Pre-/Interconception Health

Preconception health counseling has been identified and endorsed by the Centers for Disease Control and Prevention as a strategy to improve maternal health and birth outcomes, as well as to reduce unplanned pregnancies. Starting in May 2016 under the auspices of the MCH Coalition and the March of Dimes, who provided the financial support, a statewide learning collaborative was established. The main goal of Every Woman Connecticut (EWCT) Learning Collaborative is to increase provider expertise and self-efficacy in implementing routine pregnancy intention screening and appropriate care, education, and services to ultimately improve birth spacing, increase pregnancy intentionality, as well as the proportion of Connecticut women who deliver a live birth and report discussing pre-/interconception health with a healthcare worker. The EWCT Learning Collaborative has representatives from clinical and community-based providers in communities throughout the state and has expanded to include a cohort of the Department of Mental Health Addictions Services (DMHAS) providers.

EWCT is guided by an advisory committee consisting of partner organizations, including state agencies, the state’s Medicaid ASO, the state’s Medicaid dental and behavioral health carve-outs, state-level private non-profits and direct service providers. The Advisory Committee has guided the provider trainings held and supported the creation of a website and twitter account to increase a general awareness around pre/interconception care and specifically around the One Key Question (OKQ) screening tool.

In response to the training needs articulated by new and existing Every Woman Connecticut partners, including DMHAS providers, the following training and networking opportunities were offered during the reporting period of July 2017 to June 2018:

• Torrington trainings and networking opportunities were held for home visitors on August 17, 2017 and for OB/GYN providers on October 26, 2017.
• On August 25, 2017 EWCT sponsored a training by Planned Parenthood of Southern New England (PPSNE) entitled  “Sexuality, Reproduction, Optimal Birth Spacing and Family Planning Options” for DMHAS funded programs.
• October 16 & 18, 2017 EWCT presented on OKQ to DMHAS Advisory Councils, including the Evidence-based Governance Committee and the State Board’s Behavioral Health Partnership.
• EWCT contributed to the November 15, 2017 CT Women’s Consortium conference on trauma by addressing, through a keynote presentation by Dr. Jordana Frost, trauma-informed  pregnancy intention screening and maternity care during the perinatal period.
• EWCT provided a training on One Key Question for members of the Prenatal, Infant and Oral Health Workgroup at their March 23, 2018 Workgroup meeting.
• On April 16, 2018 EWCT sponsored in collaboration with the CT Women’s Consortium a training on trauma and trauma informed care. The trainers were Dr. Jordana Frost and Ms. Eileen Russo.
• On May 30, 2018 EWCT sponsored a day long training on implicit bias and microaggressions by Dr. Lisa Werkmeister Rozas from the UConn School of Social Work.
• On June 11, 2018 a presentation on OKQ and its implementation in CT was conducted for the Springfield MA MCH City-wide group.

The EWCT and DMHAS partnership has benefited from a report done by Ms. Michal Klau-Stevens, the MSW/MPH student intern who did her first year with the March of Dimes (2017) and her second with DMHAS (2018).  The report entitled An Assessment of the Integration of One Key Question ®Pregnancy Intention Screening and Reproductive Life Planning into Seven Women and Children’s Residential Substance Use Treatment Programs in Connecticut is informing the work being done in EWCT’s collaborative work DMHAS and its programs. The report is guiding the EWCT/DMHAS partnership with a focus on supporting and sustaining the embedding of OKQ into program protocols and policies. The activities undertaken to embed and sustain OKQ will be included in the next reporting cycle.

Through a partnership with the CT Coalition Against Domestic Violence (CCADV),

EWCT has begun broadening its reach by planning next steps for bringing OKQ to providers who work with women experiencing Intimate Partner Violence (IPV). CCADV is the membership organization of Connecticut’s 18 domestic violence service agencies that provide critical support to victims including counseling, support groups, emergency shelter, court advocacy, safety planning, and lethality assessment, among other services. Partnership activities discussed in July 2018 include: introducing and training on OKQ for CCADV advocates who work directly with individual women and/or run groups and incorporating OKQ in presentations CCADV staff do for medical providers. Activities done in collaboration with CCADV will be included in the next reporting cycle.

