NPM 1 - Percent of women, ages 18 through 44, with a preventive medical visit in the past year

 

Introduction: Preventive Medical Visit

For the Women/Maternal Health domain, Hawaii selected NPM 1, Well-Women Visits, based on the 2020 five-year Title V needs assessment results. The 2025 Title V state objective is to increase the percentage of women who have a preventive medical visit from 78% to 87%.

 

Data: The FY 2022 data (2021 data) indicates that 69.5% of women in Hawaii received a preventive medical visit, which did not meet the annual objective and was significantly lower than the previous year. This is likely due to COVID isolation, shutdowns, and healthcare service disruptions during 2020-22. Hawaii’s rate was similar to the national estimate of 69.7%. The BRFSS preventive checkup survey measure was revised in 2018 and is not comparable to previous survey years. There were no significant differences in reported subgroups by race/ethnicity, maternal age, household income, health insurance, or marital status based on 2021 data.

 

Objectives: The state objectives reflect a projected annual increase of two percentage points.

 

Title V Lead/funding: This priority was significantly affected by program funding changes and key personnel vacancies over the past year.

• The Title V Women’s and Reproductive Health Section (WRHS) in the Maternal and Child Health Branch (MCHB) provides key leadership for this issue and is partially Title V funded. This supervisory position has remained vacant since November 2021. Recruitment efforts are ongoing for this position.
• MCHB no longer administers the federal Title X Family Planning grant for Hawaii. The program was temporarily sustained in 2020-21 using Title V funds but eventually ended.
• The state-funded Family Planning supervisor position was vacant from May to November 2021. This position was filled temporarily from November 2021 to September 2022 and has been permanently filled since September 2022.
• The programs in the WRHS section also include Adolescent Health. The Adolescent Health Supervisor vacancy was filled in August 2022. The Program Specialist IV position remains vacant in the unit.

 

Strategies/Evidence: The strategies for this priority, in large part, reflect the work of the Hawaii Maternal and Infant Health Collaborative (HMIHC), which has provided community-led leadership for women’s health and perinatal issues in the state for the past 10 years. Title V helped establish HMIHC and continues to be part of the organization’s leadership team. In FY 2021, a fourth strategy was added, focusing on health equity. The Title V strategies are:

• Promoting women’s wellness visits through systems-building
• Promote pre- and inter-conception healthcare visits
• Promote reproductive life planning
• Promote health equity

 

Research provided by AMCHP and the MCH Evidence Center indicates that most women’s health evidence-based practices focus on clinical and direct service approaches rather than Hawaii's broad systems-level change strategies. Hawaii has been implementing two evidence-based approaches that promote pre- and inter-conception care and women’s wellness visits for the past six years.

• One Key Question® (OKQ)
• Long-Acting Reversible Contraceptives (LARC)

The MCH Bureau Infant Mortality Collaborative Innovation and the Improvement Network (CoIIN) promoted the two approaches as best practices.

 

COVID Impacts: COVID-related safety restrictions were largely eliminated in 2022, with healthcare providers reopening for in-person clinic visits and continuing some telehealth appointments. Telehealth remains part of the ‘new normal’ as the state transitions to COVID as endemic status. Throughout 2022, many of Hawaii’s families continued to struggle economically to meet basic essential needs (rent, employment, education, and food security), given rapidly increasing inflation and housing costs. These factors have affected access to healthcare.

 

Strategy 1: Promoting Women’s Wellness Visits through Systems-Building

This strategy recognizes that public health issues are best addressed by developing and sustaining partnerships between and within community organizations, academic institutions, and government. These partnerships provide opportunities to improve women's health before, after, and between pregnancies. In Hawaii, women’s wellness is currently integrated into three major state plans and collaboratives:

 

• The Hawaii Early Childhood State Plan
• The Early Childhood Action Strategy (ECAS) Plans
• The HMIHC Strategic Plan

 

The state plans all embrace a life course approach that acknowledges the importance of women’s wellness as a foundation for healthy women and the health and well-being of their infants, children, and families.

