National Performance measure (#1):
Percent of women with a past year preventive visit.
Interpretation of state performance measure data:
Oregon’s rate of women attending an annual well-woman visit continues to remain below the national average. There has been a slight decrease in the percent of women attending an annual well-visit between 2014 and 2017, from 59.1% to 56.5% respectively.
Strategy: Case-management to improve utilization of well-woman care.
ESM 1.4: Number of public health programs routinely screening women of reproductive age for their pregnancy intention.
Progress on ESM
All Babies First! and Nurse Family Partnership Home Visiting Programs in Oregon (N=38) have standards which include screening clients for pregnancy intention.
Accomplishments
Program guidance for the public health MCH Nurse Home Visiting Babies First! program was updated so that there is more focus on pregnancy intention screening, reproductive health planning and supporting access to appropriate well-woman and pre/interconception care among clients.
Crook, Deschutes, Jefferson, Lincoln, Marion, and the North Central Local Public Health Authorities provided case-management activities through the public health MCH Nurse Home Visiting programs. They implemented the One Key Question within the protocols for the home visitors and used the question as a starting point to assist women in accessing appropriate clinical preventive services.
The Klamath and Warm Springs Tribes worked to build a program which supports women throughout pregnancy and the post-partum period. The programs provided case management and incentives. They also included goals around prenatal and postpartum visit attendance as well as facilitating connections to ongoing clinical care.
Challenges & emerging issues
The ownership of the One Key Question (OKQ) moved from the Oregon Foundation for Reproductive Health to the National Power to Decide Organization. The move came with increased training costs and requirements for using the OKQ model which has proved to be a barrier for local programs. There have also been challenges around how to include the use of the OKQ in electronic medical records. Home visitors have expressed an interest in training so that they are more confident in their ability to have reproductive health conversations in a culturally competent way.
Scheduling practices within the Indian Health Services system has created challenges for women in accessing postpartum care appointments. Case managers have been working with scheduling staff to streamline this process.
ESM 1.2: Number of women reached using traditional and social marketing campaigns such as CDC Show Your Love brochures, social media including Facebook and Twitter, attendance at health fairs and community meetings, and public service announcements.
Progress on ESMs
Local grantees have had difficulty tracking the number reached through social media due to a lack of staff time and skill in evaluating the effectiveness of outreach campaigns.
Accomplishments
State Title V staff worked with communications staff from the Oregon Health Authority to build our social media presence and have supported local grantees through technical assistance and collaboration.
Marion County worked to build their social media presence locally with messages aimed at women of reproductive age. Marion County has also worked to promote Text4baby as a way of reaching women in their community.
Challenges and emerging issues
The expertise and time needed to build effective marketing campaigns has been a challenge for both state staff and local grantees. With changes at the national level to the Text4baby program, we no longer have support for outreach materials or access to data. Due to these changes, we will not continue promotion of Text4baby. At the state and local-level we have had difficulty tracking this strategy.
Strategy: Provide education/training on preconception/interconception health for providers.
Accomplishments
- The Oregon Preventive Reproductive Health Advisory Committee (includes Title V staff) developed and disseminated Oregon guidance for the provision of high-quality contraception services.
- State Title V staff worked on quality improvement activities around the implementation of the One Key Question in public health programs.
- Oregon guidance on prescribing opioids for perinatal women was developed by the Pregnancy and Opioids Workgroup (convened by Title V staff). The guidelines were presented at the Oregon Opioid Conference (May 2018) and the Annual meeting of the Oregon Perinatal Collaborative (September 2018). State Title V staff have been disseminating the guidelines to clinicians caring for women of reproductive age.
- North Central Public Health District provided training to community partners including early learning providers through organized trainings and established community meetings.
Challenges and emerging issues
Building meaningful partnerships with clinical partners at the state and local level can be a challenge because clinicians and health systems have not prioritized efforts around well-woman care in the same way that our MCH program has. It has also been difficult to sustain work around the implementation of guidelines that have been developed by workgroups.
Strategy: Provide access to well-woman care through Family Planning Clinics.
Accomplishments
- In collaboration with state Reproductive Health staff, Title V staff presented a training webinar on Oregon’s Reproductive Health Equity Act for Title V grantees (December 2017).
- Union County, Marion County and the North Central District implemented use of the One Key Question within Family Planning Clinics.
Challenges and emerging issues
Some local grantees have moved to a model of providing less direct clinical services making it more challenging to provide care through Family Planning Clinics. Rules for family planning clinics limit the ability of providers to offer a comprehensive well woman care.
Strategy: Use of the postpartum health care visit to increase utilization of well-woman visits.
Accomplishments
Title V staff worked with the Metrics and Scoring Committee of the Oregon Health Authority to include postpartum care visit attendance as an incentive metric for Oregon’s Coordinated Care Organizations.
