansas Early Childhood Developmental Services program, in 13 of the 19 counties. All 19 counties are designated Mental Health Provider Shortage Areas, and timely access to quality perinatal mental health treatment is limited. The aim of the pilot is to increase the availability, accessibility, and affordability of evidence-based maternal mental health treatment services by:

• Increasing timely detection, assessment, and treatment of PMADs in postpartum women using evidence-based practices;
• Increasing RCDC staff capacity to provide maternal mental health specialty treatment services to caregivers of children participating in RCDC services; and
• Supporting infrastructure development and create a replicable and sustainable model for addressing maternal mental health conditions through early childhood systems.

 

The pilot allows infants and their caregivers to receive therapeutic services from one

organization. While reducing barriers in accessing care, the pilot also increases local capacity by expanding the mental health professional network and subject-matter expertise in a mental health professional shortage area. RCDC has employed two licensed master’s social workers (LMSW) currently pursuing their clinical licenses who receives referrals for treatment from other RCDC program staff. Both professionals are bi-lingual and provide therapy services in English and Spanish. Maternal mental health therapy services are made available in-person and by telehealth and in collaboration with the individuals’ healthcare providers to coordinate comprehensive care for the caregiver and the family. These services can also be provided in a home visit.

 

From the launch of the pilot through this reporting period (May 1, 2021 – September 30, 2022), 48 referrals have been received by project staff. Of these, therapy services were initiated with 30 individuals. Reasons for the 18 individuals who were referred but did not participate in therapy services through the project include: therapy not indicated upon further assessment, already participating in services with another clinician, not interested in therapy at this time, and lost to follow-up. Project staff have completed about 200 therapy sessions; on average, participating individuals receive about six or seven therapy sessions.

 

Title V continues to offer resources, instruction and technical assistance to RCDC, including coordination with Kansas Medicaid, to ensure services will be sustained beyond the pilot project period and can be replicated by other early childhood development centers.

 

Peer & Social Networks: Title V continues to support pregnant individuals and new parents through the KPCC model, which allows parents to connect with one another during this important time and share lived experiences in an authentic and supportive environment. Plans to extend the program past birth are underway, which will provide an opportunity for parents to share birth stories as well as postpartum struggles – reinforcing a network that can reduce isolation and promote healing and resilience. For women not participating in BaM, Title V staff will vet and promote secure and safe peer support options through social media, training and marketing including those offered through Postpartum Support International (PSI) and within Kansas Support Groups.

 

As previously mentioned, a KCC/KPCC training plan was created based on provider responses to the Perinatal Behavioral Health Survey administered with KPCC sites in May 2021. A topic of interest was implementation/availability of perinatal peer support groups. As such, KCC supported the development and maintenance of perinatal peer support groups by offering a Kansas Moms in Mind: Perinatal Peer Support (KMIM: PPS) Project to community programs servicing pregnant and postpartum parents. Two ATL grantees, Delivering Change and Saline County Health Department, participated in KMIM: PPS, which convened from September 2021 through June 2022. They received technical assistance from Wichita State University’s Community Engagement Institute (WSU-CEI), a key KCC partner, to help establish a support group within their community, using the previously developed Perinatal Support Group Guidebook as a reference and implementation resource. The Guidebook includes information on recruitment and promotion, establishing a support group agreement, group structure and environment, choosing a group’s location (e.g., in-person and virtual meeting place considerations), facilitator roles and responsibilities, how to keep a support group going, and supporting group members who are experiencing a crisis.

 

Participant spotlight: [Client] struggled during her pregnancy and postpartum periods. She stopped meeting with her Navigator. When the support group was getting ready to start, the Navigator reached out to all current and previous clients and shared information about the group. [Client] accepted the invitation to join, came to the first meeting, and enjoyed being there!

 

As part of the project, staff from WSU-CEI, Saline County Health Department, and an individual with lived experience presented a “Perinatal Peer Support and Guidelines” session during the 2022 Governor’s Public Health Conference, as well as a session at the annual KU School of Medicine-Wichita Center for Research for Infant Birth and Survival (CRIBS) Symposium. The sessions focused on the role and impact of peer support and shared lived experience within the continuum of care, as well as provided attendees with information and resources, such as the Guidebook, to begin the process of developing or improving peer support and systems within their own communities.

 

Through the KCC program, two handouts were created to promote use of the Guidebook and impact of peer support for pregnant and parenting individuals.

