SPM 5 - Percent of women of childbearing age who self-rate their health status as excellent, very good, or good

 

Objective 1: By 2020, enroll 75% of Texas birthing facilities in the TexasAIM Initiative with 50 percent enrolled at the Plus Level in a Learning Collaborative.

Objective 2: By 2020, increase the proportion of women who discussed preconception health with a health care worker prior to pregnancy to meet a target of 23.4% (PRAMS, 2012 baseline = 20.1%).

Objective 3: By 2020, increase the proportion of women giving birth who attend a postpartum care visit with a health care worker to meet a target of 88.5% or higher (PRAMS, 2012 baseline = 85.4%).  

Objective 4: By 2020, reduce the proportion of women who self-report poor mental health for 5 or more days during the past month to meet a target of 19.0% (BRFSS, 2012 baseline = 24.4%). 

 

Adopted in December 2017, the DSHS Healthy Texas Mothers and Babies (HTMB) Strategic Framework is modeled after the Prevention Institute’s Spectrum of Prevention, and provides strategic direction for alignment, improvement, and development of existing and new interventions to support the triple aim of healthy women, healthy mothers, and healthy babies. The HTMB Framework integrates all MCHS women’s, maternal, perinatal and infant health programming and expands upon MCHS’ commitment and investments toward improved infant health outcomes through the previous Healthy Texas Babies (HTB) Initiative by elevating and amplifying an emphasis on women’s and maternal health and safety.

The HTMB framework includes the domains of Individual and Public Awareness and Knowledge, Professional Education, Community Empowerment, Community Improvement, and the Perinatal Quality Improvement Network, which includes a variety of interrelated and complementary initiatives that provide public health knowledge, partner mobilization, and implementation resources to drive system changes to support adoption and diffusion of quality improvements for maternal and infant health and safety.

 

Effective February 1, 2019, the Healthy Texas Mothers and Babies Branch was established within the Maternal and Child Health Unit to elevate this framework and provide structure to support MCHS ongoing commitment to women’s, maternal and infant health improvement.

 

Figure 1: Healthy Texas Mothers and Babies Framework

 

To more accurately capture MCHS’ enhanced focus on women’s and maternal health, MCHS replaced reporting of NPM 1 in FY19 with new State Performance Measure, SPM 5: Percent of women of childbearing age who self-rate their health status as excellent, very good, or good. MCHS continues to support improvement of the quality of women’s health and healthcare via promotion of preconception and interconception health. However, MCHS seeks to extend programmatic efforts to settings outside of the primary care visit to include policy, environmental and systems level changes to prevent and control chronic disease and promote wellness throughout a woman’s reproductive years. Women in Texas experience increasing rates of obesity, diabetes, hypertension, substance abuse disorder and other morbidities. High rates in Texas of unintended pregnancy, preterm birth, maternal morbidity, and maternal mortality are often preventable outcomes of poor preconception health. Self-reported health status is a helpful measure to account for the multiple factors that impact a woman’s preconception and interconception health beyond the primary care visit. As described by Broussard et al (2011)[1], DSHS epidemiology and program subject matter experts contributed, along with experts in other states, to a multi-state consensus-based selection process to develop a set of Core State Preconception Health and Health Care Indicators. SPM 5 is a core preconception health indicator and is the only indicator of general health status that was included by the Council of State and Territorial Epidemiologists in this core measure set. A lower rating of self-rated health status has consistently been associated with “increased mortality, incident adverse health events, health care utilization and illness severity, even after medical risk factors have been accounted for.”[2]

 

Effective August 2017, the Texas Legislature amended Texas Health and Safety Code Chapter 34 by adding Section 34.0156, which directs DSHS, in collaboration with the DSHS/Texas Maternal Mortality and Morbidity Review Committee (MMMRC) (formerly the Maternal Mortality and Morbidity Review Task Force), to implement a maternal health and safety initiative. Specifically, the initiative must promote and facilitate the use of maternal health and safety informational materials among Texas health care providers. Materials may include tools and procedures related to best practices in maternal health and safety.

 

In December 2017, DSHS applied for enrollment as an “AIM State” to the American College of Obstetricians and Gynecologists (ACOG) Alliance for Innovation on Maternal Health (AIM) Program and was selected as Lead Coordinating Entity for the implementation of AIM Maternal Safety Bundles in Texas with a focus on implementing the Obstetric Care for Opioid Use Disorder (OB-OUD), Obstetric Hemorrhage (OBH), and Severe Hypertension in Pregnancy (HTN) bundles. Using only existing staffing and resources including Title V funding, DSHS launched a large-scale quality improvement effort, the TexasAIM Initiative, in June 2018.

 

Hospital participation in TexasAIM is voluntary. Hospitals participating in the TexasAIM Program may join at one of two levels of participation: TexasAIM Plus and TexasAIM Basic. Hospitals that participate at Basic level receive the fundamental tools and support to adopt AIM bundles. These hospitals complete an intake assessment, form a quality improvement team, and report structure and process measures to the TexasAIM data portal. TexasAIM Basic participants also have access to quality improvement webinars, networking events, and technical assistance.

 

TexasAIM Plus uses the Institute for Health Care Improvement (IHI) Breakthrough Series Collaborative Model for Achieving Breakthrough Improvement to accelerate uptake of the AIM bundle’s recommended practices by participating hospital teams and creates a network of support from partnering hospitals. Hospitals in TexasAIM Plus complete all of the TexasAIM Basic data reporting requirements but will also report on additional quality improvement measures. In the Learning Collaborative, hospitals identify goals for improvement and make plans to achieve them. Participating TexasAIM Plus hospitals receive access to quality- and process- improvement training and guidance as well as practical information about the bundle components from experts through in-person meetings, monthly networking calls, peer-to-peer learning and mentoring, targeted, individualized coaching, online toolkits and discussion boards, and other supports, resources, and partnerships.

