FFY 2019 Annual Report

 

Women’s/Maternal Health – State Priority #1: Reduce maternal mortality and morbidity.

 

The factors impacting women's health are complex and varied, ranging from social-emotional, environmental, health insurance status, access to health care, and any number of other factors including the social determinants of health in which individuals are born, grow, live, play, work and age.  Improving women’s health throughout the life course is essential to improving the health and wellness of women.  The NYS Title V program promotes and supports a myriad of efforts to improve the health of all women. 

 

Over the past year pursuant to the State Action Plan (SAP), the NYS Title V program continued to focus on improving access to health care, increasing access to the most effective forms of contraceptives, supporting preconception health, promoting whole women’s health through the life course, and improving screening and treatment for maternal depression and substance use.  Of importance to these efforts is the goal to promote health equity for all New Yorkers, which is emphasized throughout all domains and reflected in the Life Course section of this application. 

 

Maternal mortality and morbidity are critical indictors for maternal and women’s health in NYS and therefore a priority in NY's Title V SAP. Understanding factors associated with maternal mortality and morbidity is essential for improving maternal health outcomes. Therefore, a strategy for this domain continues to be a more complete analysis of factors impacting maternal mortality and morbidity. As stated in previous Title V applications, NYS has a history of more than a decade in assessing factors leading to maternal deaths and developing strategies to reduce the risk of maternal mortalities. NY’s Title V program led the effort to establish the Maternal Mortality (MMR) Initiative in 2010, which is a comprehensive review of all maternal deaths. In the MMR Initiative, the NYS Department of Health’s (NYSDOH) conducts comprehensive surveillance activities based on linked birth and death record data, hospital in-patient and emergency department data and a hospital-based adverse event reporting system to identify maternal deaths.

 

Recently, the report of maternal deaths for 2012- 2014 was published. The findings from this cohort indicated the top six leading causes of pregnancy-related deaths (N=96) was: embolism (not cerebral) (23%), hemorrhage (17%), infection (17%), cardiomyopathy (11%), cardiovascular problems (7%) and hypertensive disorders (6%). This is consistent with the results from 2012-2013 cohort.  The expansion of the cohort to include 2014 revealed that Non-Hispanic Black mothers accounted for 45% of pregnancy-related deaths versus 30% for Non-Hispanic White mothers. The majority of pregnancy-related deaths were covered by Medicaid.

 

Racial disparities in maternal deaths are persistent; the statewide 3-year-rolling Black to White mortality ratio ranged from a high of 4.3 to 1 in 2005-2007 to a low of 3.2 to 1 in 2011-2013, with the most current ratio (2015-2017) falling at 3.3. The most recent data showed small geographic differences. In New York City, the Black to White ratio decreased from 3.4 in 2013-2015 to 3.0 in 2015-2017. This decrease in Black to White ratios was due to a slight increase in the maternal mortality rate among White women and the decrease in the maternal mortality rate among Black women. Outside New York City, the Black to White ratio decreased slightly from 3.9 in 2013-2015 to 3.4 in 2015-2017. This decrease in Black to White ratios was due to a slight but bigger decrease in the maternal mortality rate among Black women than the decrease in the maternal mortality rate among White women.

 

Recent data from NYS Vital Statistics showed that maternal deaths increased to 20.2 per 100,000 live births in 2014-2016 but remained lower than the Prevention Agenda (PA) 2013-2018: New York State's Health Improvement Plan goal to reduce maternal mortality (MM) to fewer than 21 maternal deaths for every 100,000 live births by 2018. By continuing the comprehensive review of factors leading to maternal deaths through the MMR Initiative and designing strategies to address those factors, Title V aims to continue to improve outcomes for mothers and babies and is expected to meet the Prevention Agenda (PA) 2019-2024: New York State's Health Improvement Plan goal to decrease maternal mortality (MM) to 16 maternal deaths for every 100,000 live births by 2024.  https://health.ny.gov/prevention/prevention_agenda/2019-2024/background.htm

 

The reviews of the recent-year cohorts of maternal deaths are underway. All 216 cases in the 2016 cohort and all 214 cases in the 2017 cohort have been completed.  For 2018, 45% of the 173 identified cases are complete using the Centers for Disease Control and Prevention (CDC) hosted Maternal Mortality Review Information Application (MMRIA) System. 

 

In 2018, recognizing the devastating effects of maternal mortality, NY’s Governor Cuomo announced a multi-pronged strategy to address this critical issue including but are not limited to:

• Creating a Governor’s Task Force on Maternal Mortality and Disparate Racial Outcomes
• Establishing a Maternal Mortality Review Board, building on the Title V Program’s current maternal mortality public health surveillance process
• Launching a Best Practice Summit with hospitals and OB/GYNs
• Piloting Medicaid expansion for doulas
• Supporting Centering Pregnancy demonstration projects (also included in Department’s Office of Health Insurance Programs (OHIP)’s First 1000 Days on Medicaid initiative)
• Requiring medical education and curriculum development to address implicit bias in health care
• Expanding the NYS Perinatal Quality Collaborative
• Launching Commissioner Listening Sessions to hear from women and families across NYS to better understand those factors that impact maternal mortality and morbidity.

