Well Woman Care - Annual Report

In the domain of Maternal/Women’s Health, we focused on increasing the number of women who have a preventive visit to optimize the health of women before, between and beyond pregnancies. As in the past, our key priority is to find ways to reduce the infant mortality rate in Delaware and we understand the importance of quality prenatal care for our mothers. In order to continue making progress in providing “whole health” care to our women and mothers, we continued to bolster and nurture our community partnerships by working together, leveraging talents and resources, and striving to find new ways to provide services.

Over the last year, we continue to monitor the Delaware Healthy Mothers and Infants Consortium’s (DHMIC) strategic plan which covers a 3-5 year timeframe.  The MCH Director was involved in the strategic planning process, as well as several other MCH stakeholders that were involved in the Title V MCH Needs Assessment process and selection of priorities, which helped with alignment of goals and strategies.  Beginning in the 1990s, Delaware’s infant mortality rate was increasing while the national trend was decreasing. Prompted by a list of 20 recommendations, developed by an Infant Mortality Task Force in 2005, the plan called for the creation of the Delaware Healthy Mother & Infant Consortium (DHMIC), a Governor appointed body, to help ensure that the recommendations were put into effect. The DHMIC is structured into five subcommittees to monitor implementation of the Infant Mortality Task Force recommendations for the following critical areas: data and science, education and prevention, health equity, standards of care, and systems of care.  Staff in the Division of Public Health’s Family Health Systems Section largely provide staff support to the committees and help carry out and execute strategies to support the DHMIC’s strategic plan. 

Education and prevention is a cornerstone of the DHMIC work, utilizing the latest social media platforms. In partnership with a social marketing firm, Worldways, the Division of Public Health and several Maternal and Child Health partners we continued to develop update and launch messaging through the use of social media, whereby we continue to post messages via blogs, Twitter, Facebook, and YouTube, in which all MCH programs and initiatives participate. The branding tagline, Delaware Thrives, evolves around the theme that “Health Begins Where You Live, Learn, Work & Play”. This year we continued to focus on updating existing content and adding new content on the website (www.DEThrives.com ) that is easy to grow, easy to maintain, and easy to navigate, and one that is search relevant. A small core workgroup continues to meet to look at the content and develop messaging for blogs, tweets and posts on preconception health topics for men and women.

We had another incredible line up of speakers this year at the 2019 Annual DHMIC Maternal and Child Health Summit, held in April.  The Delaware Healthy Mothers and Infants Consortium (DHMIC) and the Department of Health and Social Services (DHSS), Division of Public Health (DPH) organize this event. This was the 14th DHMIC summit.  The summit brings together leaders in the area of family health to discuss new approaches to enhance the health of women, children and families of all ages. The theme this year was “Raising Our Voices, Strengthening our Communities: Advocating for Healthy Women, Men, Babies, and Families”.

Guest national speakers included:

• Daniel J. Frayne, MD, Family Medicine Doctor for Mountain Area Health Education Center Family Medicine (keynote speaker)
• Arthur R. James, MD, Obstetrician, Gynecologist, and Associate Clinical Professor for the Ohio State University Wexner Medical Center (keynote speaker)
• Kenn L. Harris, LMin, Vice President for Community Engagement and Director of the New Haven Healthy Start program at the Community Foundation for Greater New Haven in New Haven, Conn. (community voice)

The audience was comprised of primarily health care providers and community representatives interested in promoting maternal and child health, the pursuit of health equity, and the expansion of community engagement in addressing the social determinants of health. Approximately 350 people attended the summit. Lieutenant Governor Bethany Hall-Long, Department of Health and Social Services Cabinet Secretary Dr. Kara Odum-Walker, DPH Division Director, Dr. Karyl Rattay, were among the lead dignitaries that spoke and shared their support of maternal and child health work.  This year, the DHMIC Annual Summit focused multiple sessions on galvanizing the community to end health disparities for black mothers, infants and families. The Consortium has undertaken an aggressive initiative to examine the social determinants of health by taking a Life Course approach to both understanding and addressing the disparities that have led to the rise in black maternal and infant mortality in Delaware.  The summit served as a prelude to Delaware’s first “Black Maternal Health Week” (April 11–17, 2019), during which DHMIC and its partners continued to engage the community at large, health care providers, policymakers, faith-based organizations, and African American influencers in understanding the impact of race-related constructs such as perceived discrimination and structural racism on black women and their families. Together the DHMIC, with their partners, hope to develop community-informed strategies that will heighten awareness, educate, and amplify the voice of black maternal advocacy groups.