 

TexasAIM Plus hospitals are assigned to one of five geographic cohorts for in-person Learning Sessions. DSHS based cohorts on Public Health Service regions, Regional Advisory Council Perinatal Care Region territories, and enrollment (See Figure 1). Each cohort has approximately 30-40 participating hospitals. Additional details of DSHS’ initial efforts in creating a maternal health and safety initiative are outlined in the report, Maternal Health and Safety Initiatives, that was submitted to the HHSC Executive Commissioner in December 2018. The report also outlines DSHS request to the 86th Legislature for an Exceptional Item to provide funds and staffing to build upon current efforts to prevent maternal mortality and morbidity.

 

Figure 2. TexasAIM Plus Learning Collaborative Cohorts by Perinatal Care Region

 

 

Recruitment and selection of members for the TexasAIM Plus OBH Clinical Faculty Team was conducted in September and October of 2018. Applications were solicited through a wide network of communication channels, and were reviewed, scored and evaluated by a selection panel including clinical subject matter experts from DSHS and Texas Hospital Association (THA). Eleven faculty members, including five nurses and six physicians, were selected and accepted the offer to participate on a voluntary basis as TexasAIM Plus OBH Learning Collaborative faculty. The faculty team is comprised of a physician faculty chair and ten additional Texas physicians and nurses with demonstrated expertise and experience in: health care quality improvement, implementation of core OBH improvement strategies, and coaching, mentoring, and team-based learning.

 

Recruitment and enrollment of hospitals for participation as TexasAIM Basic and Plus continued throughout FY19. A total of 188 hospitals were enrolled to participate in the TexasAIM OBH Bundle Initiative at the beginning of FY19, representing approximately 340,000 (89 percent) of the state’s annual births. Of these, 175 hospitals were enrolled in the TexasAIM Plus OBH Learning Collaborative. By the end of FY19, 219 hospitals had enrolled in TexasAIM, including two hospitals that subsequently closed their obstetric services (a third non-enrolled hospital also closed their OB services in 2019). In August 2019, there were 217 hospitals (96 percent of Texas hospitals with obstetric services) enrolled, representing approximately 97 percent of the state’s annual births. Of these, 181 (84 percent of enrolled hospitals) were enrolled in the TexasAIM Plus OBH Learning Collaborative, including 18 hospitals that had initially enrolled at the Basic level.

 

The TexasAIM Plus OBH Learning Collaborative kicked off in August 2018 with a Welcome and Pre-work call. Webinars providing information about getting started with TexasAIM and orientation to quality improvement basics were provided throughout the pre-work period through October. Two-day in-person Learning Sessions were held throughout November and December for each of the five regional cohorts. Across the five meetings, 587 members of TexasAIM OBH improvement teams attended from 164 hospitals participating in the TexasAIM Plus OBH Learning Collaborative to: learn details about the OBH bundle components, receive coaching and work with their teams to establish plans and strategies for process improvement, and engage in networking and facilitated shared learning sessions to identify practical approaches and resources for bundle implementation. From April-May 2019, OBH Learning Collaborative Improvement teams (169 hospitals and 563 attendees) again convened in their regional cohorts for Learning Session 2 of the Collaborative to engage in collaboration and shared learning about experiences with implementing the bundle, focused team work, and support and coaching from expert faculty. Additionally, the Texas Collaborative for Healthy Mothers and Babies (TCHMB) Obstetric Committee provided education on implementation of Maternal Early Warning Systems (MEWS) at Learning Sessions 1 and 2.

 

Between Learning Sessions, improvement teams worked during these Action Periods to test and implement practice and system changes for integration of the bundle elements into routine practice. Monthly Action Period Calls provided continued coaching and reinforcement on bundle content and implementation strategies as well as practical examples of implementation of the bundle components from participating teams. Topics covered include Quantification of Blood Loss, OBH Drills and Simulations, Components of Readiness, Recognition and Prevention, Response, Reporting & Systems Learning, and cohort specific calls. A bi-weekly newsletter with announcements and resources were sent to over 1200 subscribers from participating hospitals throughout the Action Periods, and improvement team members accessed tools and resources, shared information and discussed strategies through a web-based member collaboration platform. A TexasAIM Media Kit was developed and shared with participants for their hospitals’ use in promoting community awareness of their participation in the initiative. Participating hospital teams entered metrics into the AIM Data Portal quarterly to report on and assess their uptake of the bundle components into routine practice. The OBH Learning Collaborative will continue through FY20 with Learning Session 3 and Action Period 3. The TexasAIM Plus OBH Learning Collaborative will be followed by the launch of the HTN Learning Collaborative. A Leadership Summit and Kickoff Meeting will be held to highlight successes of the OBH Collaborative and mark the transition to launch of the HTN Collaborative.

 

In addition to their participation in the TexasAIM Plus OBH Learning Collaborative, ten hospitals across the state with experience providing care for infants with neonatal abstinence syndrome signed on to test implementation of the newly developed OB-OUD bundle in their hospital settings. While no TexasAIM programming related to bundle implementation was provided to the hospitals during this time, AIM national OB-OUD resources were shared with the hospitals as they independently approached planning and strategy development for implementation of the OB-OUD bundle components. Lessons learned through their initial experiences with trialing the components of the OB-OUD bundle will inform planning for programming including development of an OB-OUD Learning Collaborative that will launch for these hospitals in FY21.

 

Numerous partnerships were developed and maintained to support implementation of the TexasAIM Initiative. DSHS continued to convene the TexasAIM Implementation Workgroup to guide and facilitate the initiative. The workgroup includes representatives of the MMMRC, the Perinatal Advisory Council, the American College of Obstetricians and Gynecologists, the Consortium of Texas Certified Nurse Midwives, TCHMB, the Texas Hospital Association, the Texas Medical Association, the Texas Nursing Association, and other key partners. A contract was executed with Texas Hospital Association in March 2019 to support THA’s continued partnership and support of DSHS’ implementation of TexasAIM.

