In the domain of Maternal/Women’s Health, we continue to focus 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 maternal and infant mortality rate in Delaware and we understand the importance of preconception care and quality prenatal care for our mothers.  In order to continue making progress in providing “whole health” care to our women and mothers, we continue to bolster and nurture our community partnerships by working together focused on addressing the social determinants of health, leveraging talents and resources, and striving to find new ways to provide services.

 

Over the last year, the Delaware DPH team worked on developing a new Five Year Delaware Healthy Mothers and Infants Consortium’s (DHMIC) strategic plan.  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.  The DHMIC Five Year Strategic Plan is available on Dethrives.com and is driving our new leadership onboarding and membership engagement process.

 

The DHMIC is currently undergoing a change in leadership, after 20 plus years of consistent leadership as well as a significant membership turnover, never experienced before. Dr. David Paul and Susan Noyes, MSN, RN, stepped down as Chair and Co-Chair on the DHMIC Executive Committee after serving for nearly two decades.  DPH staff worked with the Governor’s Boards and Commissions to elevate the DHMIC Nominations committee recommendations for leadership successors as well as vacant positions to allow for a smooth transition over a very condensed 3 month timeframe.  A very special tribute video was developed and show cased at the 17th Annual DHMIC Summit and can be viewed Annual Summit 2023 | Delaware Thrives (dethrives.com) . Onboarding the new leaders and members will require a historic overview of the inception and purpose of DHMIC, a review of its current infrastructure and revisiting its bylaws and committee structure.  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.  The current Committees and workgroups include:

1. Well Woman/Black Maternal Health Committee - The focus of this committee is on a comprehensive, evidence-based approach to reproductive health and the health of women before, during, and after pregnancy - one that is woman-centered and clinician-engaged.  The group functions to meet the diverse and often complex needs of reproductive-age women, particularly from more vulnerable populations, and works to foster leadership and information sharing, solicit voices of the consumer, encourage innovation, build awareness, and promote reproductive life planning. 
   1. The Black Maternal Health Workgroup (BMHW) sits under and reports to the Well Woman Committee.  The purpose of the BMHW is to address the disproportionately high and unacceptable rates of maternal mortality and morbidity in Black and Indigenous People of Color (BIPOC) communities in Delaware.  The BMHWG will work to ensure all women of reproductive age in Delaware will be healthy and have access to safe, respectful, culturally appropriate maternal care before, during and beyond pregnancy.

 

2. The Social Determinant of Health Committee which seeks to understand where people live, work, play and pray can help create actionable engagement strategies to improve health outcomes by addressing barriers rooted in structural racism.  This group works to collaborate with the community, offer space for shared learning with providers, review policies and programs to identify opportunities for change, evaluate best practices, identify health needs, and engage the faith-based community.  The SDOH Committee is focused focus on housing for pregnant and parenting women and a guaranteed basic income demonstration program as a priority.   The Social Determinants of Health Committee of the Delaware Healthy Maternal Infant Consortium, is undergoing a change in leadership and Representative Minor-Brown will be paired with a new co-chair, focused on two demonstration projects to address housing insecure pregnant women launched in Spring 2022.   Some basic program model components are described below:

• GBI Eligibility

• Pregnant women in 1st or 2nd trimester
• Eligibility based on current income;​ under 185% FPL
• Eligibility based on $1,000 extra earnings per month​
• Live in a HWHB High risk Zones

 

• Minimum requirements:
  • Program recipients must be a part of the evaluation (survey and interview) every 2-3 months
  • Work with a Case worker/Community Health Worker, preferred weekly to 2x per month; required every quarter
  • Work with a Financial Coach and Career Team (if applicable); preferred weekly tot 2x per months; required every quarter

 

Updates on both projects are below:

a)     Guaranteed Basic Income Demonstration Project

Currently both cohorts totaling 40 women are enrolled and receiving $1,000 per month for 24 months. Eligibility includes women in their first or second trimester, under 185% of federal poverty, and that live within specific zones shown to have disparate birth outcomes. Once determined eligible, women are informed using a Federal Reserve Bank of Atlanta tool, of any benefits that might be impacted by receiving $1,000 extra each month. It is up to each eligible woman to decide if she would like to enroll.

