DOMAIN: WOMEN’S/ MATERNAL HEALTH
Annual Report for FY19-20 (October 19-September 20)
Women’s/Maternal Health – State Priority #1: Reduce maternal mortality and morbidity
The factors impacting women's health are complex and varied, ranging from social-emotional, environmental, health insurance status, access to health care, and any number of other factors including the social determinants of health in which individuals are born, grow, live, play, work, and age. Improving women’s health throughout the life course is essential to improving the health and wellness of women. The NYS Title V MCHSBG program promotes and supports a myriad of efforts to improve the health of all women.
Over the past year pursuant to the State Action Plan (SAP), the NYS Title V MCHSBG program continued to focus on improving access to health care, increasing access to the most effective forms of contraceptives, supporting preconception health, promoting whole women’s health through the life course, and improving screening and treatment for maternal depression and substance use. Of importance to these efforts is the goal to promote health equity for all New Yorkers, which is emphasized throughout all domains and reflected in the Life Course section of this application.
Maternal mortality and morbidity are critical indictors for maternal and women’s health in NYS and therefore a priority in NY's Title V SAP. Understanding factors associated with maternal mortality and morbidity is essential for improving maternal health outcomes. Therefore, a strategy for this domain continues to be a more complete analysis of factors impacting maternal mortality and morbidity. As stated in previous Title V MCHSBG applications, NYS has a history of more than a decade in assessing factors leading to maternal deaths and developing strategies to reduce the risk of maternal mortalities. NY’s Title V program led the effort to establish the MMR Initiative in 2010, which is a comprehensive review of all maternal deaths. In the MMR Initiative, the NYSDOH conducts comprehensive surveillance activities based on linked birth and death record data, hospital in-patient and emergency department data and a hospital-based adverse event reporting system to identify maternal deaths.
Recently, the report of maternal deaths for 2012-2014 was published. The findings from this cohort indicated the top six leading causes of pregnancy-related deaths (N=96) was: embolism (not cerebral) (23%), hemorrhage (17%), infection (17%), cardiomyopathy (11%), cardiovascular problems (7%) and hypertensive disorders (6%). This is consistent with the results from 2012-2013 cohort. The expansion of the cohort to include 2014 revealed that Non-Hispanic Black mothers accounted for 45% of pregnancy-related deaths versus 30% for Non-Hispanic White mothers. The majority of pregnancy-related deaths were covered by Medicaid.
Racial disparities in maternal deaths are persistent; the statewide 3-year-rolling Black to White mortality ratio ranged from a high of 4.3 to 1 in 2005-2007 to a low of 3.2 to 1 in 2011-2013, with the most current ratio (2015-2017) falling at 3.3. The most recent data showed small geographic differences. In New York City, the Black to White ratio decreased from 3.4 in 2013-2015 to 3.0 in 2015-2017. This decrease in Black to White ratios was due to a slight increase in the maternal mortality rate among White women and the decrease in the maternal mortality rate among Black women. Outside New York City, the Black to White ratio decreased slightly from 3.9 in 2013-2015 to 3.4 in 2015-2017. This decrease in Black to White ratios was due to a slight but bigger decrease in the maternal mortality rate among Black women than the decrease in the maternal mortality rate among White women.
Recent data from NYS Vital Statistics showed that maternal deaths decreased from 20.2 per 100,000 live births in 2014-2016 to 18.9 per 100,000 live births in 2015-2017, and remained lower than the Prevention Agenda (PA) 2013-2018: New York State's Health Improvement Plan goal to reduce maternal mortality (MM) to fewer than 21 maternal deaths for every 100,000 live births by 2018. By continuing the comprehensive review of factors leading to maternal deaths through the MMR Initiative and designing strategies to address those factors, Title V MCHSBG aims to continue to improve outcomes for birthing people and babies and is expected to meet the Prevention Agenda (PA) 2019-2024: New York State's Health Improvement Plan goal to decrease maternal mortality (MM) to 16 maternal deaths for every 100,000 live births by 2024. https://health.ny.gov/prevention/prevention_agenda/2019-2024/background.htm
The reviews of the recent-year cohorts of maternal deaths are underway. The review of all 216 cases in the 2016 cohort and all 214 cases in the 2017 cohort have been completed, and the program is currently working on the MMR report for 2016-2017 cohort. For the 2018 cohort, New York State Department of Health (NYSDOH) and NYC Department of Health and Mental Hygiene (NYCDOHMH) each convened a committee for the review of all maternal deaths of NYS residents aged 10-60 years old who died during pregnancy or within one year from the end of pregnancy. The NYSDOH committee, called the MMRB, reviews all deaths of mothers occurring outside of NYC (i.e. Rest-of-State [ROS] and out-of-State), While the NYCDOHMH committee, called the Maternal Mortality and Morbidity Review Committee (M3RC), reviews all deaths of mothers occurring within NYC.