 

Over the past year, Title V staff continued to work on several of Governor Cuomo’s priorities to improve maternal health outcomes and address health disparities. 

 

After meeting three times in 2018, the Task Force on Maternal Mortality and Disparate Racial Outcomes (Taskforce) released its report in March 2019 (Attachment #1) which included the following 10 recommendations:

1. Establish a Statewide Maternal Mortality Review Board in Statute
2. Design and Implement a Comprehensive Training and Education Program for Hospitals on Implicit Racial Bias
3. Establish a Comprehensive Data Warehouse on Perinatal Outcomes to Improve Quality
4. Provide Equitable Reimbursement to Midwives
5. Expand and Enhance Community Health Worker Services in New York State.
6. Create a State University of New York Scholarship Program for Midwives to Address Needed Diversity
7. Create Competency-Based Curricula for Providers as well as Medical and Nursing Schools
8. Establish an Educational Loan Forgiveness Program for Providers who are Underrepresented in Medicine and who Intend to Practice Women's Health Care Services
9. Convene Statewide Expert Work Group to Optimize Postpartum Care in NYS
10. Promote Universal Birth Preparedness and Postpartum Continuity of Care.

 

As part of Governor Cuomo’s initiative to reduce maternal mortality, the NYSDOH led by Dr. Zucker conducted a series of seven listening sessions across NYS to engage Black women in conversations about their experiences accessing health care and giving birth in NYS. Through these seven sessions over 240 women participated and shared their experiences. Feedback from each session was gathered and analyzed by NYSDOH staff to identify common barriers, opportunities, and suggestions for improvement. That information was shared with taskforce members to aid in the development of recommendations and eventually compiled in a report entitled, “Voice Your Vision – Share Your Birth Story: A Conversation on Maternal Health in New York State” which was released in Summer 2019.

 

Throughout the listening sessions women identified common barriers including: 

• Disrespect by providers 
• Not getting their questions answered and their concerns addressed 
• Insufficient time with the provider, and not receiving individualized care
• Not receiving important information so that they had information to make proper decisions
• Feeling pressured into certain medical procedures
• Lack of social support during the prenatal and postpartum periods.  

 

Common suggestions for addressing the racial disparities in maternal mortality included:

• More Black and Hispanic health care professionals that reflect the community
• Increase health care professional awareness of racial disparities in health outcomes
• Train health care professionals on the impact of implicit bias on health care outcomes
• Increase in provider support during the postpartum period
• Increase availability of social support for example, birthing classes, centering pregnancy, doulas, midwives, community health workers and parenting classes
• Increase availability of community services and resources, for example, community health worker services, home visiting services.

 

Direct engagement of community members was critical to the Taskforce recommendations, and the NYSDOH and Title V program will continue to incorporate the voices of community members most impacted by disparities as part of the process to improve birth outcomes.

 

One of the initiatives underway is a Medicaid Doula Pilot. In launching the Doula Pilot, OHIP gathered information for doula programs currently operating in NYS as well as Medicaid doula programs in other states. OHIP considered several data metrics to determine the eligibility areas for the Medicaid pilot including the availability of doulas and volume of Medicaid births and data that showed high maternal and infant mortality.  Based on these metrics, OHIP decided to launch the doula pilot in Erie and Kings Counties. Under the pilot, doula services are available for any Medicaid-eligible pregnant woman in fee-for-service or Medicaid Managed Care in these geographic locations. Prior to the launch OHIP hosted several webinars on the pilot including billing coding. Phase 1 of the pilot project began March 1, 2019 in Erie County. Phase 2 of the project will include selected zip codes in Kings County once provider capacity has been achieved.  This two-year pilot includes an analysis of data including breastfeeding rates and adherence to postpartum visits.  It will also assess doulas’ and mothers’ experiences and feedback on participation in the program.  OHIP has ongoing engagement with stakeholders and has made several adjustments in order to increase participation in the pilot by both pregnant women and doulas. 

 

Another ongoing project included in both the Governor’s Maternal Mortality efforts and as a priority in the First 1000 Days on Medicaid initiative is a pilot project to assess feasibility of making the CenteringPregnancy prenatal care model a Medicaid covered benefit. Led by the Department’s OHIP, this project focused on studying the impact of CenteringPregnancy on infant health outcomes. NYSDOH engaged the Centering Healthcare Institute (CHI), the agency that developed the Centering Pregnancy model, to help develop tools and project materials to assess the impact of their model in areas of NYS with the poorest birth outcomes.  Webinars and ongoing TA have been held for both Managed Care Plans and providers/clinics who will be participating in the project. The pilot’s target areas include the five NYC boroughs and ten counties that have been known to have relatively higher rates of poor birth outcomes in NYS.  Several Medicaid Managed Care health plans and prenatal care clinics expressed interest and have been engaged in the pilot project. Enrolled sites are working to engage women in the pilot study, both as part of the control and experimental groups. Phase 1 of the project, with those clinics already operating an established Centering Program, began in June 2019. Clinics will continue to serve women, collect data on their participation in CenteringPregnancy, and report information on their birth outcome upon delivery. Phase 2, which will expand to include sites just beginning to implement CenteringPregnancy, will begin in Spring 2020.  

