Women/Maternal Health

Annual Report Year

Priority: Improving women’s reproductive health.

Increasing access and utilization of preventive health care services for women of reproductive age continues to be a priority for the District. In 2018, the Behavioral Risk Factor Surveillance System (BRFSS) reported that 82.4% of women in the District had a routine check-up by a doctor within the past year. Nevertheless, there continues to be a disparity in preventive care use by income levels. Those with a lower income (64%) are less likely to visit the doctor regularly than those with middle income (74%) or high income (89%). From 2015-2016, 51% of District women who gave birth to a live infant were of a healthy weight prior to pregnancy, 41.6% were either overweight or obese before their pregnancy, and 4.3% were underweight. This was a slight reduction from the 2011 to 2013 percentages. Black and Hispanic mothers in the District were more likely to be overweight or obese (55.4% and 46.4%, respectively) than non-Hispanic white mothers (21.3%). Pre-pregnancy hypertension and pre-pregnancy diabetes have been shown to increase the chance of a mother giving birth to a low birthweight baby. In the District, the majority of infant deaths, along with preterm and low birth weight births, are attributable to maternal complications. Although District women are engaging in some preventive care services, rates of women accessing prenatal care are significantly lower. Between 2009 and 2016, the percent of infants born to mothers receiving prenatal care beginning in the first trimester decreased from 74.7% to 65.7%; and the percent of women who initiated prenatal care in the third trimester or had no entry to prenatal care increased from 5.8% to 6.3%.  

Goal 1: Increase use of preventive care services among reproductive age women.

In FY19, Title V continued to fund La Clínica del Pueblo’s, Mujeres Saludables (Healthy Women) Program. As a Federally Qualified Health Center (FQHC) and NCQA-recognized Level III Patient Centered Medical Home (PCMH), La Clínica continues to employ a family practice model of care that is rooted in a holistic approach aimed at eliminating barriers to care. The PCMH model is La Clínica’s overarching evidence-based approach to increase the utilization of well woman visits. In FY19, La Clínica engaged in capacity building activities to enhance their use of population level monitoring and follow-up for gender-specific services (inclusive of well-women visits and prenatal care). More specifically, the project goals were to: 1) strengthen La Clínica’s capacity to address women’s holistic health needs through the integration of population health and social determinants tools; 2) increase awareness among immigrant and low-income Latino women of reproductive age regarding preventive and prenatal services; and 3) enhance access to comprehensive prenatal care for immigrant and low-income Latina pregnant women. In order to meet the project goals, the program implemented activities in the following areas:

• Primary/Health Services — Integrate a single sign-on interface for Population Manager system into the Electronic Medical Records, and train care teams on using the new platform.
• Outreach and Community-based Services — Provide health education to women of reproductive age regarding preventive and prenatal services by hosting prenatal classes, conducting Mujeres Saludables Working Group, and training a cohort of health promoters to distribute informational resources and carry out charlas (small group conversations) in the community. Strengthening La Clínica’s provision of universal education around gender-based violence (GBV) for all female patients of a reproductive age by training clinical staff on how to recognize it in a primary care setting.

By the close of FY19, the program:

• served a total of 245 women (164 through charlas; 70 through the health fair, 11 through 2 cohorts of prenatal classes with 9 sessions each);
• successfully navigating all 15 of the 50 women identified as needing assistance with accessing health care services;
• referred 2 women to the Entre Amigas Gender and Health Program for education regarding gender-based violence;
• organized two community baby showers for 50 expecting or young mothers;
• identified two medical providers as Prenatal Clinical Champions to standardize protocols and workflows that improve maternal care services
• Partnered with Futures without Violence to host a 5-hour capacity-building session for 56 staff members to increase awareness on the importance of safe spaces for survivors of gender-based violence  
• Collaborated with DC Breastfeeding Coalition (Title V Grantee) to increase internal capacity on breastfeeding education and support, thereby becoming a breastfeeding-friendly health center

The biggest challenge the program faced was the integration of the single sign-on population manager system into La Clinica’s electronic medical records (EMR), which required extensive coordination with multiple parties. Despite this challenge, La Clinica understands the value of this integration and continues to develop strategies to overcome the barriers they face.

Title V provided funding for the DC Pregnancy Risk Assessment Monitoring System (PRAMS) to promote maternal health and reduce infant morbidity by producing actionable data on attitudes and experiences before, during, and shortly after pregnancy. PRAMS data will inform maternal and child health program and policy development. DC PRAMS targets DC-resident women who give birth to a live newborn in the District of Columbia (DC) within 2-6 months of the time of the survey. A portion of the information collected from DC PRAMS ascertains barriers women experience to engaging in early and continuous prenatal care, as well as other experiences that influence respondents’ overall health. Identifying these barriers will help DC Title V to develop strategies to increase the use of preventive care services, improving preconception, and ultimately the health of infants.