The reviews of the recent-year cohorts of maternal deaths are underway. All 216 cases in the 2016 cohort and all 214 cases in the 2017 cohort have been completed. For 2018, 45% of the 173 identified cases are complete using the CDC hosted Maternal Mortality Review Information Application (MMRIA) System.
One of the initiatives underway is a Medicaid Doula Pilot. In launching the Doula Pilot, OHIP gathered information for doula programs currently operating in NYS as well as Medicaid doula programs in other states. OHIP considered several data metrics to determine the eligibility areas for the Medicaid pilot including the availability of doulas and volume of Medicaid births and data that showed high maternal and infant mortality. Based on these metrics, OHIP decided to launch the doula pilot in Erie and Kings Counties. Under the pilot, doula services are available for any Medicaid-eligible pregnant woman in fee-for-service or Medicaid Managed Care in these geographic locations. Prior to the launch OHIP hosted several webinars on the pilot including billing coding. Phase 1 of the pilot project began March 1, 2019 in Erie County. Phase 2 of the project will include selected zip codes in Kings County once provider capacity has been achieved. This two-year pilot includes an analysis of data including breastfeeding rates and adherence to postpartum visits. It will also assess doulas’ and mothers’ experiences and feedback on participation in the program. OHIP has ongoing engagement with stakeholders and has made several adjustments in order to increase participation in the pilot by both pregnant women and doulas.
Another ongoing project included in both the Governor’s Maternal Mortality efforts and as a priority in the First 1000 Days on Medicaid initiative is a pilot project to assess feasibility of making the CenteringPregnancy prenatal care model a Medicaid covered benefit. Led by the NYSDOH OHIP, this project focused on studying the impact of CenteringPregnancy on infant health outcomes. NYSDOH engaged the Centering Healthcare Institute (CHI), the agency that developed the Centering Pregnancy model, to help develop tools and project materials to assess the impact of their model in areas of NYS with the poorest birth outcomes. Webinars and ongoing TA have been held for both Managed Care Plans and providers/clinics who will be participating in the project. The pilot’s target areas include the five NYC boroughs and ten counties that have been known to have relatively higher rates of poor birth outcomes in NYS. Several Medicaid Managed Care health plans and prenatal care clinics expressed interest and have been engaged in the pilot project. Enrolled sites are working to engage women in the pilot study, both as part of the control and experimental groups. Phase 1 of the project, with those clinics already operating an established Centering Program, began in June 2019. Clinics will continue to serve women, collect data on their participation in CenteringPregnancy, and report information on their birth outcome upon delivery. Phase 2, will expand to include sites just beginning to implement CenteringPregnancy.
To build on NYSDOH’s work related to maternal death reviews, the Title V MCHSBG staff is currently implementing an enhanced process for maternal death reviews that was developed in collaboration with ACOG-NY. The goal of these efforts is to address this significant public health issue with not only the population health approach, which includes surveillance and planning on a statewide level, but also provide health care providers and others with information needed to improve and enhance health care standards and practices. Substantial progress was made towards achieving these objectives during the reporting period. Two staff (one analytical and one programmatic) who support the Maternal Death Review initiative have been deployed full-time to respond to COVID-19 and a third staff (analytical) has been deployed part-time to COVID-19 efforts.
NYS was awarded a five-year CDC Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) grant in August 2019. The purpose of this grant is to support Maternal Mortality Review Committees to prevent maternal deaths. Currently, NYS has two active, multidisciplinary maternal mortality review committees: The NYSDOH MMRB and the NYCDOHMH M3RC. Under this grant, NYSDOH is collaborating with NYCDOHMH to identify and review all pregnancy-associated deaths in NYS. The MMRB reviews all deaths occurring outside of NYC, while the M3RC reviews all deaths occurring within NYC. Both committees are conducting a complete assessment of the causes of death, factors leading to death, preventability, and opportunities for intervention. The data and determinations for both committees will be entered into the statewide CDC central-hosted MMRIA, and the NYSDOH will compile and analyze the statewide data to inform opportunities for intervention and provide recommendations for statewide initiatives.