 

To build on NYSDOH’s work related to maternal death reviews, the Title V staff is currently implementing an enhanced process for maternal death reviews that was developed in collaboration with ACOG-NY. The goal of these efforts is to address this significant public health issue with not only the population health approach, which includes surveillance and planning on a statewide level, but also provide health care providers and others with information needed to improve and enhance health care standards and practices. Substantial progress was made towards achieving these objectives during the reporting period. 

 

NYS was awarded a five-year CDC ERASE MM grant in August 2019. The purpose of this grant is to support Maternal Mortality Review Committees to prevent maternal deaths. Currently, NYS has two active, multidisciplinary maternal mortality review committees: The NYSDOH Maternal Mortality Review Board (MMRB) and the NYC Department of Health and Mental Hygiene’s (NYCDOHMH) Maternal Mortality and Morbidity Review Committee (M3RC). Under this grant, NYSDOH will collaborate with NYCDOHMH to identify and review all pregnancy-associated deaths in NYS. The MMRB will review all deaths occurring outside of NYC, while the M3RC will review all deaths occurring within NYC. Both committees will conduct a complete assessment of the causes of death, factors leading to death, preventability, and opportunities for intervention. The data and determinations for both committees will be entered into the statewide CDC central-hosted Maternal Mortality Review Information Application (MMRIA), and the NYSDOH will compile and analyze the statewide data to inform opportunities for intervention and provide recommendations for statewide initiatives.

 

Legislation to create and empower the NYS MMRB was signed into law on August 1, 2019.  In addition to creating, empowering, and protecting the MMRB itself, the legislation included explicit powers and protections for the NYSDOH in its role supporting the MMRB.  Title V staff will use this authority to gather case information from more sources than were previously available, which will enable the MMRB to examine the details of these women’s lives in order to identify and understand the non-clinical factors that may have contributed to the deaths. The MMRB held its first full meeting on August 22, 2019.

 

The MMRB’s findings on recent trends and issues will be translated into action through collaboration with ACOG-NY and other key stakeholders to develop Issue Briefs, Grand Rounds, and quality improvement projects through the New York State Perinatal Quality Collaborative (NYSPQC) and its partners (e.g., hospital associations, professional associations, regional perinatal centers and affiliate obstetrical hospitals, among others). A statewide maternal mortality report will also be issued to provide data and information that can be broadly used to improve maternal outcomes.  The 2014 maternal mortality report is complete and posted on the Department’s website: https://health.ny.gov/community/adults/women/docs/maternal_mortality_review_2014.pdf

 

Due to the prevalence of maternal mortality and morbidity in NYS resulting from maternal hemorrhage, the Title V staff through the NYSPQC is leading the NYS Obstetric Hemorrhage Project, which seeks to reduce mortality and morbidity by improving the assessment, identification and management of obstetric hemorrhage.  Title V is collaborating on this project with ACOG-NY, Healthcare Association of NYS (HANYS), Greater New York Hospital Association (GNYHA), and National Institute for Children’s Health Quality (NICHQ).  This project began in November 2017, and 67% (83/123) of NYS birthing hospitals are participating.  Hospitals document completion of a hemorrhage risk assessment to improve recognition and care based on risk level.  The percent of maternity patients with a documented risk assessment for obstetric hemorrhage completed on admission increased by 27.0% during the project period, from 64.4% in March 2018 to 81.8% in October 2019.  Documentation of risk assessment for obstetric hemorrhage completed post-partum (between birth and discharge) increased by 74.4% during the project period, from 31.7% in March 2018 to 55.3% in October 2019. 

 

Title V funding supports the work of the New York State Family Planning Program (FPP), a statewide network of providers that deliver high-quality comprehensive reproductive health services to low-income individuals.  The FPP’s contracted training and technical assistance center, the New York State Family Planning Training Center (NYFPTC), has provided training to family planning providers to emphasize equity and reinforce reproductive justice principles in the delivery of family planning services.  In 2019, the annual NYS Family Planning Program provider meeting featured a keynote address related to exploring unintended pregnancies through a reproductive justice lens.  In addition, the NYFPTC conducted a series of in-person regional trainings for family planning providers across the state that focused on developing individual and organizational strategies to mitigate unconscious bias in family planning settings.