Seventy eight percent (78%) of women enrolled are Black, eighteen percent (18%) are Hispanic, and 5% are Caucasian. Two rounds of surveys, interviews and focus groups have focused on: Changes to financial well-being and access to services, Immediate impacts on stress and well-being, Initial feedback on the program, including the coaching and case management, and Preliminary spending patterns. Initial interview findings include program is easy to enroll and access the funds, work with case managers has been helpful, and program has positively impacted their lives with improved mental health, reduced stress, improved access to food, healthcare, daycare, and transportation, and lastly, other children have experienced positive impacts.

The average income of enrolled women prior to enrollment was $1,146 per month, and after enrollment was $2,246. Participants are becoming connected with Medicaid, WIC, food assistance, and housing assistance. Stress level decreased from pre-survey to first quarter survey, and most women reported an increased ability to get clothing, childcare, phone, medicine/health care. The top three expenditures are groceries/food/restaurants (30%), rent (12%) and wholesale or discount stores (9%).   It is important to note, even with the GBI program, women reported spending about 48% of their monthly income on rent.

b) Housing Stabilization Demonstration Project

In partnership with the Delaware Housing Assistance Program (DEHAP), the program launched last fall with a focus on women at risk of losing their housing as opposed to those who have already lost their housing. Women were identified by HWHB providers and referred into the program. Due to the restrictions of DEHAP, some women had already received the benefit and thus were no longer eligible. A total of 11 applicants were received, of which 9 were ineligible. The two eligible applicants were in the process of enrolling when DEHAP announced they were closing the program due to lack of funds. The social determinants of health committee will continue to pursue housing options for pregnant moms and are currently seeking some alternative longer-term solutions.

DPH is supporting the GBI demonstration project, Healthy Women Healthy Babies Opportunity, with State Infant Mortality funds as well as ARPA funds to expand and support this demonstration project, which was approved by the Office of the Governor. 

 

Health Management Associates (HMA) was hired contractually by the Division of Public Health to analyze conditions in Delaware that would inform these two demonstration pilots, such as housing stability, enrollment size and criteria, funding availability, and evaluation needs.  As part of this, HMA also engaged childbearing women who are or who have been housing insecure to help in the design of the pilot.  The findings should help the DHMIC’s implementation workgroup and the SDOH Committee make recommendations to the broader DHMIC on how to design and monitor these demonstration pilots.

 

3) Maternal and Infant Morbidity/Mortality workgroup, which examines the data and evidence of the health status of women in Delaware, particularly those in the 14- to 44-year-old age range and those with poor birth outcomes (e.g., premature birth, low birth weight).  This group works to foster leadership, identify gaps in data, cultivate relationships, enhance provider knowledge, review findings, reframe postpartum/interconception care, enhance capacity for statewide quality improvement, and explore best practices to address risks. 

 

Education and prevention are a cornerstone of the DHMIC work, utilizing the latest social media platforms. In partnership with a social marketing firm, Aloysius Butler and Clark (AB&C), 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, YouTube, and most recently added Instagram, 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, DPH launched the newly designed website (www.DEThrives.com)  at the 17th Annual DHMIC Summit, which is easy to grow, easy to maintain, and easy to navigate, and one that is search relevant.  

 

On April 18, the Delaware Healthy Mother & Infant Consortium (DHMIC) held its 17th annual summit to discuss ways to prevent infant and maternal mortality and to improve the health of women of childbearing age and infants throughout Delaware. The DHMIC focuses on understanding and addressing the racial, ethnic and geographical disparities that are present in high-risk zip zones to reduce poor health outcomes in mothers and their infants. The 2023 theme was “RENEW. RECONNECT. RECHARGE. Join our journey as we strengthen our commitment to healthy women, babies, and communities.”.

This was the first in-person summit in three years, largely due to the COVID-19 pandemic. There were 365 registrants maxing out the venue’s capacity. The event drew in many healthcare professionals, policymakers, community influencers, community partners, stakeholders, and citizens such as nursing students who were interested in learning ways on how to provide access to proper care for all Delaware mothers, before, during, and after pregnancy, their babies, and families no matter their socioeconomic, racial, or ethnic status.