 

In September 2018, MCHS staff applied for, and was one of nine sites competitively selected to participate in, the 2019 Centers for Disease Control and Prevention (CDC) and Harvard T.H. Chan School of Public Health (HSPH) Program Evaluation Practicum for evaluation of the TexasAIM Initiative. The Practicum involved matching a pair of HTMB program and epidemiology representatives with two HSPH graduate students in a paired practicum to attend a one-week program evaluation training in January 2019 in Atlanta at the CDC. The HSPH students then participated in a week-long field-placement in Texas, where they worked onsite alongside DSHS program and epidemiology staff to learn details of the program for development of an evaluation plan. After leaving the field placement, the students received technical assistance from CDC and HSPH faculty subject matter experts to finalize the plan before submitting their final evaluation plan proposal to DSHS. The plan will inform and guide DSHS evaluation activities for the TexasAIM Initiative.  

 

In November 2018, ACOG/AIM National recommended TexasAIM to the Johns Hopkins University (JHU) Armstrong Institute for Patient Safety and Quality as a partner for a demonstration of the Safety Program for Perinatal Care, Phase 2 (SPPC-II) project. JHU approached the DSHS TexasAIM Program and requested support in coordinating with JHU for them to host in-person training of the trainer workshops with hospital improvement teams participating in TexasAIM. The workshops were designed to apply team work and communication methods for implementation of the obstetric hemorrhage bundle. To facilitate JHU’s familiarity with the TexasAIM Initiative and support their planning of a pre-intervention assessment for their SPPC-II workshops, a member of the JHU team was invited to attend and participate in the Learning Session 1 San Antonio meeting in December 2018.

HTMB staff served on Stakeholder Panels 1 and 2 for the Safety Program in Perinatal Care-II in February and July 2019. The first panel involved reviewing and providing input for the SPPC-II toolkit/training materials, including materials to be used in the workshop and a draft field test plan. The panel made several recommendations for changes to the materials and suggested for the materials to be reviewed by rural hospitals. DSHS facilitated a referral of a TexasAIM rural hospital partner to field test the materials. The second panel involved review and advisement on the workshop implementation plan and SPPC-II evaluation plan. DSHS met in July 2019 with the Agency for Healthcare Research and Quality (AHRQ) and Johns Hopkins University (JHU) in collaboration with the Health Resources and Services Administration (HRSA) and ACOG AIM staff in conjunction with the AIM National Meeting in Falls Church, VA. The meeting was to discuss logistics of recruiting hospitals to participate in the SPPC-II one-day workshops. The workshops were originally planned to occur in conjunction with the springtime Learning Session 2 in FY19 but were delayed due to administrative budget issues between AHRQ and JHU. DSHS will partner with JHU to recruit TexasAIM hospitals for participation in the one-day SPPC-II workshops in up to five locations, with plans to hold the workshops in FY20.

 

In January 2019, HTMB staff established communications with MoMMA's Voices, a national coalition of patient organizations and individuals with "lived experiences" in maternal complications in pregnancy and the postpartum period that use their voices to increase awareness and support improvements in systems of care. DSHS promoted awareness about MoMMA’s Voices at the TCHMB Annual Meeting in January, which was heavily attended by TexasAIM hospitals. Subsequently, MoMMA’s Voices partnered with DSHS to identify Texas-based survivors of obstetric hemorrhage to participate and share their experiences with TexasAIM participants in each of the five TexasAIM Learning Session 2 meetings. Presentations from each of the “patient voice” speakers were followed by presentations and networking sessions related to development and implementation of staff, patient and family support programs as a component of the OBH bundle. 

 

In March 2019, the HTMB Branch Manager/Nurse Consultant, who functions as the TexasAIM Program Director, the TexasAIM Faculty Chair, who also serves as co-chair of the TCHMB Obstetric (OB) Subcommittee and a leader in the TCHMB MEWS Project, and the University of Texas Health Science Center at Tyler (UT Tyler) QI Nurse who supports the TCHMB MEWS Project travelled to Boston to participate in the Institute for Healthcare Improvement’s (IHI) Breakthrough Series College. The College is a professional development program to prepare participants to plan and conduct a large-scale quality improvement project using the IHI Breakthrough Model for Collaborative Improvement. The College included pre-work, a three-day in-person workshop and access to ongoing collaboration with attendees and implementation resources through the IHI Extranet. The goal of attending was to build collaboration and alignment of the TexasAIM Obstetric Hemorrhage Learning Collaborative and the TCHMB MEWS project while strengthening capacity for implementation of each initiative.

 

In July 2019, the Healthy Texas Mothers and Babies Branch Manager, one of two Maternal Health and Safety Coordinators, and the TexasAIM Faculty Chair, who collectively comprise the “TexasAIM Team”, attended the AIM Annual Conference in Falls Creek, VA. The conference featured presentations related to implementation of the AIM bundles including information on data, health equity, and rural health.

 

Information about maternal morbidity in Texas and the TexasAIM Initiative was shared at state and national conferences and meetings, including the Texas Hospital Association (THA) Foundation Quality and Patient Safety Conference, THA Quality and Patient Safety Council and Hospital Physician Executives meeting, the Association of Maternal and Child Health Programs (AMCHP) Annual Conference, the Dr. Ralph J. Anderson Women’s Health Symposium, the Neonatal Abstinence Syndrome Symposium, the HRSA Region VI Opioid Forum in Dallas, and at meetings of the Perinatal Advisory Council, Texas Medical Association, and the Regional Advisory Councils, among others.

 

DSHS continues to contract with UT Tyler to facilitate the TCHMB, Texas’ perinatal quality collaborative. TCHMB’s mission is to advance health care quality and patient safety for all Texas mothers and babies through the collaboration of health and community stakeholders in the development of joint quality improvement (QI) initiatives, the advancement of data-driven best practices, and the promotion of education and training. The organization’s goals include: reducing preterm birth and infant mortality, reducing maternal mortality and severe maternal morbidity, reducing disparities in the health outcomes of mothers and babies, ­improving the health outcomes of mothers and babies, ­increasing the involvement of fathers / families, and improving women’s health throughout the life cycle.