 

Title V in NYS also continued to support and promote direct outreach to engage women into health care and promote health insurance enrollment and entry into prenatal care. Through the Maternal and Infant Community Health Collaborative (MICHC) program, Community Health Workers (CHWs) focused on educating women on improved birth spacing, adherence to the postpartum visit, and use of an effective contraceptive method. In 2019, the MICHC program connected 397 women to health insurance, 79.7% of clients engaged in prenatal care in the first trimester, and 39.9% of postpartum clients attended a postpartum visit and an additional 45% had a visit scheduled at the time of reporting. As per the recommendations of the Task Force on Maternal Mortality and Disparate Racial Outcomes, the scope and breadth of work of the MICHC program were enhanced via the CHW Expansion grant. In August 2019, CHW Expansion contracts were awarded to the 23 established MICHC agencies throughout NYS to address key disparities, including providing more childbirth education and support, assisting in the development of collaborative child care and social support networks, assisting with the development of a birth plan and supporting increased health literacy among communities around the state. With these funds, approximately 50 new CHWs were hired statewide to provide services to an additional 2,000 prenatal and postpartum women.

 

Evidence-based home visiting programs (Nurse-Family Partnership and Healthy Families New York) also emphasized birth spacing, importance of the postpartum visit and effective contraceptive usage. In 2019, 49.0% of clients enrolled in the Maternal, Infant, and Early Child Home Visiting (MIECHV) programs attended a postpartum visit within 8 weeks of their delivery.

 

Another strategy used to engage more women in health care is the promotion of telehealth. In January 2019, Governor Cuomo launched efforts to promote access to rural telehealth services for perinatal care.  This initiative includes four components: providing up to $5 million in capital funds to increase regional perinatal center, rural birthing hospital and private provider access and capacity for perinatal telehealth services; establish a Perinatal Telehealth Workgroup with national experts including the founders of the successful Arkansas Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS); engaging in hospitals participating in the Rural Health Care Access Development Program (RHCADP) to encourage expansion of perinatal telehealth initiatives; and establishment of a Project ECHO™ (Extension for Community Healthcare Outcomes) telementoring initiative to engage and enhance obstetric provider skills. 

 

In order to meet the goals of this initiative, Title V staff collaborated with the Office of Primary Care and Health Systems Management (OPCHSM) to integrate the telehealth capital funds into a Statewide Healthcare Transformation Grant; the request for applications for these funds will be issued in early 2020.  Additionally, Title V staff have collaborated with the Department’s Charles D. Cook Office of Rural Health, to provide information and updates for RHCADP participating hospitals. 

 

In May 2019, the Department launched the Rural Perinatal Telehealth Workgroup, which includes representatives from rural birthing hospitals, regional perinatal centers that serve rural communities, rural private practitioners, and representatives from the ACOG-NY, New York State Association of Licensed Midwives, HANYS, Arkansas ANGELS project, and other stakeholders.  The first meeting included a presentation from Dr. Curtis Lowery, founder of Arkansas ANGELS, Tina Benton (ANGELS Project Manager), Dr. Thao Doan (Westchester Medical Center Perinatal ECHO Project), and Drs. Heather Brumberg and Edmund LaGamma (Westchester Medical Center RPC). 

 

Finally, in collaboration with OPCHSM, Westchester Medical Center launched a pilot Project ECHO™ on perinatal health.  The first session, Perinatal Measles, Prevention and Vaccine Hesitance and Refusal, was presented by Dr. Shetal Shah, MD, FAAP on June 27, 2019, reaching 15 providers at 9 spoke sites.  This timely presentation was offered at nine spoke sites in the Lower Hudson Valley; at the time, this region had a significant measles outbreak, as part of the largest measles outbreak in the US in recent history.  The second session, Hypertensive Disorders of Pregnancy, was presented by Dr. Frances Hseih, MD, on September 26, 2019, and reached 16 attendees at 11 spoke sites.

 

In addition to addressing women’s physical and reproductive health, NY's Title V program is addressing women’s social-emotional health. Maternal depression has a significant impact on mothers and the social-emotional stability of their children and families. NY’s Title V program is committed to addressing the comprehensive needs of women. In 2014, legislation was enacted requiring hospitals to educate patients about maternal depression, maternal depression screening and referral. The Title V program in collaboration with the Department’s OPCHSM notified all obstetric hospitals of this requirement. Staff also researched and updated resources on the NYSDOH web site and continue to regularly review this information to ensure resources are current and applicable. In addition, the Title V program participated in the Moving on Maternal Depression (MOMD) project, convened by the Center on Law and Social Policy (CLASP), with the Office of Mental Health (OMH) and other key stakeholders to address strategies to improve maternal depression screening and enhance resources for those women experiencing depression. New York’s goal for the MOMD project is to improve the health and well-being of mothers and children by strengthening state and local policies that identify, screen, prevent, refer, and treat maternal depression and other maternal mental disorders. Finally, legislation was passed mandating that, to the extent depression screening is already a covered benefit, insurers must pay regardless of which health care provider performs the screening. 