Since October 2016, CT DPH has been participating in an Association of State and Territorial Health Officials (ASTHO) sponsored learning collaborative focusing on increasing access to contraceptives. In March 2018, the CT’s Increasing Access to Contraception (IAC) Learning Community Team Lead transitioned from the Chronic Disease Unit to the MCH Unit. The current members are Marc Camardo, Title V Director; Regina Owusu, RN, BSN, MPH, Nurse Consultant; Amy Gagliardi, Maternal-Infant Program Officer, Community Health Center, Inc; Amanda Kallen, MD, President of CT ACOG Chapter; Dr. Jordana Frost, March of Dimes; and Susan Lane from PP. The CT team participated in IAC Learning Community In-Person meeting held in Richmond Maryland on May 2018, which served as a closeout to the Learning Community Collaborative with the national program staff continuing to provide technical assistance. CT’s achievements to date includes: enhancing connections of the LARC team with important women’s health partners such as Planned Parenthood, the March of Dimes, FQHCs, and Every Woman Counts Connecticut; transitioning the lead on LARC activities to the MCH Program; providing an overview presentation to Every Woman Counts Connecticut Advisory Committee. The CT IAC team, which has since been subsumed by an ad-hoc workgroup stemming from the Every Woman Connecticut Advisory Committee, has continued to pursue its goals, which include: 1) explore alternative payment methods for LARCs in FQHCs; 2) identify and deliver training to health care providers re: shared decision making and LARCs best practice, safety, and efficacy; and 3) increase access to contraception with an emphasis on same-day availability of comprehensive contraception care and methods, including LARCs.

The CT team has explored payment options for LARCs through 340b pricing and FQHC engagement with group purchasing organizations that may offer sub-340b pricing for LARC devices. Both of these approaches require significant and ongoing administrative engagement to be put into place. It is expected that this process will extend well beyond the time frame of the project. However, through the ASTHO work, these important avenues have been explored and may prove to be helpful in ultimately achieving the project goal. One particular option that has been explored (and will continue to be explored), in partnership with the CT Department of Social Services and its Medicaid Medical Director, Dr. Robert Zavoski, and with the leadership of the EWCT IAC team, is the possibility of partnering with Stellar RX, a pharmaceutical distribution company based in PA. Through its Xpedose unit, Stellar RX would provide our CT-based clinical partners in community health centers and hospital-based L&D units, with a no-cost solution to the system barriers that we identified, namely the upfront cost to provider practices to stock LARC devices, and the resulting delay in obtaining patients’ chosen contraceptive methods.

Reproductive Health Services

Reproductive healthcare services were provided to 38,173 clients regardless of their ability to pay, of whom 90% were females and 10% males. Of those served 15% were teens, the race and ethnicity breakdown of those served is as follows: 27% Hispanic, 37% White/Non-Hispanic, 28% Black/African-American, and 2% Asian all of whom had incomes at or below 250% of the federal poverty level. The program provided pregnancy tests and counseling to 3,088 program participants and translation services to 1,558 program participants, along with 794 Herpes tests, 27,629 Gonorrhea tests, 10,489 syphilis tests, 26,797 chlamydia tests, and 10,993 HIV tests. Seventy three percent of program participants received reproductive health care services regardless of ability pay (over goal of 60%); fewer than one fourth of program participants were covered by commercial health insurance (53% Medicaid/Husky/public insurance, 24% private insurance, 23% no insurance/self-pay). Ninety seven percent of female program participants receiving a preventative reproductive health exam participated in the development of a Reproductive Life Plan (over goal of 90% and up from 93% last year); 76% of those between the ages of 15 and 25 received a screening for chlamydia/gonorrhea at their visit or within the last year (not meeting goal of 90%, but up from 70% last year), 97% received a Pap test or were current with their Pap screening schedule (over goal of 90% and up from 86% last year); 96% received a clinical breast exam (over goal of 90% and up from 89% last year), and 36% received an HIV test and referral for care as needed (not meeting goal of 65%).

The program significantly increased the use of highly effective methods of birth control such as pills, patch, hormonal injection and Long Acting Reversible Contraception (LARC) to reduce rates of unplanned pregnancies.  The latest outcome measure sample indicated over 18% of PPSNE’s female patients who were not pregnant or seeking pregnancy were using LARC (up from 16% in the 2017 grant year).

Teen pregnancy and childbearing are at historic lows in CT. The teen birth rate in CT declined 77% between 1991 and 2016. Teen birth rates have fallen for all racial and ethnic groups, and in some cases the gap in teen birth rates by race/ethnicity has narrowed, but disparities remain.