During FY19, the DC PRAMS Coordinator and team members worked with CDC and the Bloustein Center for Survey Research (BCSR) to ensure that DC PRAMS Integrated Data System (PIDS) was upgraded. The DC PRAMS team worked with CDC’s programmers to develop a DC sampling framework along with the SAS programs and testing in PIDS staging environment. DC PRAMS collaborated with the DC Women, Infants, and Children (WIC) program within the Agency to promote PRAMS and develop and implement outreach strategies, including obtaining phone numbers for contacting eligible mothers. DC PRAMS also collaborated with Vital Records Office to provide new language to be included in the Vital Records Modernization Act (VRMA) 2018 that would change the wording or remove the “opt-in” requirement on the Mother’s Worksheet. The “opt-in” option was replaced by mothers having to intentionally “opt-out” and implemented in November 2019. Approval for this change was a huge success in expanding the reach and utility of DC PRAMS, stepping closer towards providing more statistically significant results from which to draw population level inferences. DC PRAMS was also successfully awarded additional funding for the Disability and Opioid Supplements. DC PRAMS IRB approval was renewed and approved. The DC PRAMS team presented preliminary data to the MCH Advisory Council from the 2017 DC PRAMS survey. This summary included information on barriers to prenatal care, experience and satisfaction of prenatal care received, discrimination in access to health services, adverse childhood experiences, maternal depression, breastfeeding, and health insurance status during preconception, prenatal and postpartum periods. DC PRAMS also surveyed the MCH Advisory Council for data dissemination planning regarding priority topics to include in Data Briefs. In addition, the DC PRAMS team presented preliminary data to the MCH Advisory Council from the 2017 DC PRAMS survey (which contain the most recent data that we have received from CDC).

PRAMS data will allow DC Health to better assess factors contributing to poor outcomes to design more effective strategies. DC PRAMS data will be shared with administrations within DC Health to help inform policies and will be used to track several DC Healthy People 2020 outcome measures. In FY19, the total number of DC-resident women who:

• opted in to be contacted by DC Health during FY19 (includes records from 2018 DC PRAMS and 2019 DC PRAMS) was 1061; and
• responded to PRAMS during FY19 (includes records from 2018 DC PRAMS and 2019 DC PRAMS) was 490.

In FY19, Title V continued to support DC Health’s perinatal health messaging campaign. The “Well-Woman Campaign” encourages women of all ages to get an annual checkup. The goal of this campaign is to begin a conversation with women to talk about their health, get screenings and seek the primary and preventive care they need to live healthier lives. As our perinatal health framework begins with every teenage girl and woman in DC taking control of her reproductive health, this simple, but necessary message is a strong start. Campaign ads ran on mass transit, online social media, geotagged areas, newspaper, with a focus on communities with higher infant mortality rates. DC Health partnered with Thrive by Five, the Mayor’s Office on Women’s Policy and Initiatives, and OSSE to host the 2019 National Maternal & Infant Health Summit. The goal of the summit was to strengthen the connection between maternal and infant health and early childhood development; explore innovations and emerging issues in perinatal healthcare; and connect residents to local healthcare and early education service providers and resources.

Title V funded staff in the Health Care Access Bureau (HCAB) to oversee the locally funded Care Transformation (CaT) grant which supports three grantees, serving five locations: Community of Hope (COH) Conway Health and Resource Center (CHRC), COH Family Health and Birth Center (FHBC), Howard University (HU), Unity Healthcare Brentwood and Unity Parkside Health Centers. Each grantee was awarded up to $375,000 per year for up to five years to focus on strengthening primary care engagement of women ages 18-45 who are at-risk of or diagnosed with chronic diseases (ex. diabetes, hypertension, and overweight/obesity). The CaT grant is a multipronged project focused on three priority areas: workforce to support team-based care, patient experience, and clinical-community linkages. The purpose of the grant is to improve patient engagement and utilization in primary care and optimize clinical interventions to drive improved clinical outcomes for this high need group. In order to improve patient experience, grantees were required to:

• Participate in trainings to gain knowledge and skills in service excellence, health equity, implicit bias, lifestyle medicine, and the DC health care landscape
• Implement Quality Improvement (QI) strategies to improve processes and systems that may be a cause of barriers for residents accessing care.