Engaged in an aggressive, ongoing initiative to significantly decrease maternal mortality and morbidity – as well as infant mortality – in Delaware’s African-American population, DHMIC devoted two sessions during its 2019 summit to this initiative. A panel discussion moderated by Dr. Kara Odom Walker, provided the foundation for a deeper conversation that enhanced keynote addresses, including topics such as preconception health care/well women care; health equity; insights from OB/GYNs and experts on barriers to accessing health care; and consumer and community advocacy.  In addition, Tiffany Chalk, governor-appointed consumer advocate of the DHMIC, shared her powerful story of loss, resilience and empowerment.  A second keynote address focused on black maternal health and community engagement efforts at the national and local level immediately following the panel discussion.  

The Delaware Healthy Mother and Infant Consortium (DHMIC) embraced the focus and framework of a preconception health approach, to optimize the health of women before, between and beyond pregnancies.

This year, Delaware is developing a Women’s Wellness initiative, Every Woman Every Time Delaware:  Reimagining the Preventive Medical Visit, which at its core seeks to strengthen the dynamic interplay between a woman and her health care provider(s) by encouraging honest and open communication about her reproductive and general health care needs.  The initiative will focus on four broad areas including 1) Pregnancy intention screening; 2) Assessment of health risk behaviors, and prevention and education tools 3) management of chronic health conditions 4) identification of social determinants of health with linkage to services.  A presentation was developed this year with plans to develop into an educational webinar for providers and MCOs and launched in the early Fall.  It will be made available on dethrives.com for ongoing provider training.

This year, planning continued and the roll out began to revisit the vision and framework of the Healthy Women Healthy Babies (HWHB) program, now in its 9th year of operations.  DPH contracts with seven health providers to deliver the HWHB services at 20 locations across the state. The Healthy Women Healthy Babies program provides preconception, nutrition, prenatal and psychosocial care for women at the highest risk of poor birth outcomes.  DPH worked tirelessly in collaboration with the DHMIC and several MCH partners to review a recent release of a comprehensive evaluation of the program and specific birth outcomes to help inform plans for improving program quality (2011-2015).  Overall, results for the program were more mixed – not as clear as the results were for African-American participants, making the case that it was time to revisit the program model to further enhance outcomes. 

There have been numerous events over the last year and a half that have helped to shape the Healthy Women Healthy Babies 2.0 program goals for the upcoming term. Five Chat-n-Chew events (i.e. focus groups) were held throughout the state with women of reproductive age to learn more about the health of women, barriers to accessing services, and knowledge and attitudes of women’s wellness before, during and in between pregnancies. The Chat-n-Chew events gathered input from consumers in an informal focus group setting and feedback was summarized in a report. Many of the themes captured in the Chat n-Chew report mirrored the themes identified in The Well Woman Project:  Listening to Women’s Voices (Handler, Arden.  Health Equity. 2018).  In October 2018, a public forum was held, Healthy Women, Healthy Babies 2.0 (HWHBs 2.0) Innovation for Impact, to learn about best practices and hear directly from community stakeholders including health care providers on priorities for the next phase of the program. 