Connecticut teen birth rates dropped 8 percent between 2013 and 2014; the rate decreased 50% between 2009 and 2014. The five year rate decrease has been even greater among African American (53%) and Latina (55%) teens. The number of abortions among women under 20 has dropped even faster (67%) between 2006 and 2016.

The City of New Britain has the 2nd highest teen birth rate in the state at 44.2 per 1,000 women ages 15-19 and the highest repeat teen pregnancy rate in the state, yet the center that provided reproductive health services was only operational on a part-time basis. This issue was addressed in the renewed Planned Parenthood contract with DPH in October 1, 2017 which provided funding to expand hours in providing services for that population.

Breast and Cervical Cancer

During the program period for fiscal year 2019 the Breast and Cervical Cancer Early Detection program enrolled and screened 2895 women as of April 1, 2019 while the WISEWOMAN program screened 746 women. The program continues to provide funding for 12 Community Health Workers (CHW) who navigated women to no-cost screening programs for cancer screening and cardiovascular screening. These CHWs also provide baseline cardiovascular services (blood pressure, blood glucose, cholesterol, height and weight) using a mobile equipment, connected participants with abnormal readings to providers and supported participants to improve their life styles to reduce their risk of cancer and heart diseases.

Genomics

The Genomics Office continued to increase public awareness of the importance of knowing their family health history and sharing this information with their family and healthcare practitioners, promoted the use of Family Health History collection by promoting the US Surgeon General’s “My Family Health Portrait” tool; updated and improved patient information resources, updated and expanded online and in-person training for healthcare providers on hereditary cancer syndromes such as Hereditary Breast and Ovarian Cancer (HBOC) and Lynch Syndrome, and the appropriate use of genetic services.

Oral Health

The OOH and its partners developed the State Oral Health Improvement Plan 2013-2018, which contains four overarching goals with 10 objectives and 26 strategies to decrease oral health disparities; Promotes a culturally competent oral health workforce; Increases the engagement of health and human service providers in promoting and integrating oral health into their practices; and improves the oral health literacy of CT residents. Under these goals, strategies address populations at higher risk for oral disease and its impacts. Strategies and action agendas were developed to achieve the oral health objectives over a two year period. The OOH and partners have been successful in implementing 60% of the goals and strategies and is in the process of addressing 40%. The State Health Improvement Plan (SHIP) Chronic Disease Oral Health Action Team continued to communicate updates by email and held quarterly conference calls. The Maternal Child Health Coalition held quarterly meetings, which included oral health performance measure activities. Achieved strategies included:

• Updating the CT water fluoridation statute to reflect the US Department of Health and Human Services’ (HHS) current recommendations.

• Enhancing school-based dental sealant programs (SBSPs) through the CT DPH SEAL CT! Program. Six SBSPs were funded with HRSA Workforce and CDC Cooperative Agreement funds increasing the number of CT high needs schools funded from 135 to 249 schools.
• Increasing the use of fluoride varnish in primary care practices, school-based programs and community access points.

During the past year, the OOH, CTCOH, and its partners successfully collaborated to implement these action agendas. During FY 2017, the OOH continued to partner with the CT Coalition for Oral Health (CTCOH), which consisted of representation from diverse dental and non-dental agencies and organizations with a keen interest in addressing the oral health and overall health of all CT residents across the lifespan. The CTCOH restructured this year formalizing its policies and procedures; this resulted in a Board of Trustees (BOT), a Governance Board, and an Executive Committee. Both the DPH Office of Oral Health Dental Director (OOH DD) and the Chronic Disease Director (CDD) were nominated to serve on the Board of Trustees that met for the first time on January 30, 2017. The OOH DD was nominated to serve on the CTCOH Executive Committee. As of August 2017, there are 91 active participating members in the CTCOH. The non-dental organizations make up 21% of the membership. The non-dental membership of the Board of Trustees is 43%. The average non-dental organizational representation on all the CTCOH work groups and Board of Trustees is 49%. All the CTCOH workgroups continued to focus their efforts on implementing key strategies included in the State Oral Health Improvement Plan. The CTCOH, OOH, and its partners continued to work toward restructuring to support long term sustainability, and growing and diversifying its membership toward increasing efforts in inter-professional integration of health services.