Lt. Governor Bethany Hall-Long provided opening remarks on the importance of why we should continue the work to address maternal and infant mortality in Delaware. There were three keynote speakers with Q&A that presented topics on the importance of reducing racial and ethnic inequities, ensuring quality, equity, and respectful care for women and their babies, and the importance of having a strong and fearless team alongside you to ensure health equity can be made available for all regardless of racial differences.

In between the three keynote speakers, there were group breakout sessions and a panel discussion moderated by DHMIC members and DPH leadership, innovation stations that showcased the Healthy Women Healthy Babies (HWHB) mini-grantees, a visual artist that captured the day’s theme, topics, and experiences in illustration and graphic form which will be used for media use, and multiple activities that encouraged group discussions among attendees and education with the innovation stations.

During the Summit, it was also the launch of the newly designed DEThrives.com website which houses DHMIC information along with Maternal and Child Health programs and initiatives and free community based resources for teens, women, men, families, and the community, to live healthier lives. The message that DEThrives encompasses is the same as the DHMIC’s, where healthy communities are made of healthy people – healthy mothers, healthy babies, healthy families, healthy communities. There were nearly 170 users who visited the newly designed site during the summit (compared to the average count of 89 users), over 160 users who viewed the DHMIC section of the website during the summit and almost 220 views on the DHMIC section of the website the day after the summit (compared to the average 77 view average). There were over 2K impressions (number of times a post has been displayed), over 150 total engagements (any action a user does on a post such as liking, commenting, or sharing the post), and more than 40 tags on social media for users who utilized hashtags of #DEThrives and #DHMICSummit2023 during the summit and into three days after the summit to help spread the word of the event and the newly designed website on social media.

DPH’s Interim Director, Dr. Liz Brown, presented the annual Kitty Esterly, MD, Health Equity Champion Awards which recognizes a person or organization who puts in the extra effort to address and change the causes of infant mortality with a health equity approach by improving the overall health and well-being of mothers and the community. The individual award was given to Mona Liza Hamlin, MSN, RN and the organization award was given to “Black Mothers in Power”. The announcement of these awards on DEThrives’ social media accounts ranked as one of the highest performing in the total number of engagements (any action a user does on a post such as liking, commenting, or sharing the post) on Facebook, Instagram, and Twitter.  Also, photos from the Summit can be viewed here on our FB page. 

Senator Marie Pinkney, a DHMIC member, presented the Black Maternal Health Awareness Week Resolution at the Summit, which recognizes that the week of April 11th through April 17th will be now be known as “Black Maternal Health Awareness Week” in Delaware.  The DPH/Family Health Systems team drafted the resolution to elevate this important week.

Summit speaker presentations have been repurposed on https://dethrives.com/summit and social media channels, including Facebook and Twitter.

 

As a continued effort on addressing maternal mortality and morbidity and to make a concerted effort to reduce our racial disparity in infant mortality, Delaware has identified Infant Mortality as a State Performance Measure.  Our work to address infant mortality is spearheaded by the Center for Family Health Research and Epidemiology, which is housed within the Family Health Systems Section, led by our Title V/MCH Director.  These efforts are very much a part of our Title V federal state partnership and continue to be supported by $4.2M in state funding allocated to DPH for prevention of infant mortality.  The DHMIC 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.  DHMIC and its partners continue 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.

 

DPH is proud to share accomplishments resulting from implementing 10 Healthy Women Healthy Baby (HWHB) Zones community-informed strategies that aim to increase awareness, educate, better serve women of reproductive age and amplify the voice of black maternal health grass roots organizations.  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 complement to our medical intervention, HWHBs 2.0.  The first-ever mini grants support the shared initiative to narrow the wide variance in birth outcomes between black women and white women by building state and local capacity and testing small-scale innovative strategies.  DPH worked with Health Management Associates (HMA), as the lead backbone entity, to develop a mini-grant process to fund local communities/organizations to implement interventions to address social determinants of health in priority communities throughout Delaware.  This year we added two new mini grantees, for a total of  ten active mini grantees awarded including: Delaware Adolescent Program, Inc. (DAPI), Delaware Coalition Against Domestic Violence (DCADV), Delaware Multicultural and Civic Organization (DEMCO), Hispanic American Association of Delaware (HAAD), Kingswood Community Center (cycle 1 only), Black Mothers in Power, Parent Information Center (PIC), Delaware Breastfeeding Coalition, Rosehill Community Center, Life Impact, and Christina Cultural Arts Center.  This past year, we added two new mini grantees addressing two priority areas including fatherhood/partner involvement and engagement and food insecurity.  A short description of the awarded community-based interventions are described below.