State Title V staff developed a proposal to implement a universally-offered postpartum home visiting program in Oregon. The postpartum home visit will provide an opportunity to assess plans for postpartum well woman care, educate and refer women to appropriate services.
Challenges and emerging issues
The current metric for postpartum visit attendance does not address the quality of visits and focuses the visit on a specific timeframe that may not be appropriate for all women.
ESM 1.1: Number of women who have been surveyed or who have participated in focus groups to identify barriers to well women care.
Progress on ESM
47 women participated in listening sessions August-November 2017. This ESM has now been retired.
Accomplishments
- Eight key informant interviews were conducted August-September 2017.
- Five listening sessions were conducted August-November 2017.
- Analysis of the key information interviews was completed, themes were documented and recommendations developed.
- Findings from the listening sessions and key informant interviews were presented to Title V Grantees December 2017.
- Findings from the listening sessions were presented at Public Health Grand Rounds March of 2018.
- A Report on the listening sessions and key informant interviews was published May 2018.
- Findings from the listening sessions and key informant interviews were presented at the Annual MCH Epidemiology/CityMatch Conference September of 2018.
- State Title V staff provided subject matter expertise to inform legislation that established Oregon’s Maternal and Morbidity Review Committee.
- Oregon HB 4133 passed establishing a Maternal and Mortality Review Committee. The Committee will consider the social determinants of health as well as access to preventive care in reviewing cases and developing recommendations.
Challenges and emerging issues
Rising rates of maternal morbidity and mortality as well as significant and persistent disparities by race are emerging issues in Oregon, as in other states. The formation of Oregon Maternal and Morbidity Review Committee will bring together new partners and focused work to improve women’s health and decrease health disparities. The current method of case finding in Oregon may have undercounted actual deaths by as much as one-third. Staff from the OHA Maternal and Child Health Section and the Center for Health Statistics (CHS) have worked together on a detailed method for finding deaths of women that occurred during or within one year of the end of pregnancy, regardless of the cause of death (these are termed “pregnancy-associated deaths”). This enhanced case-finding method will allow us to better understand maternal morbidity and mortality in Oregon. The reviews will allow us to characterize and intervene in maternal mortality and morbidity. These interventions aim to connect with efforts to identify upstream root causes of morbidity, including social determinants of health, to effectively develop and implement prioritized strategies for primary, secondary, and tertiary prevention.
Challenges in formation of the committee to date have revolved around getting a diverse and complete roster of committee members approved and appointed through our Governor’s office in a timely manner as well as challenges associated with using the authorization, installation and implementation of MMRIA (a CDC data system).
Accomplishments
We have convened a learning collaborative with every other month meetings for local grantees and our Healthy Start partners to share learnings and resources around well woman care.
ESM 1.3: Percent of local health departments receiving technical assistance to support implementation of the well woman care priority area.
Progress on ESMs
100% of local grantees (health departments and tribes, N=9) received technical assistance.
2018 Report: Oral Health (Women)
National Performance measure (#13):
Percent of women who had a dental visit during pregnancy.
Interpretation of state performance measure data:
The percent of women who had a dental visit has been consistently higher in Oregon than the national average since 2012. The state has mirrored the national decrease in this outcome between 2012 and 2015, with Oregon dropping from 56.1% to 53.5% over that time frame.
Accomplishments
- Developed monthly oral health messages that were posted on the MCH and Public Health Division’s Twitter and Facebook accounts.
- Drafted a fact sheet that focuses on the impact of diabetes and gestational diabetes and the risk of developing periodontal disease.
- The Oral Health Unit presented posters and exhibited at the Oregon Rural Health Conference in October 2017, Oregon Oral Health Coalition’s (OrOHC) Fall Conference in November 2017, and the WIC Statewide Meeting in May 2018. The posters utilized described the link between oral health and chronic diseases and how oral health can be integrated into chronic disease systems of care. Oral health educational materials were disseminated at the conference.
Challenges and emerging issues
The Oral Health Unit intended to collaborate with the Health Promotion and Chronic Disease Prevention Section’s Sustainable Relationships for Community Health (SRCH) grant initiative but did not have enough capacity to establish this relationship. Obtaining funding outside Title V is necessary to support SRCH grantees, and no grant opportunities were available during the grant period. The Oral Health Unit did not have existing capacity to develop materials and provide training for SRCH grantees.
ESM 13.1.1: Number of materials developed on the common risk factors and associations between chronic diseases and poor oral health such as cavities and periodontal disease.
Progress on ESMs
ESM 13.1.1: Three brochures and one fact sheet were developed.
Accomplishments
- Nine grantees – seven local health agencies and two tribes – were provided with individualized technical assistance throughout the grant year.