 

This strategy is measured by ESM MWH-5: Percentage of women enrolled in Medicaid who are screened for maternal depression during postpartum care.  The Title V program is monitoring this strategy using PRAMS data effective this past grant year. The collaborative project with OHIP originally reported has concluded. According to PRAMS data from 2016, which is the most recent data available for NYS, 81.5% of women on Medicaid report that a doctor, nurse or other healthcare worker asked at the postpartum check-up if they were feeling down or depressed. While a significant percentage of women are being screened, evidence is lacking regarding use of standardized screening tools and there is room for improvement in percentage of women screened. Additionally, practitioners often identify lack of treatment services as an issue for women who screen positive. 

 

NY's Title V program is committed to continued work to address this significant health issue for mothers and children. Through the Report on the Status of New York Women and Girls, 2018 Outlook, NYS Governor Andrew Cuomo launched efforts to address maternal depression and reduce maternal mortality.  The components of the maternal depression efforts include: the Department of Financial Services requiring all health insurance policies to include coverage for maternal depression screening;  expediting referrals and treatment, including expansion of Project TEACH (NY’s model for pediatric psychiatry consultation) to connect primary care providers and obstetricians and gynecologists with mental health specialists; enhanced screening and referrals at WIC clinics; increased access to telepsychiatry for those in rural communities; and a media campaign to increase awareness of and decrease stigma about maternal depression.

 

Title V staff work with OMH staff in increasing awareness of the expansion of Project TEACH for maternal mental health. WIC has added the Patient Health Questionnaire-2 to the screening questions on enrollment into the program. They have also increased training for WIC staff on maternal depression. The NYSDOH promoted awareness through social media and revised the NYSDOH consumer web pages on maternal depression. Social media kits were sent to local MCH providers for use in their social media efforts. 

 

In addition to the above, NYS initiatives addressing maternal depression include: First 1000 Days on Medicaid (Dyadic therapy and home visiting proposals); HealthySteps grants; the Early Childhood Comprehensive Systems (ECCS) Impact Grant, and participation in the Moving on Maternal Depression learning collaborative with the Center for Law and Social Policy. The NYS Early Childhood Advisory Council (ECAC) identified early identification, prevention and intervention for maternal depression as a current priority and convened a workgroup to develop and help advance relevant strategies. ECAC members were active in NYS’s First 1000 Days on Medicaid initiative (described elsewhere in this application), advocating for efforts to improve screening and treatment for maternal depression and dyadic therapy. They also are participating in the Moving on Maternal Depression learning collaborative discussed below. Title V staff participate in this ongoing workgroup.

 

Two of the initiatives in the 10-point plan selected under the First 1000 Days on Medicaid initiative (described elsewhere in this application) could positively affect maternal depression: One is for Medicaid to allow providers to bill for the provision of evidence–based parent/caregiver–child therapy (also called dyadic therapy) based solely on the parent/caregiver being diagnosed with a mood, anxiety, or substance use disorder; the second is statewide home visiting, which would include a pilot in three communities and an identification of common programmatic elements that could be reimbursed through Medicaid funding.  The first would allow for treatment of mothers identified as depressed and the second would help identify women through maternal depression screening conducted by home visitors. OHIP worked with OMH and Office of Addiction Services and Support (OASAS) to catalogue existing statewide efforts related to dyadic therapy and researching the provision and payment of the benefit. Currently, OHIP is drafting a Medicaid Update article to clarify this benefit that is planned to be released by Spring 2020.  The home visiting workgroup has been convened and parameters for the work established. Title V staff participate on the leadership team for the workgroup and pilot. To develop the pilot, Title V staff have been involved in the Aligning Early Childhood and Medicaid (AECM) initiative, which provides technical assistance to help design the pilot. The AECM initiative has linked OHIP and Title V staff to other states who have aligned Medicaid and home visiting. The pilot is anticipated to begin in Spring of 2020.  

 

In August 2018, NYS was selected to participate in the Center for Law and Policy’s (CLASP) 18-month Moving on Maternal Depression learning collaborative that aims to advance polices around maternal depression prevention, screening, and treatment. The NYS Team is co-led by OMH and the Schuyler Center for Analysis and Advocacy (Schuyler Center) and includes members from OMH, NYSDOH, OASAS, American Academy of Pediatrics (AAP), ACOG-NY, Postpartum Resource Center, and the Children’s Agenda. Title V staff participate on the core team and on several subcommittees. NYS has five broad goals: 1) leverage and coordinate existing activity around maternal health and mortality and early childhood health and development, to generate action on maternal mental health; 2) meaningfully engage women with lived-experience into policy/advocacy for maternal depression; 3) develop key metrics/data relating to maternal depression; 4) develop an understanding of the scope, options and location of existing services to treat maternal depression; and 5) integrate policies and information across state agencies and partnerships at the community level. 

 

To build on the work that began in June 2018 at the CLASP learning collaborative, Title V staff have participated on regular calls with the core team, as well as the workforce, equity, and data subcommittees. The data subcommittee is committed to developing a matrix that includes data measures on programs throughout NYS. The equity subcommittee worked to set up two equity webinars to gather input on equity that will help inform the in-person workforce meeting as well as other aspects of our work. The workforce subcommittee has worked to develop a continuum of care that highlights preconception, pregnancy, high-risk, and postpartum activities to address maternal depression. This document will help to inform the core group’s work on addressing maternal depression in NYS.