Transforming the TCHMB organizational structure and governance was a significant focus in FY19. The organizational structure at the beginning of FY19 included an executive committee and three active subcommittees, each with two co-chairs, including the Obstetric (OB), Neonatal, and Community Health Subcommittees. Throughout FY19, meetings were held to negotiate a new governance structure for the TCHMB, to begin in FY20, that would expand the TCHMB leadership structure to incorporate Perinatal Care Regions (PCRs)/Regional Advisory Councils (RAC)[3] representation. The goal of governance structure revisions is to bolster the reach of the quality improvement projects with the support of the RACs’ statewide reach and to reduce redundancy of efforts. The governance structure was also revised to include key stakeholder organizations as non-voting advisory members of the TCHMB Executive Committee. Six non-voting organizational members were appointed to join the Executive Committee beginning with the October 2018 meeting, including the THA, Texas Medical Association (TMA), American College of Obstetricians and Gynecologists (ACOG) District XI, Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN), Texas Association of Community Health Centers (TACHC), and Texas Pediatric Society (TPS).  Also in October 2018, UT Tyler hired a quality improvement nurse consultant to support quality improvement efforts, beginning with the OB Subcommittee’s MEWS project.

 

The TCHMB Executive Committee continued to meet quarterly throughout FY19 to work on and make updates to TCHMB QI projects, the TCHMB Communications Plan, governance plan including incorporation of PCR members, stakeholder and membership engagement, and annual meeting plans. A presentation was made to the Executive Committee about an evidence-based prenatal education model to lower risk of postpartum depression called ROSE (Reach Out, Stay Strong, Essentials for mothers of newborns). Teleconference calls were held monthly to quarterly for each subcommittee in support of planning or implementing subcommittee QI efforts, and subcommittees held in-person meetings with attendees at the TCHMB Annual Summit in January.

 

The TCHMB Annual Summit was held in January 2019 with the theme “Maternal Safety.” More broadly, the conference focused on the role of perinatal quality collaboratives (PQC) in translating evidence‐based practices to improve outcomes for women and newborns. The meeting was widely promoted to TexasAIM participants and other Maternal and Child Health stakeholders. The meeting was attended by over 360 participants, and over 100 people had to be denied registration due to reaching space capacity. Distribution of participants include 69 percent nurses, 14 percent physicians, two percent social workers, and 15 percent “other”.  For 85 percent of attendees, the summit was their first participation with TCHMB. A total of 12.5 CMEs, CNEs, and social work credits were made available to participants. Women’s and maternal health topics included a focus on implementation of AIM bundles, maternal levels of care designation, long acting reversible contraceptives, best practices in postpartum care, maternal mortality, mental and behavioral health, and simulation for obstetric emergencies. TexasAIM teams were invited to attend a dinner key note presentation with Dr. Ann Borders, Executive Director and Obstetric Lead, Illinois Perinatal Quality Collaborative, who presented lessons learned from the Illinois Perinatal Quality Collaborative with implementation of hypertension and maternal care for women with opioid use disorder bundles. The agenda, recorded presentations, and a detailed impact report are available at: https://www.tchmb.org/2019conference.  

 

TCHMB subcommittees worked on three quality improvement efforts related to women’s and maternal health during FY19 including the OB/Data Subcommittee’s Induction of Labor (IOL) project and Maternal Early Warning System (MEWS) project, and the Community Health Subcommittee’s Increasing Access to Reproductive Healthcare & Services project (IARHS,  formerly One Key Question©/OKQ). Two of the three hospitals that were enrolled in the IOL project, which aimed to reduce failed induction of labor, continued to attend bimonthly calls and report on core measures through the project’s end in February 2019.

 

The MEWS project was launched with a webinar that was widely promoted to TexasAIM participants. The TCHMB Introduction to MEWS webinar was held in September 2018 and attended by 193 participants. TCHMB OB Subcommittee Chairs and UT Tyler support staff presented on MEWS at each of the five TexasAIM Learning Session 1 and Learning Session 2 meetings across the state, and provided every hospital attending Learning Session 2 with a MEWS Information Packet including a MEWS algorithm, MEWS Badge Buddies, MEWS documentation forms, a MEWS FAQ page, a guide to using the Model for Improvement to implement MEWS, and journal articles supporting the use of MEWS. TCHMB recruited 15 TexasAIM-participating hospitals that reported they had already begun to implement a MEWS to participate in the TCHMB “MEWS Reinforcement Cohort” to share learnings and report data related to their uptake of practices related to implementation of MEWS. The Cohort began in January 2019 and participated in monthly conference calls throughout the year. TCHMB also offered access to all TexasAIM-participating hospitals to MEWS technical assistance, including sharing TCHMB-developed tools, webinars, and personalized assistance from the MEWS QI nurse. In addition to the introduction webinar, a webinar on MEWS Triggers and Notification was held in February 2019 with approximately 200 attendees and a webinar on MEWS Electronic Health Record (EHR) Integration & Data Tracking was held in July 2019 with approximately 60 attendees.

 

The first meeting of the IARHS TCHMB Collaborative was held on August 23, 2018 and participating clinics established a monthly meeting schedule beginning in October 2018. Participants, including clinic sites that had received training in FY18, worked through the fall and winter to finalize measures and data collection mechanisms and to refine implementation plans. A webinar was conducted in April 2109 including a description of the QI project, an overview of One Key Question© (OKQ) by Power to Decide, and two clinics from the project’s first cohort shared their experiences with implementing OKQ. A second webinar about discussion of contraceptives with patients was held in June 2019.

 

The 85th Texas Legislature Budget Rider 198 requires HHSC to develop a five-year strategic plan to reduce barriers for Medicaid recipients and those with and without health benefit plan coverage who may be eligible for Healthy Texas Women, the Family Planning Program, or CHIP-Perinatal to access long-acting reversible contraceptives. HHSC must collaborate with the TCHMB to develop the five-year strategic plan and submit the plan by November 2018. The TCHMB Executive Committee provided input to and review of the draft strategic plan. The plan was finalized in November 2018, and is now posted on the HHSC website at https://hhs.texas.gov/sites/default/files/documents/laws-regulations/reports-presentations/2018/rider-105-larc-strategic-plan-nov-2018.pdf. 