 

• Delaware Adolescent Program, Inc.: serves teen mothers and their partners providing mentoring services and Support for social and emotional well-being and support in navigating the health and social services system.
• Delaware Coalition Against Domestic Violence: This organization provides support to victims of domestic violence and administers flexible Health Access Funds to support the safety and health of the participants.  DCADV also trains health care providers on best practices for domestic violence assessment and response.
• Delaware Multicultural and Civic Organization (DEMCO): Provides life skills supports and job training education to young women of childbearing age, including those who are pregnant and parenting
• Hispanic American Association of Delaware: This organization provides pregnancy and postpartum support in Spanish to women ages 15-44 who live in ZIP code 19720 in New Castle County.
• Rose Hill Community Center: Provides fitness, nutrition counseling and self-improvement classes to women at no cost as well as case management support to pregnant women receiving Guaranteed Basic Income.

• Parent Information Center (PIC):  Train six doulas, who will provide nonclinical emotional, physical, and informational support before, during, and after labor and birth.  In partnership with community organizations, the program will also provide virtual training on childbirth education, breastfeeding initiation, prenatal nutrition, healthy family relationships, and community supports; empower women to be their own self-advocates; provide one-on-one coaching calls with pregnant women (prenatal and postpartum) starting six weeks before due date and continuing six weeks postpartum; offer postpartum support groups with other new parents as well as breakout sessions on breastfeeding, sexuality, mental health, and infant development; and create an awareness campaign focused on prenatal and postpartum support.
• Black Mothers in Power (BMIP), a grassroots organization focusing on Black mothers in the community and underserved populations.  The BMIP will provide and sponsor a doula program to train 10 black women to become certified doulas through the National Black Doula Association.  The organization will be training five doulas in New Castle County and Kent County, and will be focusing on engaging at-risk pregnant women who live in high-risk zones.  Each doula will help women during the critical times of pregnancy, birth and postpartum, and early parenting.
• Breastfeeding Coalition of Delaware will provide breastfeeding support groups to the HWHB high-risk zones of Wilmington, Claymont, and Seaford.  It will offer accessible support, engaging groups, text check-ins, access to variable levels of lactation support, and incentives for participation.  In addition, the Breastfeeding Coalition of Delaware will hire three diverse breastfeeding peer counselors (BPC) and one lactation consultant to provide breastfeeding support to women.  At the completion of the program, the Breastfeeding Coalition of Delaware will host a baby shower for participants, where they will provide needed baby supplies, education, and support to pregnant and postpartum women.
• Impact Delaware, Inc.  Impact Life is an innovative behavioral Health Organization whose mission is to build a solid foundation of recovery through unique recovery residences, peer support, workforce development, cultural and spiritual experiences, opportunities for peer leadership and service work projects. This organization is piloting two programs. The first program is a cashless grocery store in New Castle County modeled off “Greater Goods” in Philadelphia, under this program Individuals come to a local bi-weekly pop-up food distribution event and are given and allotted number of tokens per person in which they can use to shop for food. Impact life is also creating a Pilot program of a “Door Dash” type mobile food distribution in Western Sussex County. Due to the rural area and lack of resources, individuals would sign up for bi-weekly food distribution that would be delivered to them. This reduces the transportation barrier as well as the shame that can be associated with food insecurity.  They will also provide Education programs that teach individuals how to grow their own food at home and make nutritious meals in Western Sussex.
• Christina Cultural Arts Center mission is to change the trajectory of a child's life by making affordable arts, education, career pathways, gallery exhibitions and live performances accessible to all in a welcoming environment. CCAC will provide self-care workshops and activities which will focus on the health and wellness of the parent/adult caregivers in a child’s life. They are expanding CCAC’s activities to appeal, attract, and maintain participation of fathers and to provide quarterly Fatherhood Initiative meetings and plan to hold activities and include a fatherhood track in 4 Self-Care Weeks.