 

Addressing the complex needs of NY's women requires interagency partnerships and collaboration among key stakeholders. The NYS OMH supports 17 HealthySteps programs in pediatric medical practices across the state. The HealthySteps model is an evidence-based pediatric primary care program focused on early child development and effective parenting.  A child development professional (HealthySteps Specialist) connects with families during pediatric well child visits as part of the primary care team.  The NYS initiative provides full-time HealthySteps Specialists in medical practices to provide screening, including maternal depression, parental protective and risk factors, and social determinants of health.  The 17 Healthy Steps providers are fully operational, engaging new parents to enroll their infants in the Healthy Steps program by 4 months of age. Over 5,000 children and their families were served as of September 30, 2019.

 

Healthy Steps Specialists provide screening to include maternal depression, parental protective and risk factors, and social determinants of health. OMH is conducting an independent evaluation.  Sites are tracking the maternal depression screening tools utilized, referrals made and/or approaches to care and report challenges to accessing services when making linkages/referrals to supports and services. The 17 sites have administered over 9,000 maternal depression screens for families enrolled in the program and provided over 3,000 maternal depression related referrals and/or services. Data are being analyzed to determine the positive screen rate and disposition of the positive screens.

 

Other program components include:

• Team-based well-child visits
• Positive parenting guidance and information
• Screening following a periodicity.
• Adverse Childhood Experiences (ACE)
• Parent Education Groups
• Home Visiting at key developmental times
• Access to support between visits
• Connections to resources
• Care coordination/systems navigation
• Early Literacy Reach Out and Read.

 

In January of 2018, the OMH HealthySteps sites completed a 12-month Learning Collaborative on Building a Trauma-Informed Practice and Integrating the Adverse Childhood Experience Survey into practices in collaboration with technical assistance and training from Montefiore Medical Group’s nationally recognized experts in Trauma Informed Care and Healthy Steps.  The sites have completed over 2,300 surveys for Adverse Childhood Experiences.

 

To further enhance supports and services, the Title V program successfully collaborated on the development of an ECCS Impact grant with the Council on Children and Families (CCF). The grant supports collaborative quality improvement projects in three high need counties (Erie, Niagara and Nassau) to improve maternal depression screening and follow-up as well as developmental screening and follow-up for young children.  CCF is working closely with NYSDOH on this grant which was initiated in 2016. With leadership from Dr. Kuo, Associate Professor and Division Chief for General Pediatrics at the University at Buffalo, the Erie/Niagara team organized a learning collaborative and designed a universal referral algorithm and form for families with young children to use in 6 local pediatric practices to make referrals to Erie County and Niagara County Early Intervention and local community supports. At the other end of the state, under the leadership of Dr. Elizabeth Isakson, the Nassau team has used ECCS activities to support the implementation of Help Me Grow Long Island. Help Me Grow Long Island offers free developmental and social emotional screens and provides free, virtual, ongoing support to families with young children on Long Island who have concerns such as their child's development or behavior, navigating service systems, or locating baby items. In addition, at the state level the ECCS initiative is connected to various technical assistance initiatives and statewide workgroups and committees such as the OHIP’s First 1000 Days on Medicaid initiative, the New York Strengthening Infant/Toddler Policies and Practices, the NYS Parenting Education Partnership, and workgroups on the NYS Governor’s Early Childhood Advisory Council and the Governor's Child Care Availability Task Force.

 

The Title V program also collaborated with CCF on the Preschool Development Birth through Five (NYSB5) project ($13.4 million in federal funding for the next three years) to strengthen and build new partnerships, coordinate the NYS early childhood care and education system, improve transitions, expand parent choice and knowledge and promote equity with a focus on vulnerable populations. The grant also seeks to institutionalize parent voice, align and strengthen interdisciplinary professional development, expand access to high quality early care and education programs and identify strategies to maximize and coordinate funding. Title V staff have been collaborating with the CCF on several NYSB5 project activities. To complete the NYSB5 Needs Assessment, OHIP provided data about Medicaid usage for young children and regularly attended the NYSB5 bi-monthly partner meetings. Title V staff participated in the NYSB5/NYS ECAC Strategic Plan Development over the course of several months. Collaboration with CCF is further strengthened through work with the First 1000 Days on Medicaid Infant Mental Health and Home Visiting Work Groups. The NYSDOH is also included as a partner on the NYSB5 Parent Portal (www.nysparenting.org) with links to NYSDOH resources. NYSB5 launched a statewide Talking Is Teaching Media Campaign in collaboration with the NYSDOH, OpAD, and the NYS Office of Child and Family Services (OCFS), which translated posters in 6 languages (Spanish, Russian, Chinese, Haitian-Creole, Korean, Bangladeshi). NYSDOH and CCF also worked closely in the development of a Family Resource Guide to Early Childhood Services – Prenatal through Age Five. The resource includes programs and supports available to families with children 0-5 like home visiting, childcare, early intervention, head start, prekindergarten and preschool special education. Title V staff presented at the first annual NYSB5 Technical Assistance Alignment Summit and worked with NYSB5 partners to establish an understanding of the technical assistance resources in NYS and begin discussion around ways to maximize resources, reduce redundancies, address technical assistance gaps and improve effectiveness.