 

 

 

Local MCH Agencies:

• Barton County Health Department recorded 151 PMAD services and 308 maternal depression screenings. They used the Edinburgh Postnatal Depression Scale (EPDS) at every visit from pregnancy through one year postpartum.
• Community Health Center of Southeast Kansas (CHC-SEK) screened 100% of postpartum clients for depression. Clients were assessed for postpartum depression at their six-week follow up visit and at each Well Child Check until the child turned one year old. CHC-SEK has embedded mental health professionals within its medical clinics in Crawford, Cherokee, Bourbon and Labette counties. Education on the signs of postpartum depression and what to do if experiencing them was provided to clients and check-in calls were made every quarter during baby’s first year.
• Delivering Change exceeded their goal to increase use of the EPDS. 306 EPDS were completed in this reporting period compared to 229 completed in SFY 2020. Additionally, Maternal Depression Screening services were provided 535 times and PMADs/Postpartum Depression education was provided 389 times. Delivering Change is in Geary County which has a higher teen birth rate compared to the state of Kansas rate.
• Hamilton County Health Department used the EPDS to screen for postpartum depression. They reported using the EPDS for every MCH visit done, including prenatal visits to provide a baseline for the client. They shared that the EPDS was simple to use and easy to administer with their clients. Having it available in Spanish was vital for their client population. It is not too lengthy, and mothers feel comfortable completing it. They also provided education on PMADs 26 times.
• Johnson County Department of Health and Environment completed 1,905 maternal depression screenings as recorded in DAISEY. APRNs called clients two weeks post-delivery and completed the PHQ-9 over the telephone. At the in-person 6 weeks postpartum appointment, the clients were given a PHQ-9 again and referrals were made if indicated. Social work staff consulted with all postpartum clients after the RN/APRN visit. Social work contacted clients at approximately 7 weeks postpartum if the client had not presented for postpartum follow-up. A mood screening was performed during those calls and referrals made, if indicated.
• Lawrence-Douglas County Health Department exceeded their goal to increase completion rate of depression screening to 75%. They continued to use the EPDS during the third trimester of pregnancy, six weeks postpartum, and again six months postpartum to screen for maternal depression. They moved from using the PHQ-2 to the PHQ-9 which is completed with the mother one year postpartum and then annually. 87% of mothers enrolled were screened for depression. Due to high-risk depression screen results, seven referrals to therapy services were made during this time. Of those seven, six clients have successfully connected to services and began treatment.
• Riley County Health Department screened 100% of MCH and/or BaM clients for PMADs with the EPDS. A total of 231 maternal depression screenings were administered. 100% of MCH clients scoring a 10 or higher or who answered "yes" to question 10 were referred same day to their PCP/OBGYN. Riley County Health Department partnered with Kansas State University Family Center in June to place student therapists at the health department to provide low or no-cost PMAD therapy services which were an identified need in the community.
• University of Kansas Medical Center-Wichita/Baby Talk enrolled 281 participants in their BaM course. 258 (92%) completed the EPDS prenatally. 148 (94%) completed the EPDS postnatally. 72 of 281 (26%) screened positive prenatally and 33 of 148 (22%) screened positive postnatally. All participants who screened positive were offered a referral. During the reporting period, the Baby Talk Team refined its referral process for participants that screened positive (score of 10+ or indication of self-harm). In January 2022, the Baby Talk Team received the Maternal Mental Health 101 training which highlighted the resources readily available to the team during follow-up. Additionally, a Baby Talk Team member attended further training regarding perinatal mental health amid the COIVD-19 pandemic to better assist participants with a positive screen.
• Catholic Charities of Northern Kansas had 69% of their PMI clients complete the EPDS. The goal was for case managers to complete the EPDS with the client during at least one postpartum visit.

Local Reports from the Pregnancy Maintenance Initiative (PMI) Program:

• GraceMed, during SFY2022, 100% of the new and existing PMI participants had access to prenatal care. Participants were provided education in their preferred language and information regarding their prenatal care, any specialty care or testing recommended by the women’s health provider, parenting skills, SIDS prevention and safe sleep practices, prenatal, perinatal and postpartum behavioral health risk, resources, substance abuse treatment options if applicable, smoking cessation and other needs identified on their intake and assessment form. These education sources were provided through books, printouts, verbal teachings, and referrals to community partners. In addition, 100% of participants were screened for insurance if they needed coverage.
• University of Kansas School of Medicine, during SFY2022, 98% of participants reported receiving prenatal care that met the level of adequate or adequate plus. In addition, the Family Support Advocates encouraged participants to complete the tobacco screening immediately following the enrollment and assessment intake, along with continued education throughout the duration of the PMI program. Participants who indicated tobacco or substance use received an immediate referral for support; all participants were referred to the KS Quitline.

 

Prenatal Education and Support Services Initiatives

Objective 1.3: Increase the proportion of high-risk pregnant women receiving prenatal education and support services through perinatal community collaboratives.