This year, based on feedback from many stakeholders, we reframed the HWHBs 2.0 program and released a new RFP to integrate an outcomes-orientation and culture throughout the contracting process and ongoing service delivery relationship. By focusing on outcomes, the program takes an equity-driven approach that deepens funder-provider-participant mutual accountability in designing and delivering services focused on reaching a core set and minimum of 6 benchmark indicators (i.e. screening for pregnancy intention; increase women who have a well woman visit; screen for substance misuse; increase the proportion of HWHB participants that abstain from tobacco use; depression screening and referral; social determinants of health screening, etc.).   Simultaneously, a second RFP was released, Healthy Women Healthy Babies Zones to address the social determinants of health.   The primary focus is innovation and to spread evidence-based programs and place-based strategies to improve the social determinants of health and equity in maternal and infant health outcomes, as a compliment to HWHBs 2.0.  

Data collection and analysis is central to this new HWHBS 2.0 model as well as CQI and a learning collaborative approach will be incorporated for ongoing learning and improvement. This means that tracking, assessing, and improving outcomes for the HWHB program will require a deliberate CQI plan and effort by providers which emphasizes quality improvement.  Another important component to the program, providers are required to coordinate and collaborate with a Community Health Worker (CHW), Health Ambassador, Lay Health Advisor (LHA), or Promotora, defined as an individual who is indigenous to his or her community and consents to be a link between community members and the service delivery system, to further enhance outcomes for women and babies.   

To compliment the work of the Healthy Women Healthy Babies program as well as strategic initiatives of the DHMIC, Delaware leveraged funding two years ago through one of four cooperative agreements awarded by the U.S. Department of Health and Human Services’ Health Resources and Services Administration Maternal and Child Health Bureau (HRSA MCHB) to a national coalition supported by UNC Center for Maternal & Infant Health (UNC CMIH) and the National Preconception Health and Health Care Initiative (PCHHC). Funding is administered through UNC School of Social Work. DE is one of four states participating in this CoIIN grant (i.e. OK, NC, CA, DE).  This Preconception CoIIN will develop, implement, and disseminate a woman-centered, clinician-engaged, community-involved approach to the well woman visit to improve the preconception health status of women of reproductive age, particularly low-income women and women of color.

There is strong evidence that home visiting supports good maternal and women’s health outcomes. Since 2010, Delaware has competitively applied for and has been awarded the Maternal Infant Early Childhood Home Visiting Grant (MIECHV) funding through the Affordable Care Act. Funding is used to support evidence-based home visiting programs through increased enrollment and retention of families served in high risk communities. Delaware grant funds are also used to sustain and build upon the existing home visiting continuum within Delaware, which includes three programs including Healthy Families America (known programmatically as Smart Start) with a new emphasis on substance abuse populations, Nurse Family Partnership, and Parents as Teachers. This year, the Child Death Review Commission formed a small home visiting workgroup including the Delaware Division of Medicaid and Medical Assistance to explore Medicaid reimbursement for evidence based home visiting programs.  To date, we have learned that there are a variety of approaches and mechanisms for reimbursement through Medicaid. 

In Delaware, there are four different Health Ambassador programs, each striving to make a difference in the lives of Delaware’s women and their families, and also serves as a compliment to home visiting services. This past year, new contracts were negotiated for delivering Health Ambassador Services, in response to an RFP released in June 2017.  Studies have shown that the use of community health workers has been documented as a method to enhance health education and promotion with high-risk, hard- to-engage, and underserved populations. As a complementary strategy to home visitation, promotoras serve as Health Ambassadors in the largely rural and Hispanic areas of southern Delaware while cultural brokers serve as Health Ambassadors in the urban communities in the City of Wilmington. Health Ambassadors use innovative, creative and culturally sensitive strategies to engage women and families. Health Ambassadors promote health education messaging on a range of maternal and child health topics:  before, during and after pregnancy, birth spacing, reproductive life planning, as well as make a direct connection to Delaware 2-1-1 to link with a variety community based services including home visiting services as well as federally qualified health centers that can provide well women care.