 

On behalf of TCHMB, UT Tyler was awarded a grant in in November 2018 by the St. David’s Foundation for the Postpartum Access to Healthcare (PATH) Project. The project aims to explore barriers to access to postpartum care in Central Texas. The project is led by UT Tyler staff and coordinated with executive committee members, who agreed to serve in an advisory capacity.

 

In December 2018, the Annual National Network of Perinatal Quality Collaboratives (NNPQC) Meeting was sponsored by the Centers for Disease Control and Prevention in Atlanta, in support of the development and enhancement of the ability of Perinatal Quality Collaboratives (PQCs) to make measurable improvements in the statewide maternal and infant health care and health outcomes. Objectives of the meeting centered around describing lessons learned and avoiding pitfalls for becoming a “fully functioning” PQC, accelerating improvement to address disparities, and engaging family partners in quality improvement. The meeting was attended by the MCHS Section/Title V Director, Jeremy Triplett, and the new TCHMB Executive Committee Vice Chair, Dr. Patrick Ramsey.

 

UT Tyler, in collaboration with the chair of the OB subcommittee, conducted and published a study of maternal risk factors and cesarean delivery.[4]  The study was e-published in the journal, Birth, in September 2019 and published in print in March 2019.

 

MCHS supports creation and strengthening of local perinatal coalitions (formerly HTB Coalitions, and now HTMB Coalitions) in Texas through provision of funding and technical assistance. HTMB Coalitions bring together health professionals, local health departments, hospitals, community-based organizations, and stakeholders to create a collaborative network of partners to address perinatal health issues relevant to their community. HTMB Coalitions convene periodically, coordinate health assessments, training, and outreach activities.

 

The HTMB Community Coalition 2018-2022 Program provides support for local perinatal coalitions in Texas communities with the greatest disparities in infant mortality. Each funded community develops and/or maintains a community coalition of partners in maternal and infant health to carry out a community needs assessment, review and assess infant morbidity and mortality data including Perinatal Periods of Risk mapping, and conduct a strategic planning process to develop, implement and evaluate interventions and programs tailored to its population to address the specific risk factors identified. Specific program support is also focused on preconception health awareness, community outreach and education.

 

A FY18 competitive Request for Proposal (RFP) process was unsuccessful in identifying a contractor to provide technical assistance to the HTMB Coalitions and to support the coalitions with evaluation, training, and capacity building for reducing disparities and increasing equity in maternal and infant health. The process was re-initiated in FY19 but was halted when it became evident that it would not be possible to align the timing of procurement with the operational requirements of the project.

 

Coalitions are located in Texas counties with the greatest rates of infant mortality and most significant disparity in infant mortality and perinatal health outcomes among racial/ethnic groups. The four Healthy Start sites in Texas each participate in a Coalition. A contract was newly executed in FY19 with the newest HTMB Coalition in City of Brownsville. The coalition catchment areas and funded organizations include:
 

• Bexar County – San Antonio Metropolitan Health Department
• Cameron County – City of Brownsville Health Department
• Dallas County – Parkland Health and Hospital System
• Jefferson County – City of Port Arthur Public Health Department
• McLennan County - Waco-McLennan County Public Health Department
• Randall County – City of Amarillo Public Health Department
• Smith County – Northeast Texas Health District
• Tarrant County – Tarrant County Public Health Department
• Webb County – City of Laredo Health Department

 

MCHS worked with partners to expand preconception/interconception health and health care outreach efforts across MCHS and stakeholder programming. Work began in FY2019 to plan and procure formative research to inform development of a new HTMB campaign. Formative market research was conducted from October through December 2018 in Dallas, San Antonio, Tyler, Amarillo, Beaumont, and Laredo through a contract with SUMA Social Marketing. The research included engagement with a total of 228 participants in focus groups and key informant interviews. In-depth interviews were conducted with key stakeholders and HTMB coalition members. Focus groups were held with preconception young women, interconception women who had two or more children under the age of five, women who had a high-risk pregnancy within the past two years, preconception young men, fathers of young children, labor and delivery nurses, and physicians. SUMA also conducted a high-level review of existing campaigns related to preconception, interconception, maternal, and infant health as well as campaigns and initiatives targeting similar audiences. This review informed selection of materials to test in focus groups. An executive summary report was provided to HTMB coalitions along with a webinar-based presentation of the findings and recommendations for incorporation into their local communications, outreach and awareness activity planning. 

 

FY18 was the final year of a three-year contract between MCHS and the University of North Texas Health Science Center (UNTHSC) for implementation and spread of the Preconception Peer Educator (PPE) program among Texas historically black colleges and universities (HBCUs). HTMB Coalitions applied information they obtained in an August 2018 #PPEPtalk Texas Networking Workshop by exploring opportunities for adoption and implementation of PPE programming in new settings through coordination with local colleges and universities in their communities.

 

MCHS staff participated throughout FY2019 in the Texas Cardiovascular Disease and Stroke Partnership to share maternal health subject matter expertise and learn from partners across the state working to implement strategic objectives in DSHS’ Public Health Strategies for Addressing Heart Disease and Stroke in Texas, 2019-2023. MCHS staff participated in the development of the plan, including leading a goal workgroup and participating in workgroups for the other goals. Strategies and indicators related to women’s, maternal and infant health are featured in the plan. MCHS staff submitted a poster highlighting the TexasAIM Initiative at the September 2019 Texas Hypertension Summit.

 

MCHS continues to share information and subject matter expertise for health care providers and other health care professionals to improve the quality of women’s and maternal preventive care services. Dr. Manda Hall, the Associate Commissioner of CHI, began serving as a consultant for the TMA Committee on Reproductive, Women’s and Perinatal Health in FY18.