 

Addressing the opioid epidemic is a public health priority in NYS, mirroring the national experience.  In 2014, Governor Cuomo established the Heroin and Opioid Task Force and signed the Combat Heroin Legislation which established a multi-faceted response to the opioid epidemic, with a focus on prevention, harm reduction, treatment, recovery and law enforcement.  In response to the Task Force and legislation, NYSDOH developed an interagency opioid surveillance workgroup that consists of various state agencies and stakeholders with an interest in addressing this public health priority. The workgroup developed a comprehensive website for opioid-related data in NYS (http://www.health.ny.gov/statistics/opioid) to improve the timeliness of reporting opioid-related data to key stakeholders. This site provides the most recent data (NYS Opioid Annual Report 2019) and trends over time on opioid prevalence, healthcare utilization (emergency department visits, hospitalizations) and mortality at state, regional and county (County Opioid Quarterly Report for NYS) level, where available.  The NYSDOH created an interactive Opioid Data Dashboard that is a visual presentation of opioid related indicators tracking fatal and nonfatal opioid overdoses, opioid prescribing, opioid use disorder treatment and the overall opioid overdose burden. Title V staff share the reports and dashboard links, as well as other resources such as webinars and educational materials, with NYSDOH Division of Family Health (DFH)-funded perinatal programs, hospitals involved in perinatal quality improvement efforts for maternal Opioid Use Disorder/Neonatal Abstinence Syndrome and other stakeholders across the state.  Access to these data and other resources allows agencies and stakeholders to more easily identify priority areas to target to address the opioid epidemic, help tailor interventions, and show improvements in NYS.

 

NY’s Title V Program is also working collaboratively with state agencies and stakeholders to increase understanding of and develop strategies to address NY’s opioid epidemic. Since Spring 2016, Title V staff participated on an interagency work group, led by OASAS, to address pregnant and parenting women with opioid use disorders. OASAS received an in-depth technical assistance grant from the National Center for Substance Abuse and Child Welfare, focused on women with substance use disorders and their substance exposed infants in Onondaga, Warren and Washington counties. This was a two and a half-year pilot (6/2016 – 2/2019) and the core team, which includes Title V staff and agencies in the three pilot counties, aimed to establish universal screening, increase treatment access, develop peer services, and address the Comprehensive Addiction and Recovery Act amendment to the Child Abuse Prevention and Treatment Act. As part of the initiative, participating counties assessed how pregnant women who use opioids would negotiate the health care and support systems in their respective counties. They identified areas of disconnect that they are working to improve, e.g., lack of communication between health care providers. NYS OASAS has issued a Local Services Bulletin to its providers with instructions on how to work with pregnant women in relation to Plans of Safe Care.  NYS OCFS and NYSDOH Title V staff are collaborating to identify how best to work with hospitals on reporting. 

 

Title V staff in collaboration with several NYSDOH sister programs, including the OHIP and the Office of Quality and Patient Safety (OQPS) staff have been co-leading an analytic project to conduct two studies of maternal opioid use and neonatal abstinence syndrome (NAS). The workgroup met four times during this reporting period to develop consistent methodology on study inclusion and exclusion criteria, exposure definition and categorization, morphine milligram equivalent (MME) calculation and other analytic points.  The data analysis planning team, comprised of Title V staff and other state agency representatives, has been addressing questions and concerns that arise throughout the study period.  The studies are on hold indefinitely due to competing needs for analytic resources.

 

Further, the NYSPQC, in partnership with ACOG-NY, HANYS and GNYHA, and with support from NICHQ, is leading the NYS Opioid Use Disorder (OUD) in Pregnancy & Neonatal Abstinence Syndrome Project.  This learning collaborative, which kicked-off in September 2018, and is currently being piloted in 17 pilot site birthing hospitals, seeks to identify and manage women with OUD during pregnancy, and improve the identification, standardization of therapy, and coordination of aftercare of infants with NAS. To date, topic areas of focus have included: verbal screening related to substance use for all pregnant women during the prenatal period and on admission to the birth hospitalization; trauma informed care; improved communication between obstetrics and pediatrics; reducing stigma; training clinical staff on the signs and severity of NAS; improving both pharmacologic and non-pharmacologic care for infants with NAS; Eat Sleep Console as a method of treatment for infants with NAS; considerations for breastfeeding for women who use substances; and linkages to care. A statewide project expansion is planned for Spring 2020.  The NYSPQC is participating in the national Alliance for Innovation in Maternal Health (AIM) through this initiative. 

