Report for October 2019 - September 2020
NPM 1: Percent of women, ages 18 through 44, with a preventive medical visit in the past year
NPM Strategy 1.1. Partner with community-based partners to provide patient navigation and health education information to disparate populations to increase the number of women who are rarely or never screened for cervical cancer through the BCHC program.
The State of Alaska’s Ladies First Program is working to increase the number of patients receiving services through the program who are rarely or never screened for cervical cancer. Patients who have not had cervical cancer screening in over 5 years are 60% more likely to be diagnosed with cervical cancer, and low-income women are more likely to not have received a Pap test in over 5 years.
Similar to previous years, Ladies First developed ArcGIS maps to visualize the cervical cancer screening rates by community with the goal of engaging partners in outreach and intervention work to increase those rates.
The program experienced challenges with using predictive analysis due to the small numbers in individual Alaska communities, so relied on Behavioral Risk Factor Surveillance System (BRFSS) and Small Area Health Insurance Estimates (SAHIE) data instead. BRFSS and Census demographic data were used to estimate screening rates by census place. Using these maps, the program identified Anchorage and the Kenai Peninsula as areas to target for enhanced outreach efforts. The maps have been updated with the most recent data.
While Anchorage had experienced a slight increase in screening in previous years, both regions experienced decreases in cervical screening and enrollment during this reporting period. Between 2016 and 2018, Anchorage saw an increase in cervical screening from 82.9% to 83.3%, while the Kenai Peninsula had a decrease in cervical screening from 65.3% to 50.5% during the same period. Between 2019 and 2020, however, in the Anchorage area, there was a 23% decrease in cervical screening (805 to 623), and a 28% decrease in enrollment (2,895 to 2,100); on the Kenai Peninsula, there was a 10% decrease in cervical screening (391 to 353), and a 16% decrease in enrollment (746 to 629). Throughout the rest of the state, there was a 16% decrease in cervical screening (1,249 to 1,045), and a 17% decrease in enrollment (2,465 to 2,055).
To address these decreases, Ladies First continues to engage with an outreach and patient navigation contractor in Anchorage, in addition to other community partners. Ladies First also increased the scope of the Kenai Peninsula outreach and patient navigation contractor to include the entire region. During the reporting period, the Anchorage contractor completed 13,332 outreach contacts and the Kenai Peninsula contractor completed 257 outreach contacts.
The development of neighborhood maps has been put on hold due to the issues with the predictive analysis model. If a more accurate alternative is found, this work will resume. In the meantime, Ladies First is using the Health Equity Index developed by the program, based on the CDC’s Social Vulnerability Index, to attain a more holistic view of our target population and the barriers to screening.
See NPM Strategy 1.3 below for progress on health systems intervention work during this reporting period.
NPM Strategy 1.3. Identify and partner with public and private providers statewide to improve and expand their preventive health services through health systems interventions that identify best practices and measure improvements (QI model).
Ladies First worked with the Alaska Primary Care Association (APCA) and Mountain Pacific Quality Health (MPQH) on the implementation of evidence-based interventions to increase cervical cancer screening at the clinic level. MPQH is in the recruitment phase, with baseline data pending.
Of the 10 clinics working with APCA that had submitted both baseline and annual follow-up data on cervical screening, two had highly significant increases, five had no change, and three had a highly significant decrease in cervical screening rates between those periods. Of the eight clinics working with APCA that had two periods of annual follow-up data, one had highly significant increases, five had no change, one had a weakly significant decrease, and one had a strongly significant decrease in cervical screening rates between those periods. The health care network’s response to the COVID-19 pandemic has had a significant impact on all health care service delivery, including preventive health screenings. Many health centers and practices had to reduce their available services during the pandemic and remained in various stages of reopening during this report period.
Some QI actions taken by participating clinics in response to decreases in cervical cancer screening rates included using telehealth when possible (which doesn't apply to cervical cancer screenings, as this is an in-person service), designated days/clinic area to complete preventive screenings, and increased use of an automated referral tracking module add-on to electronic health record systems to manage patients with care gaps.
During this reporting period, the Adult Health Unit (ADU) Manager (also the State of Alaska’s Title X Project Director) in WCFH participated in a national convening intended to increase collaboration between Title X Family Planning Services grantees and federally qualified community health centers (FQHCs), jointly hosted by the Office of Population Affairs (the federal Title X funding agency) and HRSA (the federal agency that funds CHCs nationwide). The goal of the 2-day meeting was to convene an expert workgroup of interested parties to discuss the benefits and challenges of integrating Title X funding and services into the primary care setting of publicly funded CHCs, and to encourage continued conversation and work towards such integration. The meeting also was attended by a representative of the Alaska Primary Care Association (APCA), but the ADU Manager has been unsuccessful to date in garnering interest from APCA in continuing this conversation. The ADU Manager intends to continue looking for ways to collaborate with both APCA and individual CHCs on opportunities to utilize Alaska’s Title X funding at CHCs statewide to improve access to family planning and related women’s preventive health services for low income and vulnerable populations.