FY19 was the first year of the CaT Grant and was designated as a planning period. The priority goals for the grantees during the fiscal year were to recruit staff to support team-based care coordination, screen and identify target women who have either fallen out of care or were not engaged in care for the CaT cohort, and to establish a patient engagement survey tool to better assess changes in the patient experience over the duration of the CaT intervention.

FY19 Grantee Performance:

• COH
  • Project Results and Successes: COH hired and trained a Program Manager, Nutritionist, Care Coordination Specialist and Patient Engagement Specialist to support team-based care coordination. In this process, COH standardized the role of the Care Coordination Specialist across the organization. The team developed a patient risk assessment and care plan to be used and integrated into their clinical workflow. Two-hundred women were identified in their Electronic Medical Record (EMR) system who were at-risk for or diagnosed with a chronic disease and eligible for the program. COH also integrated the CaT program into their Centering Pregnancy program to recruit women with gestational diabetes. The identified women were slated to receive services in FY20. Additionally, COH revised their patient experience survey to include key patient experience domains suggested by DC Health to better capture and assess patient experience. The revised patient experience survey was developed in FY19 to be piloted in the fall of FY20. COH was able to collect vital data through their EMR system on their CaT participants to establish the baseline of primary care utilization and health outcome measures necessary for comparison and to track the effect of this intervention. In  FY19, COH recruited and served 35 women into the CaT program and responded to 992 calls on their 24/7 Nurse Triage Line to support appropriate use of the health care system.
  • Challenges: In FY19, COH experienced recruitment challenges in finding culturally competent and highly qualified candidates to fill their second Nutritionist and Care Coordinator positions. Another challenge was providing COH with tailored QI technical support as per DC Health’s responsibilities in the Request for Applicants (RFA). DC Health experienced challenges securing a QI Consultant/Contractor and therefore the QI portion of the grant was delayed.
  • Areas of Improvement: DC Health’s Public Health Analyst developed a data dictionary and methodology of reporting key performance indicators and evaluation questions for grantees to accurately assess process and outcome measures. DC Health will continue to monitor key performance indicators, data collection and reporting to protect the integrity of CaT program data. DC Health also aims to refine how patient experience data is collected and analyzed in order to track changes in the CaT cohort when compared to the control group.
• HU
  • Project Results and Successes: In FY19, HU hired a Program Manager and Trauma Informed Yoga Instructor. They also recruited for the Patient Recruiter and Patient Navigator positions. HU developed a formalized priority list of partnerships for clinical-community linkages that support CaT cohort access and engagement to lifestyle medicine classes for chronic disease management or reduction in risk for chronic diseases. Additionally, HU identified 345 women in their EMR system and 38 through community outreach who met the criteria for the CaT intervention. Lastly, HU integrated all of DC Health’s revisions to their patient experience survey, including questions to capture: domains in patient medical home, getting needed care, getting care quickly, how well providers communicate trust and respect, customer service, patient satisfaction, and demographics. This new survey was implemented in Fall of 2019 to establish a baseline for patient experience for the CaT intervention.
  • Challenges: HU’s administrative barriers in FY19 prevented the timely hiring of the Patient Recruiter and Patient Navigator for the CaT grant. In addition, HU requires IRB approval for all grants prior to implementation. This requirement led to significant delays in timeline of the project.
  • Areas of Improvement: There are opportunities to improve HU’s data collection. DC Health developed a data dictionary and common methodology of reporting key performance indicators and evaluation questions that accurately assesses the process and outcome measures to track and gauge the success of project. HU’s data collection and reporting will be monitored on an ongoing basis.

• Unity Healthcare
  • Project Results and Successes: In FY19, Unity completed workforce recruitment at Brentwood and Parkside locations to support team-based care coordination. Unity’s CaT program manager assessed and designed role specific diabetes training to strengthen diabetes care coordination. Unity developed and shared the outreach plan to recruit the target population of women at-risk for diabetes to engage in preventive care. They initiated the roll out of a new diabetes medication management (for those with uncontrolled diabetes A1C>9) workflow to enhance diabetes control with training support from a new Clinical Pharmacist at Brentwood and the diabetes Project Extension for Community Healthcare Outcomes (ECHO). Unity engaged and served 130 women in the CaT cohort and revised their organizational patient experience survey to better assess patient experience.
  • Unity Healthcare Challenges: In FY19, Unity experienced minimal challenges related to staffing. They requested a site change from their original proposal from Anacostia to Parkside due to internal staffing changes. DC Health experienced challenges in securing a QI Consultant which impacted DC Health’s ability to provide Unity with tailored QI support.
  • Unity Healthcare Areas of Improvement: N/A

Goal 2: Decrease unplanned pregnancies.