 

During the reporting period, the NYSPQC began participating in the Association of State and Territorial Health Officials (ASTHO) Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative (OMNI) Learning Community. The purpose of the learning community is to provide technical assistance, build capacity, and disseminate strategies and best practices to support program and policy implementation on substance use disorder (SUD) among pregnant and postpartum women and infants prenatally exposed to opioids, including NAS.  Agencies and organizations convened as part of this effort include ACOG-NY; HANYS; GNYHA; Northwell Health; NYSDOH OHIP, AIDS Institute, and Office of Drug User Health; OASAS; NICHQ; and Community Health Care Association of New York State (CHCANYS).  The overarching goal of the NYS OMNI team, in alignment with the NYS OUD in Pregnancy & NAS Project’s goal of increasing the percent of pregnant women screened for SUD with a verbal screening tool, is to train prenatal care hospital staff on standardized screening, develop provider resources for screening and referral, and connect diverse work happening across the state.

 

As an outgrowth of the OASAS in-depth technical assistance project and the NYSPQC OUD in Pregnancy & NAS Project, ACOG-NY convened a discussion of Vermont’s Children and Recovering Mothers initiative in March 2019.  Invited participants included staff from advocacy organizations, NYSDOH, OASAS, OMH, hospitals, and AAP.  ACOG-NY developed and released recommendations for NYS from the convening that included funding in the state budget for:

• One Children and Recovering Mothers (CHARM) champion at each of the Regional Perinatal Centers (RPCs)
• Establishment of a division for CHARM-related activities that includes a state coordinator specifically for regional “hub & spoke” implementation components given the geographic expanse of NYS
• Provider education that offers implementation tools to better assist women’s health care providers in caring for pregnant women with OUD.

 

Further recommendations included:

• Developing a Regional “Hub and Spoke” Model
• Enhancing Care Coordination and Linkage to Services Locally
• Offering Multidisciplinary Provider Training.

 

Title V staff continue to be involved in planning and discussions to enhance supports and services for women with OUD and their infants.

 

In addition, NYSDOH’s Growing Up Healthy Hotline (GUHH), NY's Title V 24/7 phone line provides information and referral in English, Spanish and other languages via the AT&T language line. Any New Yorker can call the GUHH for information on a wide range of programs and services and is used in public health media campaigns. From October 1, 2018 to September 30, 2019, GUHH responded to 12,547 calls, which included calls requesting referral and information related to prenatal care, health insurance and Medicaid, and perinatal depression, among other priority MCH needs.

 

This NYS priority is tracked through NPM #1: Percentage of women with a past year preventive medical visit; data are obtained through Behavioral Risk Factor Surveillance System (BRFSS).  In 2015, 68.4% of women interviewed had a past year preventative visit as compared to 73.3% in 2016. This represents an increase in NYS and exceeds the national measure of 67.4% in 2016. SPM 1: The percentage of women age 18-44 years who report ever talking with a health care provider about ways to prepare for a healthy pregnancy which is also calculated from BRFSS data showed a slight drop from 37.3% in 2014 to 35.1% in 2016; this may be attributed to a larger sample size in 2016.  Finally, SPM 2: The percentage of women age 15-44 years and enrolled in Medicaid using the most effective, or moderately effective methods of contraception, which is calculated using Medicaid claims data, declined from 27% in 2015 to 24.5% in 2016. 

 

NYS Title V Program has selected several NOMs to evaluate this priority.  NOM #2 Percent of delivery or postpartum hospitalizations with an indication of Severe Maternal Mortality (SMM).  NYS far exceeds the national measure of 171.4 incidents of SMM per 10,000 delivery hospitalizations as reported in Healthcare Cost and Utilization Project (HCUP) data in 2015.  For the same time period, NYS is reported to have 214.2 per 10,000 delivery hospitalizations.  Since federal data are no longer available/reportable for NOM #3 Maternal mortality rate per 100,000 live births, NYS is now reporting this measure using Maternal Mortality Review (MMR) deliberations and NYS vital statistics. Based on the MMR result for the 2017 cohort, the number of pregnancy related deaths during pregnancy or within 42 days of the end of pregnancy was 24. Based on NYS vital statistics, the number of live births in 2017 was 228,501. As a result, the latest NYS rate for NOM #3 Maternal mortality rate per 100,000 live births is 10.5. NYS also demonstrates significant success in NOM #7 Percent of non-medically indicated deliveries at 37, 38 weeks gestation among singleton deliveries without pre-existing condition continued to decline, decreasing from 2.0% in 2015-2016 to 1.0% in 2016-2017, which is lower than the national average of 2.0%.  Finally, for NOM #11 The rate of infants born with neonatal abstinence syndrome per 1,000 hospital births, NYS continued to fall below the national average with the NYS rate 4.2 vs the national average 6.4 in 2015.

 

The application continues to reflect ongoing efforts to address these priority public health issues to achieve selected targets.