 

Hawaii Maternal and Infant Health Collaborative (HMIHC): The HMIHC is a collaborative group that focuses on improving birth outcomes, reducing infant mortality, and promoting intended pregnancies. The HMIHC strategic plan recognizes and supports women’s health as critical to its goals. Over 120 individuals participate in HMIHC, including physicians, clinicians, public health professionals, community service providers, and health plan/healthcare administrators. HMIHC provides the lead for the ECAS Healthy and Welcomed Births focus area.

 

In-person ECAS and HMIHC meetings and activities resumed in 2022-23. The HMIHC continues to meet via teleconference with active involvement of many physicians in HMIHC. Virtual meetings have helped sustain more participation by doctors and other clinical providers.

 

Strategy 2: Promote pre/inter-conception healthcare visits

This strategy focused on the efforts of the HMIHC Pre/Inter-Conception Workgroup and the implementation of the OKQ and LARC strategies.

 

HMIHC Pre/Inter-Conception Workgroup: The Pre/Inter-Conception Workgroup focuses on promoting women’s optimal health, both before, after, and between pregnancies. Its goal is to reduce unintended and untimed pregnancies statewide by promoting comprehensive clinical, educational, and programmatic supports for reproductive life planning. Particularly important is the use of culturally appropriate approaches to improve access to family planning services.

 

The State Medicaid program and a family practice physician currently co-chair the workgroup, which includes: representatives from the Hawaii American College of OB-GYNs (ACOG); University of Hawaii John A. Burns School of Medicine (JABSOM) Department of Obstetrics, Gynecology and Women’s Health; Queen’s Physicians Network; Hawaii Healthy Mothers, Healthy Babies Coalition (HMHB); Planned Parenthood; and several federally qualified health centers (FQHC), among others. The involvement of Medicaid and FQHCs helps to focus and deliver services to more lower-income, at-risk women of reproductive age. The workgroup continued to meet regularly and remotely throughout 2022.

 

One Key Question® (OKQ): In FY 2022, the Pre/Inter-Conception Workgroup reduced efforts around OKQ promotion and training. OKQ is a simple tool to engage women in a discussion about their pregnancy intentions by asking, "Would you like to become pregnant in the next year?" Depending on the woman’s response, follow-up is based on a women's yes/no response or ambivalence about pregnancy, following a matrix of standardized protocols. Client discussions would then lead to desired reproductive planning and follow-up for preventive healthcare. Many organizations are opting to continue screening but no longer adhere strictly to the QKQ protocols. This change will provide clinicians and counselors with more options and flexibility in reproductive counseling questions/approaches and enable more diverse counseling-related training and education.

 

Title V WRHS contracted with Healthy Mothers, Healthy Babies to provide OKQ-certified training through the national Power to Decide (PTD) program in 2021. The curriculum and materials were offered as a self-paced, one-month online course with continuing education credits offered. This HMHB contract was implemented during the height of COVID, from May 2021 to January 2022, when many providers were closed and/or reduced clinical services. Participating in OKQ training was not deemed critical at that time given fewer patients seen and COVID safety concerns. A total of 146 participants signed up for the online workshop, and 28% (42) completed the Power to Decide (PTD) training.

 

LARC: LARC was chosen as an evidenced-informed approach by Hawaii to help reduce rates of unintended pregnancy. LARC placement occurs in a single provider visit/encounter and does not require additional medication or follow-up visits. Although LARC is considered a “highly-effective” form of contraception, practitioners are instructed to provide non-directive counseling and respect clients’ decisions about their acceptance of LARC.

 

If discussion of reproductive health intent/goals can occur prior to or immediately following delivery, the provider can counsel and facilitate insertion of LARC at the birthing hospital prior to discharge. This benefits women at risk for short-interval pregnancies and/or those less likely to return for recommended postpartum care.

 

The HMIHC Pre/Inter-Conception workgroup developed and distributed a LARC toolkit in 2021 that includes billing guidance related to inpatient stocking of LARC and a chart with reimbursement codes. It is also available at all birthing hospitals and with many women’s health providers.

 

Despite the updated Medicaid LARC policy, changing birthing hospitals' operational/insurance practices is challenging. HMIHC continues working with several hospitals to establish inpatient pharmacy protocols to ensure that LARC is in-stock. HMIHC is also addressing issues with Medicaid reimbursement and private insurance coverage.