 

At the time of this writing, the third full year Evaluation report for the Healthy Women Healthy Baby Zones will be released in September 2023.  Some of the preliminary findings from the participants demonstrate progress and a positive impact as it relates to the overall NPM1 Well Woman:

• Demographic data:  500 women and girls served; majority of participants from Zip codes 19702, 19720, 19801, 19804, 19805, 19901, 19904; 605 of participants were black, 35% were white, 6% identified as “multi-racial/other”; 105 participants said Spanish was their primary language; About ½ have a high school diploma or GED.
• Most common expressed needs by the women screened and engaged in the mini grantee interventions were referred to resources for stable housing, utility assistance, help reading health materials (health literacy), and access to food. Nearly half struggle with childcare, transportation, social support or access to medical care.
• 72% of participants have either been pregnant, are parenting, or is currently pregnant.
• Participants were screened for pregnancy intention and referrals were made as appropriate to local family planning provider sites and Healthy Women Healthy Babies providers.  The majority of participants are not intending to become pregnant in the next year.
• Of the DEMCO participants, on average 82% of participants felt that they had improved their professional skills and increased confidence to prepare for employment.
• Of the DCADV participants, 96% of flex fund recipients reported that the funds "Significantly" or "Completely" reduced their financial stress.
• Of the Rosehill participants, 59% of participants lost weight.  On average, participants lost 3lbs over the course of the program.
• Of those that participated in the DAPI intervention, they were asked “To what extent did the program increase resilience to relationship pressure and intention to apply refusal skills?”  75% of students reported confidence applying refusal skills (“I would feel comfortable saying no to my partner when I don't feel like having sex”). 
• Participants showing statistically significant improvements in depression, anxiety and stress.
• Adapted wrap around services and support during Covid-19 included “flex funds”, computers and internet needs.  Flex funds were most commonly used to meet basic needs such as food, diapers, winter coats, and feminine hygiene products, to support needs of children, to pay utility bills, to meet physical needs, and to buy essential furnishings.

 

One key component of the HWHB Zones initiative is the provision of coaching and technical assistance (TA) to the mini-grantees (and one unfunded organization) throughout the life of the initiative to build capacity and ensure sustainability of the interventions, as well as focus on continuous quality improvement.  In Grant Cycle 1, 2, 3, and 4 the TA consisted of two learning collaborative meetings as well as individual coaching and TA.  Each mini grantee has a coach from HMA with whom they meet regularly.  The frequency and length of coaching and TA calls and meetings over the last year were developed by each coach and mini grantee in collaboration.

 

The DHMIC embraced the focus and framework of a preconception health approach, to optimize the health of women before, between and beyond pregnancies.  Delaware developed the 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 focuses 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.  DHMIC, through DPH has a contractual support position, a Women’s, Infants, and Families Nurse Consultant that devotes time and expertise to lead the Women’s Wellness initiative.  This year, a new  WIF Nurse Consultant was hired to focus on a one year workplan.  Some of the core responsibilities include:

• Identify and develop life course perspective tools for health care providers and community outreach centers.
• Develop and carry out education programs.  Prepare educational materials and assist in planning and developing health and educational programs for health care providers, peer counselors, consumers and community.
• Act as a resource and support workgroup activities to advance preconception health as well as the Healthy Women Healthy Babies 2.0 as it relates to well women care.
• Promote at the grass roots level the programs and initiatives of the DHMIC, this may include conducting workshops, conferences, and seminars such as decreasing unintended pregnancy rates, improving well woman care/preconception care, postpartum rates, birth spacing, etc.; required to speak before special interest groups, community organizations, medical and health care groups, or the general public.
• Provide expert consultation in women's and fetal/infant health and recommend modifications to programming based on knowledge of best practices. 