NYCDOHMH, a NYS subcontractor of the ERASE MM grant, is required to submit the quarterly reports to fulfill the sub-contract requirement. During the reporting period, NYCDOHMH submitted three quarterly reports to NYSDOH. NYCDOHMH reported that they held five M3RC meetings to review 2018 cases, delivered three presentations, and submitted two reports. In March 2020, NYS has successfully submitted the NYS ERASE MM grant Evaluation and Performance Measurement Plan to CDC. In April 2020, NYSDOH submitted the annual performance report for both NYSDOH’s MMRB activities and NYCDOHMH’s M3RC activities, per ERASE MM grant report requirements. The program also submitted the grant reapplication for Year 2 and received CDC approval.
Legislation to create and empower the NYS MMRB was signed into law on August 1, 2019. In addition to creating, empowering, and protecting the MMRB itself, the legislation included explicit powers and protections for the NYSDOH in its role supporting the MMRB. Title V MCHSBG staff have used this authority to gather case information from more sources than were previously available, which will enable the MMRB to examine the details of these women’s lives in order to identify and understand the non-clinical factors that may have contributed to the deaths. A small number of Title V MCHSBG staff have access to the NYS Department of Corrections database that provides information on individuals with incarceration histories. Additionally, a small number of Title V MCHSBG staff have access to the NYS Office of Mental Health Psychiatric Services and Clinical Knowledge Enhancement System that shares HIPAA compliant information about behavioral health services provided in outpatient settings and in state operated psychiatric centers. The MMRB held its second full meeting on September 15, 2020. The MMRB meetings are now being held virtually due to COVID-19. While some Board members have not been able to attend the meetings due to their COVID-19 responsibilities, the attendance has regularly been high overall.
The MMRB’s findings on recent trends and issues will be translated into action through collaboration with ACOG-NY and other key stakeholders to develop Issue Briefs, Grand Rounds, and quality improvement projects through the NYSPQC and its partners (e.g., hospital associations, professional associations, regional perinatal centers and affiliate obstetrical hospitals, among others). A statewide maternal mortality report will also be issued to provide data and information that can be broadly used to improve maternal outcomes. The 2014 maternal mortality report is complete and posted on the Department’s website: https://health.ny.gov/community/adults/women/docs/maternal_mortality_review_2014.pdf
Due to the prevalence of maternal mortality and morbidity in NYS resulting from maternal hemorrhage, the Title V staff through the NYSPQC is leading the NYS Obstetric Hemorrhage Project, which seeks to reduce mortality and morbidity by improving the assessment, identification and management of obstetric hemorrhage. Title V is collaborating on this project with ACOG-NY, Healthcare Association of NYS (HANYS), and Greater New York Hospital Association (GNYHA), with support from NICHQ. This project began in November 2017, and 67% (80/120) of NYS birthing hospitals are participating. Hospitals document completion of a hemorrhage risk assessment to improve recognition and care based on risk level. The percent of maternity patients with a documented risk assessment for obstetric hemorrhage completed on admission increased by 26.1% during the project period, from 75.5% in March 2018 to 95.2% in September 2020. Documentation of risk assessment for obstetric hemorrhage completed post-partum (between birth and discharge) increased by 88.6% during the project period, from 41.3% in March 2018 to 77.9% in September 2020. We experienced delays in data submissions from hospitals due to their staff and resources diverted to COVID-19 activities. In some cases, obstetrical services were closed or moved to a different location and no data could be collected by the hospital during that time period.
During the reporting period, NYSPQC staff have spent time responding to the COVID-19 pandemic and specifically providing support to NYS birthing hospital teams. Several staff from the NYSPQC team have been deployed to COVID-19 response activities. Two staff (one analytical and one programmatic) who support the NYSPQC have been deployed full-time to respond to COVID-19 and two additional NYSPQC staff have served part-time as duty officers. Remaining staff have taken on their roles, in addition to their own. Further, NYSPQC staff have assisted in the development of COVID-19 guidance from the NYSDOH related to the MCH population. In December 2020, the Department updated its protocol for COVID-19 testing for Pregnant People and Support Persons. The updated guidance is in the approval process.