- The Oral Health Unit collaborated with the Oregon Oral Health Coalition to promote the Maternity: Teeth for Two training program with four grantees. The Maternity: Teeth for Two curriculum informs pregnant women and medical professionals, such as public health nurses, on the importance of oral health during pregnancy. It trains health professionals on how to integrate oral health education and referrals into primary and prenatal care.
ESM 13.2.1: Number of school oral health programs and Title V local grantees provided with technical assistance to enhance the quality of oral health services and increase oral health visits.
Progress on ESMs
ESM 13.2.1: Nine Title V local grantees were provided with technical assistance to promote dental visits for pregnant women.
Accomplishments
- Coquille Indian Tribe and Jackson, Marion and Tillamook Counties provided oral health education and referrals for dental care in their home visiting programs (Babies First! and Maternity Case Management).
- Washington County provided oral health education and referrals and had their nurse home visitors apply fluoride varnish when applicable.
- Marion and Tillamook Counties provided First Tooth and Maternity: Teeth for Two trainings for staff.
Accomplishments
- Crook County partnered with a dental hygienist from Advantage Dental to provide oral health screenings and fluoride varnish to pregnant women in the WIC Program.
- Douglas County collaborated with the Douglas County Oral Health Coalition to develop a messaging plan around the importance of oral health prevention for parents/caregivers.
- Klamath County provided the Maternity: Teeth for Two training for staff and assisted in establishing a local Oral Health Coalition in their area.
- Cow Creek Band of Umpqua Tribe of Indians provided pregnant women with an incentive of an electric toothbrush after seeing the dentist at least once during pregnancy.
Strategy: Promote community water fluoridation.
Accomplishments
- Klamath County developed educational materials promoting the safety of community water fluoridation.
National Performance measure (#14):
A) Percent of women who smoke during pregnancy;
Interpretation of national performance measure data:
The rate of smoking during pregnancy has steadily decreased in Oregon, from 11.3% in 2010 to 8.9% in 2017. This has mirrored a steady decline nationally, although Oregon values in this performance measure are consistently higher than the national average.
Accomplishments
Technical assistance has been provided to local MCAH Programs implementing the Smoking Priority. Two webinars were conducted to share work, successes and challenges. Email communications were maintained, with materials and articles provided to local grantees. The MCAH Program also maintained collaboration with staff from the Public Health Division’s Tobacco Prevention and Education Program (TPEP) in order to encourage collaboration at the local level between TPEP grantees and MCAH Program grantees.
In order for the MCH Section to more effectively disseminate materials to Title V Programs, work began on developing a web-based “shopping” experience (Shopify) for our partners. This streamlined ordering and delivery process ensured that local programs had the necessary materials to supplement their work. This allowed Oregon MothersCare Programs throughout the State (funded by Title V funds) to obtain and easily distribute Oregon Quitline information to pregnant women.
In addition to print materials, the MCAH Program worked with TPEP and the OHA Health Transformation Center (HTC) to develop tobacco cessation training modules for providers. The HTC contracted with Optum, the organization that runs the Oregon Tobacco Quit Line to develop the training modules, including a separate module for pregnant women. MCAH Title V funding was used to pay for the module development about pregnant women, costing $4000. Our office provided oversight around the development, and invited our local MCAH Smoking Priority programs to provide input. Content of the entire training included best practice interventions – the “2As and an R”, how to refer, and resources. (see Supporting Document 5 for Tobacco Cessation Training, Pregnancy module)
Upon development, links were sent to all Smoking Priority and Oregon MothersCare staff/coordinators throughout Oregon. The finalized link can be seen at: https://tcrc.rapidlearner.com/p/3462253711/story_html5.html
The Title V-funded MCAH Program, Oregon MothersCare (OMC - a patient navigation program for pregnant women), is conducted at the local level by Smoking Priority county programs as well as those who have not chosen the Smoking Priority. Some Smoking Priority Counties have incorporated OMC into their Title V work plans. However, all OMC Programs are required to provide screening and intervention for their pregnant clients who smoke. Thus throughout Oregon, 1000 pregnant women who smoked received an intervention and referral to the Oregon Quitline in 2017 and 2018 (data is only available in calendar years).
Since 2015, Tobacco has been a priority within the Oregon Public Health Division. A Tobacco State Health Improvement Plan (SHIP) was developed, and collaborative efforts within many sections (including the MCAH Title V Program) were made with successes seen. The purpose of Oregon’s State Health Improvement Plan (SHIP) is to identify population-wide priorities and strategies for improving the health of people in Oregon. The SHIP serves as the basis for taking collective action on key health issues in Oregon. The Tobacco priority includes a measure for smoking prevalence among Oregon mothers and uses the Oregon birth certificate statistical files as the database. According to birth certificates in Oregon, women who have just given birth report lowering their smoking rates from 11 percent in 2012 to 8 percent in 2018. This aligns with 2017 Oregon PRAMS data which shows 7.5 percent of pregnant women reporting smoking in the last three months of their pregnancy. However Oregon PRAMS from 2011 – 2017 shows a drop in women smoking 3 months prior to pregnancy from 23.2 percent to 17.7 percent. Oregon considers smoking just prior to knowledge of pregnancy a proxy for smoking in the first trimester of pregnancy.