 

The WIF Nurse Consultant promoted the Preconception Peer Education Program and encourages new colleges and universities to adopt and operationalize the program.  The PPE program was implemented in May 2007 by the Office of Minority Health (OMH) of the Department of Health and Human Services, supported by DPH and the DHMIC for replication.  This national program was launched as part of its initiatives to eliminate health disparities among racial and ethnic minorities in the U.S.  The Preconception Peer Educators (PPE) Program was developed to raise awareness among college students about being well before, during, and beyond pregnancy.  The overarching goals of the PPE program are to reach college-aged populations with targeted messages stressing the importance of preconception health and health care, train college students, particularly minority students as peer educators, and provide them with the tools necessary to educate other students of reproductive age (15-44) on their respective campus about the importance of receiving preventive care, education, and counseling before deciding to create a baby.  While the program initially was going strong at the University of Delaware, there were some changes in leadership that made sustainability a little rocky and therefore, the WIF Nurse Consultant worked tirelessly over the last year to re-engage the University of Delaware to establish the program and provided a training to the new UD advisors and new students.  The WIF Nurse Consultant provided technical assistance and support to the University of Delaware to ensure sustainability of the University of Delaware’s PPE chapter. 

 

Recognizing the potential of doulas to improve outcomes for our most vulnerable women and babies, the State of Delaware is exploring ways to improve access to doula care for this population, including Medicaid reimbursement.  DPH and the Division of Medicaid and Medical Assistance (DMMA) under the auspices of the DHMIC have begun having conversations with community stakeholders (including birthing hospitals) about the support doulas can provide to women prenatally, during labor and delivery and postpartum and what would be needed to move towards credentialing and Medicaid reimbursement.  The DHMIC established a Doula Adhoc Committee, which is led by DHMIC member and legislator, Representative Mimi Minor Brown, to continue to address doula policy and reimbursement opportunities.  While many of the services provided by doulas are nonmedical, there is evidence of the benefits of doulas to address health disparities and improve maternal and infant outcomes.  There are barriers to designing a reimbursement structure and process for seeking Medicaid reimbursement. Some of these barriers include establishing minimum requirements for certification & training, reasonable reimbursement rates for both Doulas and Medicaid, and billing coverage if doulas enroll as independent providers.  Also, ​because many doulas see themselves as rooted in their communities and not necessarily the formal healthcare system, there is currently no single national doula network or credentialing association and we do not know how many doulas there are in the state/people interested in offering doula services.  

 

DPH engaged doulas across the State of Delaware to gather their insights on issues related to training and certification to inform the development of a statewide infrastructure to increase access to high quality doula are for women most at risk of poor birth outcomes in the state. The stakeholder engagement study aimed to gain an in-depth understanding of community-based doulas’ knowledge, attitudes, feelings, beliefs and experiences in relation to training and certification, as well as other perceived needs in the state. Our specific research questions included the following: How do doulas perceive training and certification requirements for their practice? Assuming certification is required for Medicaid reimbursement, what core competencies do doulas believe should be included in approved training programs in order to meet the needs of low-income women and women of color? What supports do doulas believe are needed to better serve the Medicaid population in Delaware?  Three focus groups were conducted in September and November 2022 for a total of 11 participants.  A brief summary of findings:

• Training and Core Competencies – Any training required for Medicaid reimbursement should include full spectrum of care, from prenatal to postpartum.  Cultural competency training is essential component.  Need-based financial assistance for training should be provided to support access to doula care.
• Certification – Provide flexibility in training requirements and include a pathway for experienced doulas to waive training requirements.
• Education of Health Care Providers – positive working relationships between licensed providers and doulas is critical for the delivery of high quality, integrated care.  Raise awareness about doulas’ scope of services and the value they offer to birthing people.
• Doula Representation – Representation of doulas in policy making, from planning to implementation is essential.
• Professional Development & Networking/Mentorship Opportunities -  the State or health care organizations should develop training, TA and support systems for navigating the Medicaid reimbursement process.

 

DMMA, per HB 343, passed in 2022 by the Delaware General Assembly, finalized a doula care services benefits package under Medicaid.  Over the past year, DMMA has been meeting with doula stakeholders in Delaware to collaborate on designing a Medicaid doula benefit. During this time, the workgroup discussed the various authority options through the Centers for Medicare and Medicaid Services (CMS), the benefit design, reimbursement, and credentialing requirements. Additionally, DMMA explored Medicaid doula benefit designs in other states, including meeting with Medicaid leaders in California and Virginia on their benefit design and development. Building on lessons learned from Virginia, DMMA connected with their Certification Board to learn more about certifying doulas for Medicaid reimbursement. The selected Certification Board has worked with Virginia and Rhode Island to develop their approach to their Medicaid Doula certification process. Next steps are to support the Delaware doula stakeholders in working with the Delaware Certification Board to develop a process and system to verify doula credential. 