 

Many hospitals now stock LARC for same-day access; however, the goal is for all 13 Hawaii birthing hospitals to stock and receive unbundled Medicaid reimbursements for LARC inpatient insertion.

Medicaid Policies: HMIHC was instrumental in the issuance of Hawaii Medicaid provider policies in 2016 to support the use of OKQ and expand contraceptive coverage. The policy promoted the OKQ screening process and eliminated prior authorization for contraceptive procedures, methods, or devices, allowing for reimbursement for a 12-month supply of oral contraceptives. The policy also unbundled LARC reimbursement from the global fee for inpatient delivery services, supported stocking of LARC in hospital pharmacies, and listed new billing codes for providers. The policy was disseminated to all Medicaid health plans, hospitals, pharmacies, and healthcare providers. HMIHC efforts have focused on ensuring implementation of the policies.

 

In December 2021, an updated policy from DHS relating to Pregnancy Intention Screening and Contraceptive Coverage (Qi-2137) was issued, which provided further clarification on outpatient coverage of LARC devices with an updated current billing code. It also encouraged all healthcare providers to adopt a reliable, evidenced-based pregnancy intention screening tool to assist members in accessing appropriate services to support individual reproductive life plans. The memo specified that OKQ is one of several evidence-based pregnancy intention screening tools available to providers.

 

Extension of Postpartum Care. In August 2022, Hawaii's request to extend Medicaid postpartum care from 2 to 12 months received federal approval as a result of 2022 State Legislature appropriation of $2.4 million to the State Medicaid program. This appropriation will be matched by $3.4 million in federal funds. Hawaii was one of several states that enacted this change due to the American Rescue Plan Act, which allows states to extend postpartum coverage. Well-women visits are particularly important postpartum given the risk of pregnancy-related deaths and severe maternal mortality, which data indicates is rising in Hawaii.

 

The extension of postpartum care is also essential since Medicaid enrollee redeterminations are being conducted at the end of the federal public health emergency declaration in May 2023.

 

Strategy 3: Promote reproductive life planning

This strategy focused on increasing access to reproductive life planning services and assuring provision of reproductive life planning services through FHSD contracts.

 

Title X ended: Initially, Hawaii stopped accepting Title X funds in April 2020 in response to the Trump Administration’s Title X conditions prohibiting grantees from providing any information regarding abortion services options. Hawaii submitted a new application under the current administration that had lifted the abortion restrictions, but the application was ‘approved, but not funded’ for an award. The Hawaii service-area grantee is Essential Access Health (EAH), which serves California’s statewide Title X provider network. EAH partnered with seven local healthcare organizations in Hawaii, including FQHCs, the University of Hawaii health service programs, and Planned Parenthood. Limited existing state funds for FP service contracts continued through June 30, 2021.

 

New RFP: Given the adverse economic impact of COVID on most Hawaii families, the MCHB-WRHS immediately issued a new RFP to help community providers continue to offer reproductive and wellness health services for underinsured and uninsured persons, using a small amount of state general funds. These new contracts began on July 1, 2021. Although the numbers served were significantly reduced (when compared to those previously served with Title X funding), the eight selected community providers delivered reproductive health services to most of the counties through FQHCs, neighbor island college health centers, and the Healthy Mothers, Healthy Babies Coalition mobile units on Oahu and Hawaii Island.

 

The new RFP allowed providers to cover a comprehensive range of preventive wellness and reproductive health services, including health assessments and routine lab tests, family planning, STD/HIV testing, pregnancy diagnosis and counseling, and care for high-risk pregnancies. Additional services covered include health education, annual women's wellness examinations, maternal and infant supplies, transportation, childcare, respite care, and health outreach activities.

 

During COVID  services closures, WRHS amended service contracts to allow for expanded telehealth services, extended clinic hours, and additional protective PPE safety supplies to help protect providers and clients. These added provisions remain in the current service contracts.

 

ESM 1.2 - The number of women aged 18-44 years served through the state MCH reproductive health and wellness program.