 

MCHS collaborated with Texas Health Steps Online Provider Education to promote its MCHS-supported suite of continuing education modules focused on preconception and prenatal health. The modules equip health care professionals with knowledge and resources to improve the health of Texas women before and during pregnancy. Health care professionals completed a variety of modules relevant to women’s and maternal health in FY19. Previously developed modules, and the number of health care professionals (HCPs) completing each module in FY19, included: Preconception and Prenatal Health-Overview (165 HCPs); Preconception and Prenatal Health-Managing Chronic Health Issues Before and During Pregnancy (151 HCPs); Preconception and Prenatal Health-Identifying and Intervening in High-Risk Behaviors (102 HCPs); and Preconception and Prenatal Health-Cytomegalovirus (70 HCPs);  and Preconception and Prenatal Health-Promoting and Maintaining Women’s Oral Health (21 HCPs).

Additionally, MCHS staff supported review, revision, and redesign of modules as part of the continuing education renewal process. The newly redesigned Preconception Health: Screening and Intervention and Prenatal Health: Screening and Intervention modules were released in FY19, and were completed by 801 and 787 HCPs, respectively. The revised and redesigned Oral Health and Dental Services for Pregnant Women module, revised Breastfeeding module, and the new Postpartum Health: Screening and Intervention module will be available beginning in FY20.

Quick courses and tutorials are also available without continuing education and include: Fetal Alcohol Spectrum Disorders: Promoting Early Identification and Support for Children, Integrating Postpartum Depression Screening into Routine Infant Medical Checkups, and Opioid and Substance Use: Caring for Texas Mothers and Babies. The modules may be accessed at www.txhealthsteps.com. 

 

MCHS staff incorporated mental and emotional health content from the Eunice Kennedy Shriver National Institute of Child Health and Human Development’s Mom’s Mental Health Matters campaign, into the WIC breastfeeding promotion campaign Breastmilk: Every Ounce Counts. The campaign’s website, www.Breastmilkcounts.com, includes information, tips and resources on self-care for women during pregnancy and after birth, information for women and their support networks about identifying the signs of perinatal depression and anxiety, and where to get help. This mental health content can be accessed in the Self-Care: Mental and Emotional Health section and the For Dad, For Grandma, and Friends and Family sections of Every Ounce Counts website at http://www.breastmilkcounts.com/self-care/mental-and-emotional-health/ and http://www.breastmilkcounts.com/teamwork/. Team work for dads was viewed 22,802 times in FY19, team work for grandma was viewed 5,334 times, and team work for friends and family was viewed 2,228 times. Information about mental and emotional health self-care was viewed 10,285 times, and helpful resources including for mental and emotional help was viewed 7,488 times.  

 

MCHS staff reviewed and provided maternal and infant health subject matter expertise toward development of HHSC WIC High Risk Screening and Referral “Red Flags” Training and toward review of a Community Health Worker training material on behaviors that effect pregnancy.

 

MCHS-funded Lactation Support Centers (LSCs) in Austin, Dallas, Houston, McAllen, and San Antonio incorporated use of the Edinburgh Postnatal Depression Scale into their intake- and follow-up assessment and referral procedures and workflow. 

 

MCHS staff continued to participate in the HHSC Better Birth Outcomes Workgroup throughout FY19. The workgroup aimed to improve access to women's preventive, interconception, prenatal, and perinatal health care. The workgroup coordinated efforts to create coordination, collaboration, and alignment on efforts including Healthy Texas Women Coverage; 17-P Progesterone Treatment; Texas NICU Project, Substance Use Disorder Treatment Increases; Mommies Program and Pregnancy and Postpartum Intervention Services Expansion; Neonatal Abstinence Syndrome Training and Research Initiatives; DSRIP Program; Texas Targeted Opioid Response / State Opioid Response;  the Someday Starts Now Campaign; Alliance for Innovation on Maternal Health Maternal Safety Bundles; MMMRC; the HTMB Initiatives; Hospital Levels of Care Designations; Long-Acting Reversible Contraception; Early Elective Deliveries; Healthy Families Initiative; Postpartum Depression; and Zika Virus Prevention.

 

 

Objective 5: Ensure that 80 cases are reviewed annually by the Texas Maternal Mortality and Morbidity Task Force (now Review Committee).

 

The Texas MMMRC, with the support of MCHS, continued to review cases of maternal mortality to gain a more in-depth picture of the causes and risk factors to make recommendations for prevention. The 85th Texas Legislature 1st Called Session (85th (1)) instituted several new legislative charges through Senate Bill 17 (SB17), that built upon past efforts to decrease maternal mortality and severe morbidity. Among other changes, the bill amended Texas Health and Safety Code Chapter 34 to extend the MMMRC’s charge. The MMMRC is now authorized to continue its work through September 1, 2027, and expanded the scope and responsibilities of the MMMRC to study other state's efforts to reduce pregnancy-related deaths, study trends, rates, and disparities in pregnancy-related deaths and severe maternal morbidity, and implement maternal safety initiatives to inform best practices for maternal health and safety in Texas. In addition, the MMMRC required membership composition was expanded from 15 to 17 multi-disciplinary members, adding a nurse specializing in labor and delivery and a physician specializing in critical care.

 

The DSHS commissioner appointed two new MMMRC members in August 2019: Dr. Sherri Onyiego, a physician specializing in family medicine and Kimberly Williams, a community advocate.

 

Work continued in FY19 to improve the quality of death certificate data to better identify maternal mortality in Texas at a system-level. SB17 required DSHS to study processes and procedures of collecting cause of death information including any challenges relating to maternal mortality. DSHS may examine: issues relating to the quality of death information collected, including the accuracy and completeness of the information; the role of medical certifiers in death information collection; the perception of individuals collecting death information regarding the information’s integrity; required training for individuals collecting death information; and structural, procedural, and technological issues of collecting the information.

 

In their study, DSHS convened a panel of experts to examine national standards, and also consulted with the Maternal Mortality and Morbidity Review Committee in developing recommendations. Findings and recommendations from the study were published and disseminated in November 2018 legislative report, Improving the Quality of Cause of Death Information Related to Maternal Mortality.