The Perinatal and Infant Oral Health Workgroup (PIOHW) focused on the significance of women’s oral health as it related to birth outcomes and the oral health of their children, and served as the advisory committee for a HRSA funded Perinatal and Infant Oral Health Quality Improvement Project (PIOHQI). The CT Dental Health Partnership (CTDHP), the state’s dental Medicaid administrative organization continued to provide intensive outreach to encourage women to access dental care during pregnancy. The PIOHW serves as the advisory to the OOH for the HRSA workforce activities related to perinatal and infant oral health. The CTDHP and CT State Dental Association, both members of the PIOHW, worked collaboratively with the OOH to promote the importance of early childhood caries prevention and oral health for women during their childbearing years.

The OOH, along with two other CTCOH Members, also served on the CT Maternal and Child Health Coalition (MCH) and attended quarterly meetings. The MCH Coalition is made up of key leaders involved with several statewide initiatives and organizations to promote maternal and child health. Inclusion on the Coalition provides an ideal forum to highlight and promote oral health for families through collaborative planning to implement the CT Plan to Improve Birth Outcomes and other statewide plans.

The OOH partnered with PRAMS to create an Oral Health and Perinatal Health Make the Connection Infographic highlighting PRAMS data and perinatal oral health and health connection considerations. The Infographic has been disseminated across state agencies and to partners and is currently be added to the DPH website.

The OOH pursued funding opportunities that allowed increased efforts in workforce development, particularly in training community health workers around the value of good oral health and providing inter-professional learning opportunities around the importance of perinatal and infant oral health and relevant resources. The OOH contracted with Southwestern AHEC (SWAHEC) to update the Smiles for Life National Curriculum Front Line Workers Module and develop three Community Health Worker (CHW, Front Line Worker) modules focusing on perinatal, early childhood, and older adults. SWAHEC also provided oral health trainings to CHWs throughout Connecticut during fall 2017 through summer of 2018.

Over the past year, the OOH continued to provide oral hygiene home care supplies, OH information, and additional resources to their community partners for their programs and state wide community events. The OOH has partnered with CTCOH, community and national organizations, and DPH Communications Office to take part in several Twitter storm events throughout the year including perinatal and infant health, children’s dental health month, fluoridation, older adults, and oral health connection to overall health. To date, over 150 Healthy Mouths for You and Your Baby, educational videos have been distributed to MCH programs and to Head Start, WIC and other MCH partners through the 2017 Perinatal Infant Oral Health Interprofessional Summit.

The OOH, DPH Drinking Water Section (DWS), and partners implemented the CWF Communication Plan and successfully updated CT’s state statute to reflect the new HHS recommendation in July 2016. As a result, CT continued to provide fluoridated water to 91 % of our residents on public water systems.

Critical partnerships with other MCHB-supported programs

The Personal Responsibility Education Program (PREP) replicates evidence-based personal responsibility education programs to high risk youth ages 13 to 21, with the intent to change behavior and delay sexual activity, increase condom or contraceptive use for those who are sexually active, and reduce unintended pregnancy. From 2017-2018 the program was delivered to 1,479 youth in a variety of settings including Bridgeport, East Hartford and Capitol Regional Education Council (CREC) high school health classes, Bridgeport middle schools, Bridgeport Juvenile Detention facility, child welfare residential and community-based settings and in the young adult mental health programs and in community programs of areas of high teen births. The program provides Facilitator training, the curriculum, educational materials, ongoing technical assistance, and training on trauma, gender and identity, birth control and motivational interviewing. The program sites are monitored for fidelity to assure that all program delivery is trauma informed, medically accurate, inclusive and age appropriate. Participants complete voluntary entry and exit questionnaires, through which the effectiveness of the program is evaluated. The Waterbury and New Britain school districts were recruited for PREP programming in the 2019-2020 school year.

The Breast and Cervical Cancer Early Detection program continued collaborative efforts with a number of organizations to promote breast, cervical and cardiovascular screening services. Some of the partners for this program period were the Consultation Center that provided evaluation services for provider delivery to participants, e-Health CT an organization that evaluates an efficient process of identifying patients eligible for age appropriate screenings or past due for program screening services. The program continued to partner with the United Way of Connecticut to advertise program services on video monitor devices placed in clinical providers’ practices for patients to view while waiting to be seen by their provider. In addition our contracted providers teamed up with the Hartford Healthcare and Yale New Haven Health Mobile Mammography Van programs to provide Mammograms and cardiovascular screens to women in their community neighborhoods. This program period, we also collaborated with Walmart to host quarterly Wellness days at all Walmart stores in CT. Another collaboration with Knox garden in Hartford, CT provided women with community gardens and an opportunity to obtain adequate food as well as improve their nutrition, social and physical activities.