 

Based on the RFP, a new Evidence-based/Informed Strategy Measure (ESM) was selected for women’s preventive medical visits: the number of women aged 18-44 years served by the state’s reproductive health and wellness program. This replaces the former population-based measure on birth spacing, which did not directly relate to the Title V strategies. The ESM relates to the evidence-based strategy Engagement of Other MCH Programs to Disseminate Information and Make Referrals for Well-Women Visits. Providers across the state were sought to offer critical wellness and reproductive health services to those most in need. The FFY 2022 data collected indicates that 3,681 women were served. Contractors are expected to work on increasing the program's reach; thus, objectives now reflect an incremental yearly increase.

 

The new ESM meets many of the MCH Evidence Center selection criteria and focuses on the quantity of effort. Because the RFP was expedited to address funding needs and service gaps for community providers, it is a formative quantity measure that will be strengthened in the future to assess quality of effort and outcome.

 

Strategy 4: Promote health equity

Health equity is a priority for all Title V work, including women’s health. The partnership with Medicaid and FQHCs through the HMIHC ensures that program activities benefit identified lower-income and underserved population groups.

 

In 2022, MCHB responded to community requests for implicit bias training for perinatal healthcare providers by partnering with the JABSOM faculty within the Native Hawaiian Health Department. The presentation was offered online in June 2022, entitled ‘Contextualizing Maternal Health in Hawaii,’ and addressed the significant historical, cultural, and social determinants of health. It included important findings from original Hawaii-based research on implicit racial bias among perinatal providers toward Native Hawaiians and Pacific Islander patients. A total of 71 providers attended this online presentation, which is available at https://www.youtube.com/watch?v=72cOtSPJjVU.

 

Current Year Highlights for FY 2023 (10/1/2022 – 6/30/2023)

Service updates:

• MCHB WHRS continued to provide ongoing reproductive health care and support services through eight community-based providers across all counties except in Kauai County and on the island of Molokai.
• Systems-building work, through the HMIHC Pre/Inter-Conception Workgroup, continued to promote OKQ and other evidence-based forms of reproductive counseling and address LARC administrative issues. The workgroup is now contacting all birthing hospitals, FQHCs, and Rural Health Clinics to assess whether LARC remains stocked in their pharmacies and identify any logistical barriers/challenges.
• A new MCH Branch contract is being executed for a Birth Control Resource Methods Access Coordinator to help expedite the work on LARC stocking in birthing hospitals and pharmacies.

 

New RFP for reproductive health services: In 2023, MCHB conducted focus groups with reproductive health providers to help identify women's health service needs for their communities. Based on the input, a new RFP was developed that includes the following:

• Services to uninsured and underinsured participants seeking reproductive health care and related preventive health services statewide and assist the uninsured in applying for healthcare insurance upon initial visit
• Supplies that are not covered by health insurance plans or occasionally difficult to obtain to maintain good health and promote healthy birth outcomes
• Subsidized transportation and child/respite care costs for participants who may have challenges (e.g., reside in rural areas and/or experiencing poverty) with attending medical appointments that are not covered by health insurance plans or occasionally difficult to obtain
• Collaboration with community programs to reach underserved populations to provide educational activities and presentations that are age and culturally respectful of the history, traditions, and values of different ethnic groups to help increase positive parenting and family support
• Provide medically accurate and cultural perspective information, education, awareness, reproductive health screening (using OKQ), family support, violence prevention, and ensuring the promotion of voluntary family planning clinical services throughout Hawaii
• Enhance and increase outreach activities/strategies by utilizing media sources

 

Health Equity: The new WHRS RFP for reproductive health services specifically targets at-risk populations that need more culturally sensitive services and support. These services are designed to reach rural populations and communities with lower income and access issues.

 

Abortion Protections: In response to the overturning of Roe v Wade by the Supreme Court, Hawaii’s out-going governor, David Ige, signed an executive order in October 2022 to protect out-of-state visitors who obtain abortions in Hawaii, as well as anyone who assists them, from civil and criminal penalties that their home states may impose. The order also protected Hawaii healthcare providers who perform surgical abortions or provide abortion medications to non-Hawaii residents.

 

The 2023 Legislature codified these protections with Act 2, which Governor Josh Green signed into law. The bill further expanded abortion access by allowing physician assistants to perform abortions. It repealed requirements that abortions be performed at a hospital or clinic to allow for non-surgical abortions.