For the past 30 years the Delaware wellness centers, located in 32 high schools, have contributed to the health of the state’s high school adolescents and have been an essential strategy to support women’s health. School Based Health Centers (SBHCs) provide prevention-oriented, multi-disciplinary health care to adolescents in their public school setting. A bill was passed in 2016 to stagger the implementation of the three additional SBHCs in the remaining public high schools over FY17, FY18, and FY19. SBHCs provide at-risk assessment, diagnosis and treatment of minor illness/injury, mental health counseling, nutrition/ health counseling and diagnosis and treatment of STDs, HIV testing and counseling and reproductive health services (27/32 sites) with school district approval as well as health education. Given  the level of sexual activity among high school students, persistent high rates of sexually transmitted infections (STIs) and the numbers of unintended pregnancies, reproductive health planning services are very important.

In addition, Delaware’s SBHCs provide important access to mental health services and help eliminate barriers to accessing mental health care among adolescents (i.e. women). Three different school district school board’s voted and approved to add Nexplanon as a birth control method in 2017, which were implemented this Fall/Spring and offered at the school based health center sites (for a total of 7 sites).  This is a major accomplishment being that each school district’s elected school board members vote on and approve what services can be offered at each SBHC site.

Unplanned pregnancies are expensive and cost women, families, government, and society. Extensive data show that unplanned pregnancies have been linked to increased health problems in women and their infants, lower educational attainment, higher poverty rates, and increased health care and societal costs.  And, unplanned pregnancies significantly increase Medicaid expenses. By reducing unintended pregnancy, we can reduce costs for pregnancy related services, particularly high risk pregnancies and low birth weight babies, improve overall outcomes for Delaware women and children, decrease the number of kids growing up in poverty, and even potentially reduce the number of substance exposed infants.

Launched in 2016, Delaware Contraception Access Now (DE CAN) (www.upstream.org/delawarecan/) improves access for all women to the full range of contraceptive methods, including the most effective, IUDs and implants. By implementing Upstream USA’s whole healthcare practice transformation approach, DE CAN created a long-term systems change for contraceptive access across Delaware. It includes three critical components to help break down barriers for all women accessing contraceptive care. First, it enables health centers to make reproductive care a routine part of primary care by implementing a Pregnancy Intention Screening Question (PISQ) – a variation of the question, “do you want to become pregnant in the next year?” – at every healthcare appointment. Second, if they do not want to become pregnant, DE CAN trains health centers to counsel patients on the full range of contraceptives available to them.  DE CAN enables health centers to be able to provide patients with their choice of contraception at that visit – the same day – by training administrative staff on business processes such as billing, coding and stocking devices. Third, DE CAN created consumer demand for contraception by developing consumer-marketing campaigns to educate women about their options for care.

The Division of Public Health’s team, along with Upstream, USA worked closely with Medicaid and several MCH stakeholders to ensure that there are no policy barriers to all women getting same-day access to all methods of birth control, at low or no cost. The Delaware Division of Medicaid and Medical Assistance (DMMA) revised its reimbursement policy for hospitals providing labor and delivery services, so that they can offer their patients placement of IUDs and implants immediately post-delivery if patients request them. This change in policy promotes optimal birth spacing and increases access to this birth control method. Currently the largest hospital system in the state, Christiana Health Care Systems IPP LARCs, as well as Nanticoke Health Systems and Bayhealth Medical Centers.  Beebe Medical Center is currently in training and will be implementing these services later this year. Upstream, USA and Division of Public Health continue to work with hospitals statewide on training and implementing these new processes and procedures. Furthermore, Delaware’s Division of Medicaid and Medical Assistance also implemented a reimbursement policy change approved by the Centers for Medicare and Medicaid Services (CMS) allowing the cost of long acting reversible contraception (LARC) to be carved out of the federally qualified health center (FQHC) prospective payment system (PPS) rate.