 

DSHS replaced the electronic system for registering and collecting birth, death, fetal death, marriage, and divorce records in Texas, known as the Texas Electronic Registrar, with a new electronic system, Texas Electronic Vital Events Registrar (TxEVER), which was launched January 1, 2019.  Features include a verification of the pregnancy check-box to improve the quality of death certificate data, and hence, the identification of maternal mortality in Texas.  

 

MCHS and University of North Texas Health Science Center (UNTHSC) staff worked throughout FY19 to continue to improve and build capacity for efficient and comprehensive case review. MCHS program staff worked to coordinate strategies to support UNT’s internal quality assurance processes, including regular meetings with UNTHSC program staff to optimize contract efficiencies and ensure completion of 15-25 cases per quarter for review by the MMMRC. MCHS program staff provided ongoing subject matter expertise for additional quality assurance oversight and feedback and worked to connect abstractors with up-to-date resources from the Review to Action website, a resource developed by the Association of Maternal and Child Health Programs (AMCHP) in partnership with the CDC Foundation and the CDC Division of Reproductive Health. To ensure consistent additional expertise for critical care cases, UNT recruited and hired a critical care nurse to provide ongoing expertise and consultation services for reporting of complex medical and critical care cases. The UNT contract was renewed in July 2019 to continue redaction and abstraction services for the MMMRC in FY2020.

 

In December 2018, members of the Center for Disease Control and Prevention’s Maternal Mortality Prevention Team provided onsite technical assistance in Austin, Texas for the MMMRC and DSHS support staff on best practices in maternal death case review. The CDC Preventing Maternal Deaths Act Grant notice of funding opportunity was released by the CDC in March 2019, and MCHS began planning to build infrastructure and work flow to align with grant requirements and support the success of DSHS application for this funding opportunity.

 

In March 2019, Texas highlighted programmatic strategies to support maternal death case review in a large state at the San Antonio AMCHP conference with its poster, Maternal Mortality and Morbidity Review in Texas: From Records to Recommendations. A companion poster, Maternal Health and Safety in Texas: From Recommendations to Actions, highlighted DSHS programmatic efforts implemented through the HTMB framework to address findings and recommendations of the MMMRC. Also at this AMCHP conference, Dr. Manda Hall, the DSHS Associate Commissioner of the Community Health Improvement Division, delivered a presentation on Maternal Mortality as part of an opening plenary session entitled “Collectively Combating Maternal Mortality: Family, State and National Perspectives”. The panel exchanged ideas and experiences on applying theory and evidence to real systems change, focusing on the family perspective on what needs to change within systems, the business case, and innovative approaches to addressing maternal mortality on the state and community levels. The panel was moderated by Joia Crear-Perry, MD President, National Birth Equity Collaborative, and other panelists included Charles Johnson, Founder, 4Kira4Moms; Janet Jones, MPH, CHES; Lead Public Health Education Specialist, Waco-McLennan County Public Health District, Texas; and Susan Nicholson, Vice President of Women’s Health, Johnson and Johnson.

 

The multi-disciplinary MMMRC Review Teams met for case calls by phone monthly for in-depth preliminary review and analysis of each case.  The MMMRC met in-person quarterly for final review of cases. Quarterly MMMRC meetings included programmatic updates from DSHS programs relevant to the MMMRC, presentation of data on severe maternal morbidity and mortality trends in Texas, refinement of MMMRC processes, and closed session confidential case review.

 

The MMMRC began reviewing cases for the 2013 case cohort in June 2018, and 75 cases from this case cohort were closed with final determinations by the end of FY19. In addition to three 2013 cohort cases reviewed during the June 2018 meeting, 128 cases from the 2013 cohort were reviewed in FY19 with 56 cases requiring in-depth study of additional information to complete the review. Final review for these cases will be completed in FY20.   

In accordance with Senate Bill (SB) 750 of the Texas 86th Legislature, Regular Session, effective June 2019, the Maternal Mortality and Morbidity Task Force was renamed to the Maternal Mortality Review Committee (MMMRC). In addition, SB750 permitted secure disclosure to an appropriate federal agency of confidential information acquired by DSHS, including identifying information of individuals or health care providers, for the limited purpose of complying with applicable requirements under the federal Preventing Maternal Deaths Act of 2018.

 

House Bill (HB) 1, Article II-20, #28 of the Texas 86th Legislature, Regular Session was signed by the Governor on June 15, 2019 and appropriated $1.33 million over the biennium and 6 Full Time Employees (FTEs) to implement maternal safety initiatives statewide, $1.17 million over the biennium and 2 FTEs to develop and establish a high-risk maternal care coordination services pilot, and $1 million over the biennium to increase public awareness and prevention activities related to maternal mortality and morbidity. 

 

In June 2019, DSHS applied to the Preventing Maternal Deaths Act Grant and was awarded funding in August 2019 through the Enhance Surveillance and Review to Eliminate Maternal Mortality program, or ERASE MM. In partnership with the MMMRC and UNTHSC and with consultation from CDC, DSHS worked throughout FY19 to develop infrastructure to increase capacity for case review. The ERASE MM grant will support DSHS to identify pregnancy-associated deaths within one year of the date of death and support the MMMRC in review of potentially pregnancy-related deaths that fall within the defined scope of the MMMRC. DSHS, in coordination with UNTHSC contract partners, will abstract and enter clinical and non-clinical data into the Maternal Mortality Review Information Application (MMRIA) data system, support the MMMRC to conduct timely multidisciplinary maternal death reviews, and enter committee decisions in MMRIA within two years of death. DSHS will improve data quality, completeness, and timeliness through use of quality assurance processes in partnership with the Centers for Disease Control and Prevention and will analyze data and share findings with stakeholders to inform policy and prevention strategies to reduce maternal deaths in Texas.

 

In FY19, the MMMRC established the Subcommittee on Maternal Health Disparities to provide recommendations on strategies to gain insight at root cases for maternal health disparities for at-risk populations, like Black women. Per subcommittee recommendations, DSHS, in consultation with the subcommittee, developed a social-spatial dashboard tool inspired by national efforts to better capture lived environmental context for maternal death case review. The subcommittee uses this resource to better capture and evaluate the impact of social determinants of health on maternal health trajectory for decedents that may be unavailable in medico-legal records alone.