 

Kansas Perinatal Community Collaboratives / Becoming a Mom: With proven success, Kansas MCH remains committed to supporting the expansion and sustainability of the KPCC initiative, providing training and technical assistance on community collaborative development and MCH program integration targeted at reaching a greater disparity population, and integrating additional services and support mechanisms for populations at greatest risk. KDHE’s Title V commitment to this model is greater than just increasing the number of KPCCs across the state, or programs who implement the BaM program. Rather it is our desire to support the model by strengthening the perinatal collaborations within the local communities, as well as growing the programs and initiatives they implement in response to their local data identifying areas of needed focus. Much work was done throughout this reporting period to help reinvigorate collaborative efforts that suffered greatly during the pandemic. Fallout from the pandemic not only left local coalitions/collaboratives struggling to reengage partners, it left many programs unstaffed and in mere survival mode. The P/I Consultant work shifted focus from plans of expansion to plans for rebuilding, stabilizing and rallying existing programs. This work included a month-long tour across the state visiting twenty-two local programs during August 2022. These visits were warmly welcomed by locals, and deemed a tremendous success, with passion and energy for the work reignited on both sides (KDHE and local). Common themes, key take-aways and actionable items were compiled following the visits and shared with our Children and Families Section. Input gleaned during these visits also helped to shape the focus of presentations already being planned for the November 2022 in-person BaM/KPCC Conference. Conference planning included one day of content focused on BaM program updates and expansions, with the second day focused on KPCC model strengthening and expansion. To view a map of existing sites and implementation progress, visit the KPCC Participating Communities webpage.

 

Data from the 2020-2021 BaM Aggregate State Report highlights the program’s reach of disparity populations (see BaM Infographic), which is a target of Kansas Title V services. According to the report, mothers receiving education through the BaM prenatal education program were more likely than other mothers giving birth in the state to be racial/ethnic minorities; younger; lower education level; enrolled in WIC; and covered by non-private insurance. The education sessions and associated activities are aimed at improving pregnancy health and infant health outcomes for all Kansas mothers but are particularly targeted at disparity populations. Interestingly, with implementation of virtual sessions during the pandemic, the number of higher educated and privately insured participants has grown drastically, shifting the demographics of the population served.

 

Since inception in 2010, KPCCs have been a driving force behind improving birth outcomes in Kansas. In two of the longest running sites, infant mortality has decreased from pre-implementation to post-implementation. The Geary County infant mortality rate has decreased significantly from 11.9 infant deaths per 1,000 live births in 2005-2009, to 5.7 in 2017-2021. The Saline County infant mortality rate has decreased from 9.0 infant deaths per 1,000 live births in 2005-2009, to 5.9 in 2017-2021.

 

 

KPCC/BaM Websites: Resources for regional and statewide implementation of KPCCs have been under development over the past several years to ensure both growth and sustainability of the initiative. The KPCC website serves as an access point to introductory information about the initiative. Updates to the site were made during this reporting period, however the full website redesign and expansion is still under development. KPCC and BaM infographics, accessed from the KPCC website, were developed to aid communication and recruitment for new communities and are updated annually.

 

New training and implementation resources were added to the existing KPCC partner-only website during FFY2022. Upon release of the 2021 updated BaM curriculum by March of Dimes (MOD) in Spring of 2022, all curriculum handouts were reviewed, and updates were made to Kansas supplemental handouts, including updated MOD, Maternal Warning Signs (MWS) and COVID-19 handouts. These handouts were posted to the website in July 2022 and work has been underway since then to coordinate mass printing of the updated curriculum for all Kansas program sites. Work has also been in progress to fully align English and Spanish curriculum resources to assure equivalent supplemental resources are available in Spanish. Session PowerPoints, lesson plans and activity plans were updated in June and July 2022 and will be posted to the website for implementation January 1, 2023, following addition of content and resources requested by local sites during the Aug. 2022 site visits.

 

While virtual prenatal education became a necessary option during the COVID-19 pandemic, evaluation efforts and anecdotal evidence has supported its continuation as a mainstay option in most communities. While resources and guidance documents for virtual implementation, including online data collection and guidance for virtual screening for PMADs, were developed and disseminated during 2021, resources continue to be built upon to this current date. This infrastructure component is continuing to be improved, supported and grown, to reach populations where programming and services are not currently available locally.

 

Pregnancy Intention Screening

Objective 1.4: Increase the proportion of women receiving pregnancy intention screening as part of preconception and interconception services.