In March 2018, the Pregnancy Intention Screening Questions (PISQ) an important door opener to discuss preconception health with a woman’s health provider was implemented into the Division of Public Health’s Electronic Medical Records System. This was no small feat, especially for a state agency such as DPH, as other DE CAN providers have been struggling with enhancing their EMRs to add a PISQ in their system.  DPH Family Health Systems considers this a huge win!  This question encourages providers to ask women of childbearing age “Would you like to become pregnant in the next year?” Women who answer “yes” receive counseling and screening to ensure optimal health in preparation for a pregnancy. Women who answer “no” or “not sure” have meaningful conversations covering all options for contraception and family planning, to ensure that each woman makes an optimal decision based on her individual circumstances. The Pregnancy Intension Screening Question has the potential to reduce disparities in care and outcomes, especially for groups with higher rates of unintended pregnancy and adverse birth outcomes. 

From May 2017 through October 2018, Upstream’s Be Your Own Baby digital marketing campaign expanded access and choice by providing free birth control to thousands of women across our state.   Finally, Upstream hired a team of 17 full time staff to lead and execute the program in partnership with the state, health centers, hospitals and community organizations.  Clearly, the state was not in a position to launch a marketing campaign or hire staff dedicated to this initiative. 

The public awareness campaign “Be Your Own Baby” was launched in late May 2017 and ended October 2018. The campaign was directed by Upstream USA in partnership with a national advertising firm. Campaign messages and the choice of media channels were informed by focus groups from Delaware, North Carolina and an online survey.  Messaging focused on access to “free” birth control (no specific method was highlighted). Messages were designed to be “fun” and “empowering.” The central message formats were professionally produced music video (hosted on YouTube) (link to video will be created with archived video), online streaming music advertisements, social media posts and online advertising. The call to action for all messaging was to visit the Be Your Own webpage (beyourownbaby.org) where visitors were steered towards a nearby clinic (via a ZIP code look-up tool) that could provide free same-day contraceptive services. Three sites from a large family planning outpatient clinic enabled online scheduling through the website. Website visitors could also submit reimbursement for transportation to a clinic or for any out-of-pocket contraceptive costs. The website also provided information about different contraceptive method types and linked to Bedsider.org for more information. The media channels included paid search and website banner advertising, paid social advertising, and organic social media traffic. Platforms included Instagram, Facebook, Google Adwords, Pandora, Spotify, and YouTube. The target demographic for ad purchasing was women age 18-29 in Delaware. 

Upstream, USA will be slowly transitioning several aspects of DE CAN out of the state (i.e. State of Washington, North Carolina and Massachusetts).  As we prepare for the full, ensuring the sustainability of Upstream’s intervention is an absolute priority and one that relies heavily on state-level policies, financial resources and regulations that remain supportive of widespread access to contraception. First, the recent passing of the FY20 state budget of $1.5M in June 2019, ensures funding and resources to ensure a system is in place for uninsured women of reproductive age. Fortunately, Delaware also passed legislation to codify the Affordable Care Act's birth control benefit in state law by requiring insurance plans, including Medicaid, individual, group, and state employee health plans, to include coverage for contraceptives with no-cost sharing to the insured individual. It also expands on the ACA's coverage by requiring 12 months of birth control dispensed at one time and insurance coverage of emergency contraception without a prescription. Additionally, it requires private insurance coverage of immediate postpartum Long Acting Reversible Contraception (LARC), which makes Delaware the first state to do so. Delaware Governor Carney signed Senate Bill 151 into law on July 11, 2018.

The early evidence of Delaware CAN’s outcomes among Delaware healthcare providers is very promising, as Child Trends released a research brief estimating that following Upstream’s partnership with the state of Delaware.  Child Trends issued a report using available contraceptive data from 2014 to 2017 in Delaware among Delaware Title X family planning clients ages 20–39. The observed movement from moderately effective contraception to highly effective Long Acting Reversible Contraception (LARCs), paired with a small decrease in no method, was linked to a substantial simulated decrease (24.2 percent) in the unintended pregnancy rate among this population. The complete report, including methodology and limitations, was commissioned by Upstream and can be found at ChildTrends.org.