DC Health continued to implement One Key Question® (OKQ) in all school-based health centers (SBHCs) and provided booster trainings for SBHC providers. In FY19, DC Health expanded with the inclusion of males in OKQ screening. SBHC providers screened 1,841 students who were primarily women. The Teen Pregnancy Prevention program screened 122 participants, including 118 women.

Title V provided support for the Perinatal and Infant Health (PIH) Division Chief. The PIH Chief provides oversight for the DC Healthy Start (DCHS) program and supervises the Healthy Start program manager. DC Health provides grant oversight, technical assistance and capacity-building to three grantee organizations: two Federally Qualified Health Centers; Mary’s Center and Community of Hope. In an effort to promote reproductive planning, DCHS encourages the use of One Key Question® for all reproductive age women to ensure participants have reproductive life plans (RLPs). Family support workers assist clients with developing RLPs. In FY19, 89% of DCHS female participants had a documented reproductive life plan, an increase compared to 86% in FY18.

Goal 3: Reduce chronic disease burden (including tobacco use) among reproductive age women.

In FY19, Title V continued to fund the Breathe DC East River Tobacco Free Project (EOR) to provide tobacco cessation services (i.e. one-on-one individual counseling, group counseling, text messaging service, or referral to Quitline) and support to pregnant women and adults who smoke and live in households shared with children under the age of 12 and children with respiratory illness. Breathe DC continued to collaborate with three Managed Care Organizations (MCOs)—Amerigroup, Trusted Health Plan, and AmeriHealth Caritas to:

• implement cessation support programs for members; 
• engage MCO and CBO staff to adopt the Ask, Advise, Refer. model to connect adults who smoke to the East of the River Tobacco Free project’s cessation support services or to the Quitline;
• train United Medical Center staff to facilitate cessation groups to its patients;
• increase awareness of smoking cessation services among CBO participants and MCO members, especially high-risk groups; and
• improve the accessibility of the District’s existing cessation support resources by promoting the Quitline (1-800-QUITNOW) through community outreach.

One-on-one counseling offered personal support and was done at the Breathe DC office, and in some special cases, via telephone. Pathways to Freedom group counseling allowed participants to create their own unique plan to quit smoking, receive encouragement and education from the facilitator, and support peers on their journey to quit smoking. The Breathe DC text messaging service included positive re-enforcement as participants took steps to quit smoking and provided a constant reminder that they have support on their journey to quitting.

During FY19, Breathe learned that educational materials alone cannot fully engage potential populations. As a result, they created opportunities for gathering people by holding Healthy Lifestyles educational sessions. Breathe DC restructured its Healthy Lifestyles Program outreach efforts by creating a staff role within the team called Health Lifestyles Outreach Educators (HLOE). The HLOEs assisted in planning, implementing, and coordinating the program activities relating to smoking cessation, lung health and wellness activities.

Breathe DC continued to experience challenges with streamlining their referral process. As health systems become more technology-based, the referral process from MCOs, primary care providers, and health programs to Breathe DC will need to follow suit. Improvements to the referral process will need to include faster turnaround times and fewer steps in the referral process. For health settings using an Electronic Health Record (EHR), possibilities include the following framework:

• ensuring that clinical staff ask patients about their tobacco use and reporting the response in the EHR;
• inquiring if tobacco cessation is a performance measure that providers in the medical practice can receive credit for (e.g. value-based payment models);
• creating a referral form within the EHR to refer tobacco users to cessation services; and
• creating a “closing-the-loop” process for completed referrals so that referring practices receive status updates on their patients.

By the end of the fiscal year, Breathe DC had an estimated reach of approximately 10,000 District residents through community outreach and project-related social media activity. Through outreach efforts and direct service, Breathe DC had a cumulative educational outreach of 1,059 individuals during FY19. Of those: 683 were women of child bearing age who received smoking cessation resources or a referral, and 98 were clinical and ancillary clinical staff who received AAR training. Breathe DC completed 23 referrals from Managed Care Organizations (MCOs), 11 referrals from primary care providers (PCPs), 16 referrals from Community Based Organizations (CBOs),  and 16 referrals from government agencies (e.g. WIC). Breathe DC also participated in 18 health fairs, 18 neighborhood fairs, 7 community based events, and conducted 12 AAR Trainings.