Although WCFH staff continued to work with State Medicaid staff on ideas for improving access to long-acting reversible contraceptives (LARC), particularly immediate postpartum placement of LARCs in the hospital setting, this work was stalled by the change in focus of both agencies due to COVID-19 mitigation efforts. The Department of Health & Social Services is also working with a contractor to explore the use of DRG payment methodology to hospitals. Immediate postpartum LARC reimbursement has been called out a special topic for the project. The Office of Rate Review reached out to the Title V program to ensure WCFH participation in this effort.
NPM Strategy 1.4. Review all pregnancy-associated deaths through the Maternal Child Death Review (MCDR) and increase awareness of recommendations.
WCFH was awarded a CDC grant to support maternal mortality review quality and prevention work. Funds from this grant have been used to secure the services of a case abstractor and to partner with the Alaska State Hospital and Nursing Home Association (ASHNHA) for recommendations dissemination and enhanced partnerships with facilities and providers. The award has also included training and technical assistance for the MCDR team and the contracted case abstractor. Training topics have included best practices in maternal mortality case abstraction and review, disparities in maternal health outcomes, health equity and addressing racism and implicit bias.
In early FFY20, MCDR completed review of all pregnancy-associated deaths that occurred in 2018. A maternal mortality fact sheet was developed and distributed at the MCDR/AKPQC Joint Summit in January 2020. The fact sheet is one of the MCDR program’s most frequently requested publications, and it is often shared with providers, students and partners in other fields such as behavioral health and suicide prevention. An update of this fact sheet is planned after review of all 2019 maternal deaths has been completed. Review of 2019 pregnancy-associated deaths commenced during FFY20 and was still underway at year end. The 2019 death year cohort unfortunately included a higher number of maternal deaths than other recent years. There have also been delays in records availability, potentially connected to the impact of COVID-19 on partner agencies including hospitals and law enforcement.
During FFY20, ASHNHA developed and disseminated the first issue in a planned series of maternal mortality review recommendations flyers. This publication was disseminated to a broad audience including healthcare and social services providers and was well-received. MCDR continues to publish quarterly reports that include recommendations generated during maternal reviews for all quarters in which a maternal mortality review was conducted.
MCDR has increased QA/QI efforts for pregnancy identification by working with the Medical Examiner’s Office, the Alaska Violent Death Reporting System (VDRS), vital records and by researching public media sources. Through these processes, at least two maternal deaths between the years 2010-2017 were identified that had not previously been known to MCDR.
Due to the well-documented racial disparities in maternal health, MCDR has prioritized equity for the maternal mortality review program. For the Alaska population, this requires integration of Alaska Native cultural knowledge and conducting reviews in a manner that is respectful of Alaska Native people. MCDR has increased the number of Alaska Native professionals who participate in reviews including cultural doulas and clinical experts who are Alaska Native and/or who have lived and worked in rural Alaska. These individuals have greatly enhanced the quality of discussion during maternal mortality reviews, bringing increased attention to factors in maternal deaths such as institutional racism, historical trauma, lack of cultural sensitivity and access. Due to Alaska’s small numbers, it is difficult to quantify maternal mortality disparities for other minority populations. However, there is evidence of disparities in maternal health outcomes for Alaska’s growing Asian and Pacific Islander communities. In response to multiple deaths in the 2019 cohort within the Hmong community, MCDR recruited a cultural expert from this population who developed a training for committee members and program staff on Hmong culture, birthing practices, and historical trauma. Efforts to leverage the MCDR program to reduce disparities in maternal mortality will continue to be a priority as well as an ongoing learning and development process in years to come.
NPM Strategy 1.5. Collect, analyze, and disseminate PRAMS Phase 8 data on women receiving “regular checkup” health care visits at a doctor’s or OB/GYN’s office, or “visits for family planning or birth control” in the 12 months before getting pregnant.
Starting with 2016 births, the Alaska PRAMS Phase 8 survey has collected data on receipt of health care visits by adult women in the 12 months before getting pregnant, including “regular checkups at their family doctor’s office or their OB/GYN’s office,” or “visits for family planning or birth control.” However, the PRAMS Coordinator was unable to add results from these questions and other non-trending indicators that were new in Phase 8 to the online Indicator Based Information System (IBIS) PRAMS Custom Query module as the data stewards are migrating away from the system and no longer update the IBIS datasets. COVID redefined priorities for the administration of the PRAMS program, in part by necessitating full telework policies for contract staff who conduct phone interviews. As such, drafting a topic-specific Epidemiology Bulletin or other data brief on the subject matter was not completed during this period.