 

In addition, the subcommittee worked to refine a health disparities tool to better capture environmental and life course indicators that impact decedents. Through the process of case review and utilization of the tool, the review committee will have additional resources to support the determination and documentation of contributing factors on the ERASE MM’s MMRIA Committee Decisions Form, including the documentation of recently added contributing factors related to structural bias, discrimination, and racism.

 

DSHS program and epidemiology staff and the MMMRC Chair and Co-Chair attended the 3rd Annual MMRIA User Meeting (MUM III) in Atlanta in June 2019. Topics included use of equity measures, data visualization, data to action, preventability, case identification, and perinatal mental health and substance use disorder.

 

 

NPM 14.1: Percent of women who smoke during pregnancy

 

Objective 1: By 2020, increase abstinence from cigarette smoking among pregnant women to meet or exceed a target of 97% (National Vital Statistics System-Natality, 2014 baseline = 96.1%).

 

Ten hospitals across the state with experience providing care for infants with neonatal abstinence syndrome signed on to test implementation of the newly developed OB-OUD bundle in their hospital settings. While no TexasAIM programming related to bundle implementation was provided to the hospitals during this time, AIM national OB-OUD resources were shared with the hospitals as they independently approached planning and strategy development for implementation of the OB-OUD bundle components. The bundle includes screening for tobacco use and provision of resources and interventions for smoking cessation as a key practice for health care workers to implement with all pregnant women. Lessons learned through their initial experiences with trialing the components of the OB-OUD bundle will inform planning for programming including development of an OB-OUD Learning Collaborative for full bundle implementation that will launch for these hospitals in FY21.

 

MCHS staff participated in the Texas Cardiovascular Disease and Stroke Partnership to share maternal health subject matter expertise and learn from partners across the state working to implement strategic objectives in DSHS’ Public Health Strategies for Addressing Heart Disease and Stroke in Texas, 2019-2023. MCHS staff participated in the development of the plan, which was released in FY19, including leading and participating in goal workgroups. Objectives and indicators related to maternal smoking are featured in the plan, including objectives to reduce the percent of cigarette smoking among pregnant women and reduce the percent of mothers who report smoking is allowed in their homes. Strategies include:

• Increasing compliance with tobacco laws and policies in schools and communities and support increased enforcement of laws prohibiting tobacco sales to minors;
• Implementing evidence-based, culturally appropriate programs to prevent tobacco use;
• Promoting media campaigns to decrease the use of tobacco products, prevent young people from using tobacco products, and increase the availability of cessation services such as the Texas Tobacco Quitline and nicotine replacement therapy medications;
• Increasing number of healthcare providers who assess, counsel, refer and treat young people and adults for cessation services (e.g. Texas Tobacco Quitline, nicotine replacement therapy medications); and
• Engaging stakeholders and partners to provide education, messaging, screening and counseling to populations with the greatest disparities in and risks from tobacco use and secondhand smoke.

 

 

Challenges/Opportunities: FY19 was a time of tremendous change for MCHS including significant structural reorganization, an active legislative session, rapid development and implementation of a large scale statewide quality improvement initiative, scaling up on MMMRC case preparation and review, and significant changes in staffing. A new Maternal Health and Safety Coordinator was onboarded in September 2018 who, along with another Maternal Health and Safety Coordinator who had recently joined the team in August 2018 and the HTMB Team Lead/Nurse Consultant, would support the TexasAIM Initiative. Soon after onboarding new staff, the Unit Program Specialist VI, who had been leading efforts related to the TexasAIM opioid bundle, resigned in September 2018. Also leaving in FY19 were the Maternal Mortality and Morbidity Review Nurse Consultant in April 2019 and the Perinatal and Infant Health Coordinator in August 2019. By the end of FY19, three staff—the former HTMB Team Lead/Nurse Consultant, who was promoted to HTMB Branch Manager in February 2019, and the two Maternal Health and Safety Coordinators— were charged to manage the full scope of HTMB women’s, maternal, perinatal and infant health programming along with support from the MCH Unit Manager, who joined the team in May 2019, and the MCHS Manager. The Legislative Exceptional Item and CDC ERASE MM grant both provide opportunities to increase staffing in FY20 to adequate levels to support and sustain the expanding scope of HTMB women’s and maternal health and safety programming.   

 

[1] Broussard DL, Sappenfield WB, Fussman C, Kroelinger CD, Grigorescu V. Core state preconception health indicators: a voluntary, multi-state selection process.

 Matern Child Health J. 2011;15(2):158-68.

[2] CSTE, Core State Preconception Health Indicators, General Health Status Domain, Self Rated Health. September 2009. Avialable online at https://www.cste.org/page/PreconIndicators

[3] In 2013, the Texas Legislature created levels of care designation for neonatal and maternal care in Texas hospitals. Texas Administrative Code established Perinatal Care Regions (PCRs) to be integrated in existing Trauma Service Areas and the applicable Regional Advisory Councils for regional planning purposes and to facilitate development of required transfer agreements among hospitals. Hospitals must be designated for a neonatal and level of care to receive Medicaid reimbursement, and maternal level of care designation will be required beginning September 1, 2021, Designated hospitals must participate in their PCRs including requirements for hospitals’ Maternal Medical Directors (MMDs) and/or Transport Medical Director (TMD), hospitals’ Maternal Program Managers (MPMs), and hospitals’ Neonatal Program Managers (NPMs) to develop collaborative relationships with their counterparts of designated facilities within their PCR.

[4] Salahuddin M, Mandell DJ, Lakey DL, Eppes CS, Patel DA. Maternal risk factor index and cesarean delivery among women with nulliparous, term, singleton, vertex deliveries, Texas, 2015. Birth. 2019 Mar;46(1):182-192. doi: 10.1111/birt.12392. Epub 2018 Sep 9. PMID: 30198160.