 

Healthy Women Healthy Babies (HWHB) program 3.0, was a focus over the last year and will be rolled out in the coming year using a similar framework focused on performance-based outcomes.  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.  There will be an important focus on incorporating a strong behavioral health component to the 3.0 model.   

 

The HWHBs 3.0 program will continue to use an outcomes-orientation and learning collaborative approach 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.).  

 

Data collection and analysis is central to this new HWHBS 2.0 model as well as continuous quality improvement (CQI) for ongoing learning and improvement.  This means that tracking, assessing, and improving outcomes for the HWHB program 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.  This year, we leveraged  additional funding streams to support community health worker expansion into high risk zones.  The HWHB community health workers conduct community outreach in the high risk zones via a systematic approach in partnership with community based organizations to address well woman care aspects of health and social determinants of health such as housing, transportation, food insecurity, and access to mental health services.

 

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) Nurse Family Partnership, and Parents as Teachers.  This year, Delaware received a highly competitive $1.89M Maternal, Infant, Early Childhood Home Visiting (MIECHV) Innovation and Implementation grant earlier this year, which DPH’s Maternal and Child Health Bureau administers and manages. The grant seeks to develop data and technology approaches that improve delivery of home visiting services.  In addition, the grant leverages existing administrative data to measure and assess social and structural determinants of health (SSDOH) contributing to disparities in access and/or outcomes of families enrolled in home visiting services.  Delaware’s proposed innovation will strengthen the referral linkages across evidence-based home visiting programs and agencies that hire, train and deploy community health workers. In doing so, families currently enrolled in evidence-based home visiting programs who have unmet adverse SSDOH that cannot be readily nor robustly addressed by home visitors will be referred to community health workers who have the capacity and capability to assist these families.

 

Delaware Division of Medicaid and Medical Assistance (DMMA) launched Medicaid reimbursement for evidence-based home visiting programs.  While we have learned that there are a variety of approaches and mechanisms for reimbursement through Medicaid, movement on solidifying reimbursement for home visiting services is finally getting some traction. 

 

School Based Health Centers (SBHCs) provide prevention-oriented, multi-disciplinary health care to adolescents in their public school setting, and also contribute to better outcomes related to NPM 1 Well Woman Care.  There is a growing interest for expansion to elementary, middle and additional high schools.  School Based Health Centers are going through a paradigm shift, and there is a lot of stakeholder interest and commitment to understand national and in state innovations in practices and policies, and explore options moving forward to enhance SBHCs in Delaware within the local healthcare, education, and community landscape.  Delaware currently defines SBHCs as health centers, located in or near a school, which use a holistic approach to address a broad range of health and health-related needs of students.  Services may also include preventative care, behavioral healthcare, sexual and reproductive healthcare, nutritional health services, screenings and referrals, health promotion and education, and supportive services.  SBHCs are operated by multi-disciplinary health professionals, which includes a nurse practitioner overseen by a primary care physician, licensed behavioral health provider, licensed nutritionist, and or dental hygienist.  SBHCs are separate from, but interact with, other school health professionals, including school nurses and school psychologists and counselors.  SBHCs also operate alongside and interact with outside health care professionals and systems. 

 

The Delaware Division of Public Health (DPH), in collaboration with several key stakeholders, completed a year long process to create a Delaware School-Based Health Center (SBHC) Strategic Plan, released in 2021.  The planning helped DE develop a model for expansion of SBHCs that is both financially sustainable and anchored in best practices.  The DPH Adolescent and Reproductive Health Bureau team is working on aligning staff to support implementation of the strategic plan, provide technical assistance to our medical sponsors and support expansion.

 

Delaware’s SBHCs provide important access to mental health services and help eliminate barriers to accessing mental health care among adolescents (i.e. women).  Over the last five years, school district school boards voted and approved to add Nexplanon as a birth control method and offered at the school-based health center sites and as of this writing total 14 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.  Offering the most effective birth control methods as an option, gives more young women informed choices so that they can decide when/if to get pregnant and ultimately reduce unplanned pregnancies. 