The Phase 8 survey will continue to be used by PRAMS through 2022 births, covering a total of 7 years. Since these questions are among the core questions on the Phase 8 survey, comparison data from other states are also available. Alaska PRAMS and Title V epidemiologists will continue to monitor the results of these survey questions as part of the annual Title V Needs Assessment update process.
NPM Strategy 1.6. Collaborate with the Alaska Division of Behavioral Health (DBH), the Alaska Prenatal Screening Program (APSP) and clinical partners across Alaska to increase screening, referral, and treatment of perinatal mood and anxiety disorders (PMAD).
The Alaska Substance Exposed Newborns Initiative (SENI), formerly known as the Alaska Prenatal Screening Program, screened 2,121 birthing people at four hospitals in Anchorage, Fairbanks, Juneau and the Mat-Su region for depression. For the report period, this is approximately double the number of screenings in the previously reported year and nearly 12% of the total number of births statewide. During the report period, 26.9% of individuals screened reported experiencing depression at any point in time. Each hospital adheres to its own referral and treatment policies and protocols when a person screens positive for depression; all hospitals do attempt passive referral and linkage to treatment. One additional large outpatient women’s clinic began screening pregnant people with the SENI tool during this period, but that clinic does not submit data to WCFH. Unfortunately, SENI was not able to improve the quality of its screening by adopting the PHQ-2 during the report period. SENI has secured adequate funding to support making this change to its screening tool and will implement this change in early 2021. COVID-19 impacted SENI staff and capacity to conduct planned data analysis during this reporting period, as well as plans to use SENI data to evaluate co-factors, such as domestic violence, substance use, nicotine use, and the woman’s expressed desire to avoid pregnancy in the coming year. These data will be used for continuing efforts to develop a SENI toolkit that supports both the learning needs of clinicians and the treatment needs of women and birthing people.
In July 2020, in response to the COVID-19 pandemic, the Alaska Perinatal Quality Collaborative (AKPQC), which is led by WCFH, conducted a Perinatal COVID-19 ECHO on maternal mental health. This ECHO is attended by providers statewide including physicians, nurses and nurse midwives. A mental health clinician from the Children’s Hospital at Providence presented a didactic that also included statewide discussion on COVID-19 impacts on maternal mental health.
NPM Strategy 1.8. Engage hospitals and birthing facilities in data-driven, collaborative quality improvement focused on reducing severe maternal morbidity due to severe hypertension in pregnancy in partnership with the Alliance for Innovation on Maternal Health (AIM) and Alaska Perinatal Quality Collaborative (AKPQC).
The Alaska Perinatal Quality Collaborative (AKPQC) continued its maternal hypertension initiative in partnership with the Alliance for Innovation on Maternal Health. Six hospitals are participating in the initiative, covering 63% of Alaska births. The goal is to reduce statewide severe maternal morbidity (SMM) among pregnant people by 20% (from 9.9% to 7.9%) by March 2021. Participating hospitals are implementing systems and standards to improve recognition of severe hypertension, increasing timely treatment with first line medications, and focusing on learning from cases of severe hypertension and SMM through debriefs and case reviews. These interventions and the timeline for this initiative align closely with the new Joint Commission Standards for perinatal safety. Hospital teams are supported through monthly facility team and data/quality improvement meetings hosted by WCFH. Hospitals are encouraged to submit monthly data for process and structure measures, and WCFH analyzes and tracks state- and collaborative-wide rates of SMM from hospital discharge data. This initiative will conclude in April 2021 with hospital poster presentations during the AKPQC annual summit. The WCFH Perinatal Nurse Consultant who coordinates the PQC is funded by Title V dollars.
The AKPQC and Alaska Maternal and Child Death Review (MCDR) hosted a joint summit in January 2020 with over 120 attendees. This two-day event featured expert state and national speakers on a variety of topics. HRSA Maternal and Child Health Bureau Technical Assistance funds supported travel and honoraria for Dr. Ann Borders, Illinois PQC, and Dr. Jeff Gould, California PQC, who shared expertise on successful collaborative quality improvement initiatives.
During the annual summit, the AKPQC launched an initiative focused on improving transfers from community (planned home or birth center) births. Alaska has the highest proportion of community births in the U.S (7.1% in 2017), and community-based midwives report lack of collaborative relationships with hospitals and hospital-based providers. This initiative convened a statewide advisory committee and five local transfer committees in Anchorage, Fairbanks, Homer, Juneau, and the Matanuska-Susitna region. These committees are establishing standards for transfers and sharing pertinent medical information, exploring implementation of protected case reviews, and partnering with EMS to improve emergency transports.
The AKPQC also convened a sub-committee starting in October 2019 to plan a neonatal-focused initiative. This committee decided to support the Substance Exposed Newborns Initiative (SENI) under the auspices of the AKPQC. More information about SENI is included in the perinatal domain.
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