 

Reproductive Life Plan (RLP) Workbook: The RLP workbook was developed through a partnership between KDHE, Cradle Kansas City, Vibrant Health, The Unified Government of Wyandotte County Public Health Department, and March of Dimes. Review, feedback and editing was provided by the Cradle Kansas City Community Action Board. The workbook was piloted and tested by community members in Wyandotte County and adjusted by KDHE for wide-spread state use.  

 

Cultural considerations for preconception health education have had an impact on provider comfortability with preconception resource education and reporting. Work emphasizing toolkits from the Reproductive Health National Training Center will be central to upcoming work in the Woman/Maternal domain.

 

Long-Acting Reversible Contraceptives (LARC): The LARC Toolkit was created through the work of many state and local partners with a shared interest in providing LARC services to women. The toolkit is intended to be utilized by Kansas Title V MCH programs, Kansas Title X Family Planning programs, and local partnering providers to collaboratively develop an adequate system of care. Information in the toolkit is based on sound research and recommendations from The American College of Obstetricians and Gynecologists.

 

Systemic barriers to accessing preconception healthcare during this year have been considered. These barriers mirror barriers to that of well woman visits and include; costs associated with devices due to pandemic related supply chain issues, provider availability, lack of access to quality childcare, pandemic related restrictions to the number of appointment attendees, no consistent state-wide, nation-wide, or employer policy paid-time-off available to attend medical appointments, as well as cultural impacts of well-woman care in Kansas.

 

Despite coverage of preventative services under the Affordable Care Act through 2021, Kansas had an uninsured rate higher than national average. KS Medicaid Medical Director, hired in 2022, continues to support and provide education around immediate post-birth LARC insertion. A State Plan Amendment to reimburse Medicaid providers for the cost of the LARC devices (including in acute settings) was requested by Medicaid and anticipated decision coming in January of 2023.

 

Other Women/Maternal Initiatives

 

Count the Kicks® (CTK) Stillbirth Prevention Initiative: Title V began the fourth year of formal partnership with Healthy Birth Day to continue the Count the Kicks (CTK) campaign to prevent stillbirth through provider and patient education around monitoring fetal movements during the 3rd trimester of pregnancy. The CTK campaign is provided across the state at no cost to maternal care providers who have full access to videos and educational materials, including posters, brochures, and magnets in English and Spanish). In FY22, CTK Toolkits containing low literacy (picture) materials and Kick Counting wristbands for individuals who may not have internet/data to access the Count the Kicks App were distributed to home visitors, WIC offices, and maternal care providers across the state. A KS-specific version of the CTK app with four follow-up questions that connect mothers directly with resources in Kansas (1-800-CHILDREN) based on expressed needs and concerns was launched in January 2022.

 

MAVIS (Maternal Anti-Violence Innovation and Sharing) Project: KDHE was selected by the U.S. Department of Health and Human Services (HHS) Office on Women’s Health to receive funding as part of the State, Local, Territorial, and Tribal Partnership Programs to Reduce Maternal Deaths due to Violence. KDHE, in partnership with Kansas Perinatal Quality Collaborative (KPQC), enrolled in the Alliance for Innovation on Maternal Health (AIM) October 2021 cohort. The Kansas maternal mortality rate of 20.9 (2017-2021) is 33.1% higher than the Healthy People 2030 goal of 15.7 maternal deaths per 100,0000 live births. These initiatives help to address the urgent matter of maternal mortality in Kansas. This cooperative agreement between KDHE and HHS functions to expand the Maternal Mortality Review Committee, into a sub-committee further examining all maternal deaths due to suicide, homicide, poisoning, or overdose. Social determinants of health considerations are reviewed by a select panel to examine a range of potential circumstances and provide recommendations to address factors contributing to preventable maternal deaths.

 

MAVIS work focuses on creating collaborative relationships and cross-training educational opportunities between the Kansas Coalition of Sexual and Domestic Violence (KCSDV) and perinatal psychiatric providers through the Kansas chapter of Postpartum Support International (PSI). KCSDV leads the charge on training providers in universal education on domestic violence through the Confidentiality, Universal Education and empowerment, and Support (CUES) intervention, and the KCC Grant Team provides education and training in PMADs to KCSDV affiliated agencies. To date, 14 IPV providers across 7 different organizations have been provided a three-session specialized training on the identification and treatment of PMADs. KCSDV facilitated one of the scheduled learning collaboratives through the MCH Third Thursday Webinar Series on offering universal education and the CUES intervention, which was attended by 74 participants and received overwhelmingly positive feedback. The organizations trained in 2021 have represented rural and frontier populations of Eastern and Western regions. Future trainings will be provided for Central Regions, Wichita, Kansas City, Lawrence, and Tribal Programs.