The MCH Section has been at the table for the duration of the development and implementation of the Tobacco SHIP priority. This past year, the Tobacco SHIP priority and Alcohol and Drug SHIP priority combined their work, meeting together to better address addiction and health issues.
Beginning January 1st, 2018 a new Oregon law took effect, which raised the legal age of purchase for tobacco and vaping products in Oregon from 18 to 21 years. As a result, a significant decrease in youth (ages 13 – 17) and young adults (ages 18 – 20) who started using tobacco has occurred. Initiation of tobacco use fell from 34% to 28% for youth between 13-17, and from 23% to 18% for young adults. For more information, go to https://www.oregon.gov/oha/PH/PREVENTIONWELLNESS/TOBACCOPREVENTION/Documents/Oregon-Tobacco-21-Impact-Evaluation-Report.pdf
Challenges and emerging issues
For 2020 – 2024, Oregon’s SHIP priorities have moved to a social determinants focus. While Tobacco is not specifically called out as its own priority, there are opportunities for tobacco strategies to be addressed. Tobacco and substance abuse are included in the new Behavioral Health Priority. The priority will be addressed by a subcommittee that will use their experience, expertise, and capacity to create a SHIP that identifies evidence based and innovative strategies for policy, system and environmental changes.
ESM 14.1.2: Percent of local Title V grantees who have selected smoking as a priority area who have at least two technical assistance contacts.
Progress on ESMs
ESM 14.1.2: 100 percent of all local Title V grantees with the Smoking Priority received at least two technical assistance contacts throughout the Title V period.
Accomplishments
In Clackamas County, 16 of 19 women who smoke were assessed using the 5As assessment. For some, the assessment was done more than once. During pregnancy, women are more motivated and willing to decrease or quit smoking. We know this is a good time to use the 5 As and offer Quit line services. We have been successful and celebrate decreases with an emphasis of quitting in 3rd trimester.
In Marion County, 96 percent of their Maternity Case Management clients who smoked received the 5As intervention. In addition, all nurses in the Reproductive Health Program were trained in the 5 A's and instructed to address it with all smokers. Twenty women out of the 1963 seen in the Reproductive Health program were identified as smokers.
Challenges and emerging issues
Due to the limited amounts of funding for the smoking priority, counties have chosen to incorporate their work within other MCAH Programs that currently exist, rather than conducting specific stand-alone interventions aimed at cessation for pregnant women. They have been encouraged to expand use of interventions beyond their specific MCH clients which could result in greater numbers receiving interventions.
ESM 14.1.1: Percent of local Title V grantees who have selected smoking as a priority area who are implementing the 5A’s with their clients.
Progress on ESMs
ESM 14.1.1: 100% of counties that selected the smoking priority have implemented 5A’s among their clients.
Accomplishments
One out of three (33 percent) prenatal care providers were trained in the Healthy Futures intervention; Yamhill County staff trained one prenatal practice out of the three that existed at that time in the county. Since then, the other two prenatal practices have left the county. However, the remaining provider is now conducting tobacco screening for their patients.
Challenges and emerging issues
The MCH Program has a focus on home visiting and is therefore not able to see all pregnant women who smoke, not all women receive referrals to providers and may miss getting interventions. In addition, because of the proximity to the Portland Metro Area, Yamhill County pregnant women may see providers in other counties and miss receiving the benefits of the trained Yamhill Provider.
Accomplishments
Through their work on improving outreach and quit rates, our local grantees have found that direct, warm referrals work better than just providing clients with the Quit Line number.
Our Home Visiting program has begun collaboration with our organization's TPEP
coordinator, providing us with opportunities to benefit from Oregon Quit Line program resources.
Challenges and emerging issues
This particular strategy has been integrated with the strategy around the 5As. It was difficult for individual counties to collaborate with a statewide entity to increase outreach and quit rates for discreet areas. Obtaining data became difficult to conduct.
Collaboration between MCH Programs and Tobacco Prevention Programs has historically been a challenge because of the differing funding requirements. MCH Programs continue to be encouraged to work with their tobacco prevention and education program colleagues.
Accomplishments
Information about tobacco cessation insurance benefits was provided to Columbia County clients who were being offered Oregon Health Plan enrollment assistance. 96 percent (26 out of 27) of all eligible clients seen were provided this information.
Challenges and emerging issues
In choosing to work on priorities, counties do so for a year, achieve their goal, and rather than continuing to integrate successful practice into their work, will drop that work (as has been done in Columbia County) to pursue another priority.
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