 

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 system 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.

 

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 during the intensive intervention.  Upstream hosted 130 trainings, trained nearly 3000 clinicians and staff from 41 partners representing 185 sites across DE.  A key component of the 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.  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.

 

DPH has successfully integrated the nationally recognized Delaware Contraceptive Access Now (DECAN) initiative into the Family Planning Program, which sits in the Family Health Systems Section in DPH, where Title V MCH also resides organizationally.  Since FY20, the program receives a consistent state GF investment in the amount of $1.5M and furthers the DPH’s priority to sustain providing low cost access of all methods of birth control, including the most effective LARCS to low income women across the state.  This initiative continues to improve public health by empowering women to become pregnant only if and when they want to by training staff on best practices in patient-centered care and shared decision-making, that will increases their knowledge of all contraceptive methods including mechanism of action, efficacy, risks, side effects and benefits.   Developments in the last year, include drafting regulations to support a bill passed into law that would extend and authorize Pharmacists to dispense and administer hormonal birth control.  The Adolescent and Reproductive Health Bureau team will support implementation.

 

The Division of Public Health’s team, is working with five of the six Delaware birthing hospitals to ensure that all patients can receive the contraceptive method of their choice immediately after giving birth, including immediate post-partum LARCS.  This change in policy will promote healthy birth spacing and give women more access to all methods of birth control.  Currently the largest hospital system in the state, Christiana Health Systems offers these services, as well as Nanticoke Health Systems and Bayhealth Medical Centers.  Beebe Medical Center has trained their providers and have implemented this service in the past year.  The Division of Public Health continues to work with all hospitals statewide on training and technical assistance with 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.

 

DPH has developed a Contraceptive Counseling training based on Upstream, USA’s team approach patient-centered contraceptive counseling model and continues to provide support to Sub-Recipient Sites on sustainability of this initiative.  This training is offered on a quarterly basis to all Title X Family Planning sites as well as Delaware Social Service Organizations to provide patient-centered contraceptive counseling for their clients experiencing challenges including substance use disorder, mental health issues, homelessness and domestic violence.  A partner resource page has been developed by Upstream, USA so that tool kits and documentation are available to providers to support and sustain the project.  

In 2022 the Delaware Family Planning program completed four full in-person training sessions on February 23, 2022, May 26, 2022, August 24, 2024 and October 26, 2022. As of today, for 2023, we have completed two full training sessions on February 23, 2023 and April 27, 2023 along with one site requested contraceptive counseling training on March 27, 2023.  These trainings included interactive conversations and games that cover topics such as the DECAN initiative, all methods of contraception, bias and coercion, patient-centered/shared decision making, patient centered contraceptive counseling, and hands-on clinical Nexplanon and IUD training for clinicians.  On June 5, 2023 we had a non-clinical training virtual training for DOC.  The DECAN program will have two additional trainings in 2023 on August 24, 2023 and October 26, 2023.  

There was a total of 29 staff members in 2022 whom were trained on the DECAN initiative, all methods of contraception, bias and coercion, patient-centered/shared decision making, patient centered contraceptive counseling, and newly added cultural competency.  There was 11 clinicians trained in Nexplanon insertions/removals and 7 clinicians trained on IUD insertion/removals.  A total of 6 provider sites took part in the 2022 DECAN trainings including staff and providers from Westside Family Healthcare, Beebe Healthcare, Tidal Health, Department of Corrections, LaRed Health Center, and Henrietta Johnson Medical Center.  So far in 2023 there has been 19 staff trained in the non-clinical portion of the DECAN training as well as 4 clinicians trained in Nexplanon insertion/removals and 4 clinicians trained in IUD insertion/removals. 

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 2016-2022.  In September 2023, a final evaluation presentation will be shared with key stakeholders.  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.  Some very preliminary findings were shared:

• We find increases in LARC use for Title X adult patients
• We find increases in postpartum LARC use for Medicaid and non-Medicaid women
• We find increases in LARC insertion for teens enrolled in Medicaid, age 15-18.We do not find statistically significant results for LARC insertion for adult non-postpartum women in Medicaid, age 19-44.