 

Review of the Action Plan

A logic model developed for NPM 1 aligns strategies and activities with performance measures and desired outcomes. This logic model was updated to reflect changes in women's health and wellness activities since last year, including the addition of a new ESM. The fourth health equity strategy was added in 2022 to the logic model to help address the need to reduce health disparities in Hawaii’s women.

 

 

The vital work of the HMIHC is continuing, despite the ongoing demands and challenges resulting from COVID, including workforce turnover. Health messaging for both providers and consumers continues to be developed by the HMIHC Workgroup on OKQ and other reproductive health counseling options, as well as access to LARC and other reproductive health services.

 

Priority Populations: Priority populations to be reached include lower-income women, particularly in light of the health, social, and economic consequences of COVID in Hawaii. Partnering with DHS Medicaid facilitates Title V efforts to address/track this growing population’s needs. Although the NPM Title V federally available data does not indicate any significant disparities by subgroup, further analysis of women’s health data using local datasets will help us identify key findings to help guide future women's health program planning efforts.

 

Teens and young adults are also priority populations in need of reproductive health and other preventive health services. Although Hawaii’s teen birth rate continues to decrease, early pregnancy adversely impacts a young woman's life trajectory. Coordinated efforts to target and address teen health needs while promoting regular adolescent wellness visits are described in NPM 10 and included in the logic model above.

 

Challenges Encountered

Women’s Health Services. With the FY 2020 loss of Title X family planning funding, MCHB is reevaluating its future programmatic focus on women’s/maternal health, as Title X funding was a cornerstone in supporting reproductive life planning, women’s health services, and workforce training.

 

Workforce Vacancies. Transitions in the women's health workforce during COVID significantly and adversely affected the Title V Women’s Reproductive Health section. Although some positions were filled, the section supervisor position and other key positions remain vacant. These program vacancies are compounded by a need for more skilled MCH epidemiological support to help track and analyze Hawaii health data, such as COVID health impacts and key women’s health disparities.

 

Hawaii also acknowledges the need to continue to improve its performance and evaluation measures when contracting for services. Gaining epidemiology support and regaining key staff support for the program is expected to assist in these efforts.

 

Some of the challenges faced in advancing widespread exclusive use of OKQ and LARC as the sole recommended reproductive health counseling option include:

• Lack of a centralized data management system to establish OKQ and LARC benchmarks, performance measures, and creating systematic data collection processes
• Continuing administrative hospital barriers to LARC stocking and use, issues with Medicaid reimbursements, and private insurance coverage of the device
• Lack of standardized healthcare plan coverage for LARC-related medical supplies and services across private insurers
• Lack of clinician interest in completing the required course content and certification process

 

Overall Impact

Despite the challenges over the past two years, Title V achieved significant milestones in promoting reproductive life planning and women’s wellness visits:

• Integration and continued efforts to improve maternal health as part of three key state plans
• Collaborative health work facilitated sharing of women's health leadership, expertise, and funding
• Successful partnership building in the formation of HMIHC with Title V’s regular leadership and participation with Medicaid, physicians, and safety net providers in Pre/Inter-Conception Workgroup. The diverse HMIHC membership helped to provide support to maintain and sustain the ongoing collaboration
• Progress in advancing two key evidence-based strategies focused on the expanding use of OKQ and LARC, including the establishment of Medicaid provider policies to support OKQ, LARC, and expanded contraceptive use (elimination of prior authorization for contraception, reimbursement for a year's supply of oral contraceptives, unbundled LARC reimbursement from delivery fees, stocking of LARC in hospital pharmacies)
• The 2021 Medicaid provider updated the title and references, clarified outpatient coverage of LARC devices, and updated the current CPT code. It also encouraged all healthcare providers to adopt a reliable, evidenced-based pregnancy intention screening tool of their choice to assist members in accessing appropriate services to support the individual reproductive life plans. The memo specified that OKQ is one of several evidence-based pregnancy intention screening tools for providers.
• Over 1,000 OKQ-trained health care providers statewide
• LARC now stocked in most of the state’s birthing hospital pharmacies.