Delaware CAN includes health centers that serve nearly 80% of women of reproductive age in the state.  Nearly 2,000 women in Delaware have taken advantage of the "All Methods Free" program.  Finally, Upstream hosted 130 trainings, trained nearly 3000 clinicians and staff from 41 partners representing 185 sites across DE.  A key component of their model is quality improvement and implementation coaching that follows each training.  During the quality improvement phase of the initiative, Upstream and health centers work together to remove barriers, implement patient centered contraceptive counseling, integrate pregnancy intention screening into the EHR and set up data collection to assess impact.    The 41 partners serve nearly 125,000 women of Delaware’s approximately 190,000 women of reproductive age. 

To assess DE CAN’s long-term impact, the University of Maryland in partnership with the University of Delaware, is conducting a rigorous and independent evaluation of the intervention.  The evaluation includes both a process and impact study and assesses outcomes such as contraceptive use, LARC utilization, Medicaid costs, and unplanned pregnancies resulting in unplanned births.  The evaluation is also exploring implementation and identifying key lessons learned to document, contextualize and deepen understanding of the impact of DE CAN. The evaluation involves eight distinct data collection activities and runs from 2016-2021. Data collection activities include: Title X patient survey, Delaware Primary Care Physician survey, interviews with women, male partner interviews, sustainability survey and stakeholder interviews and surveys.             

Oral Health for Pregnant Moms – Annual Report

At the onset of this grant cycle, we set specific objectives for this health priority and we sought to increase the percentage of women who have a dental visit during pregnancy from a reported rate of 40.5% to 43%.  We have achieved our goal of increasing the rate to 43%, but we intend to continue our efforts so that we move closer to achieving the national average of 53%.  According to PRAMS, the percentage of Delaware women who reported visiting a dentist or dental clinic during their most recent pregnancy rose between 2007 (36.0%) and 2015 (44.4%).  While this information shows a positive trend for women in Delaware, we continue to lag behind the national average of 53% in 2015.

Delaware’s Oral health national priority work focuses on not only national data, but also feedback gained from local professional development trainings.  According to findings from our 2018 Stakeholder Survey, there is a high desire to address this health priority, but partners feel there is little progress being made thanks, in part, to inadequate resources.  The respondents believe there are evidence-based strategies available to help move the needle in this area, but not enough “boots on the ground” to make it happen.  The findings actually tell us that the oral health for pregnant woman and oral health for children is our weakest area of success and respondents advised us to stay the course with seeking to improve oral health rates for both of these domains.

The comments and suggestions from the survey overwhelmingly point out that Medicaid coverage for adults over the age of 21 remains the single biggest barrier to pregnant women getting an oral health checkup during pregnancy.  While Medicaid coverage for adult oral health preventive services are making advances, coverage for emergencies and restorative care remain non-existent.

Our CDC Epidemiologist has prepared a data brief that focuses on Oral Health in Mothers and Children (See Appendix D).  The data brief provides select indicators on oral health among pregnant women from Pregnancy Risk Assessment Monitoring Survey (PRAMS) data from 2012-2015. Our Healthy Women, Healthy Babies program provides support dental services for Healthy Women, Healthy Babies patients through two Federally Qualified Health Centers FQHCs (including one in Sussex County) to help promote access to oral health.   Poor oral health has been identified as a risk factor for poor birth outcomes yet dental care is not readily available, especially in Southern Delaware. In collaboration with the FQHCs and the DPH’s Bureau of Oral Health and Dental Services Program, more women of childbearing age will have access to dental care. We are happy to report that our sister agency, Delaware Medicaid and Medicare Assistance (DMMA) recently negotiated with one of their Managed Care Organizations (MCO) to include Medicaid coverage for adults over the age of 21 for one preventive oral health visit and one set of laboratory dental x-rays per year.  This is exciting new progress for Medicaid and MCH will continue to work with DMMA to expand coverage in the future for problem and urgent dental care coverage.  We anticipate that the expansion of coverage for preventive oral health care will show trending successes in the coming years.