In response to the COVID-19 pandemic, in April 2020, the NYS COVID-19 Maternity Taskforce was created. NYS birthing hospital staff who actively participate in the NYSPQC are represented on the Taskforce. Additionally, NYSPQC Executive Director, Marilyn Kacica, MD, MPH, has had an active role as a staff member of the group. The Taskforce issued recommendations to Governor Cuomo related to COVID-19 and maternity care, which Governor Cuomo fully endorsed. One of the six recommendations of the group was for the NYSDOH NYSPQC to host webinars addressing the management of maternity care during the pandemic and one specifically on obstetrical care and implicit bias within the context of the COVID-19.
Six Educational Webinars related to the management of pregnant people during the COVID-19 pandemic were held on March 30, April 20, May 7, May 28, July 13, and December 15, 2020. These events were hosted by the NYSPQC in collaboration with the ACOG District II Safe Motherhood Initiative and featured NYS obstetric leaders sharing their experiences, success and challenges related to treating pregnant and postpartum people during the COVID-19 pandemic. Additionally, NYSPQC staff, in collaboration with colleagues in the NYSDOH Division of Family Health, hosted a webinar focused on Maternal Equity & COVID-19 in June 2020. The webinar featured a panel discussion facilitated by Dr. Joia Crear-Perry, MD, FACOG, Founder and President of the Birth Equity Collaborative and seven panel members from various NYS hospitals, midwifery/doula programs, and community organizations. In addition to the COVID specific webinars, discussions around COVID-19 were integrated into two NYSPQC project Coaching Call webinars.
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Staff from the NYSPQC have participated on several national webinars related to COVID-19, and its relation to obstetric and neonatal outcomes. On these webinars, NYSPQC staff and affiliated birthing hospital providers had several opportunities to share their experiences in relation to COVID-19.
During the reporting period, a COVID-19 Resources section was added to the NYSPQC website. The page contains both CDC and NYS specific materials. It also includes links to recordings of all COVID-19 related webinars hosted by the NYSPQC. These materials can be accessed by NYSPQC participating birthing hospitals and the general public. Additionally, NYSPQC team members have been triaging questions from NYS perinatal providers directed to the project’s listserv since March.
Title V MCHSBG funding supports the work of the New York State Family Planning Program (FPP), a statewide network of providers that deliver high-quality comprehensive reproductive health services to low-income individuals. The FPP’s contracted training and technical assistance center, the New York State Family Planning Training Center (NYFPTC), has provided training to family planning providers to emphasize equity and reinforce reproductive justice principles in the delivery of family planning services. In 2019, the annual NYS Family Planning Program provider meeting featured a keynote address related to exploring unintended pregnancies through a reproductive justice lens. In addition, the NYFPTC conducted a series of in-person regional trainings for family planning providers across the state that focused on developing individual and organizational strategies to mitigate unconscious bias in family planning settings.
NY’s Title V MCHSBG also continued to support and promote direct outreach to engage women into health care and promote health insurance enrollment and entry into prenatal care. Through the Maternal and Infant Community Health Collaborative (MICHC) program, Community Health Workers (CHWs) focused on educating women on improved birth spacing, adherence to the postpartum visit, and use of an effective contraceptive method. In 2019, the MICHC program connected 207 women to health insurance, 79.7% of clients engaged in prenatal care in the first trimester, and 55.2% of postpartum clients attended a postpartum visit and an additional 35.4% had a visit scheduled at the time of reporting. As per the recommendations of the Task Force on Maternal Mortality and Disparate Racial Outcomes, the scope and breadth of work of the MICHC program were enhanced via the CHW Expansion grant. In August 2019, CHW Expansion contracts were awarded to the 23 established MICHC agencies throughout NYS to address key disparities, including providing more childbirth education and support, assisting in the development of collaborative child care and social support networks, assisting with the development of a birth plan and supporting increased health literacy among communities around the state. With these funds, 30 new CHWs were hired statewide to provide services for prenatal and postpartum women.
In response to the COVID-19 pandemic, MICHC agencies were able to maintain CHW services by working remotely. In-person home visits rapidly transitioned to virtual visits, and CHWs continued regular communication with their clients via phone and web-based apps/services (e.g., FaceTime, Zoom, etc), supporting clients in accessing needed services and support networks. Though MICHC staff were able to make this transition to remote services with little delay, the COVID-19 pandemic has had an impact on the scope and volume of virtual visits conducted.
With the transition to remote working, and social distancing practices in place in all communities served by MICHC, community outreach efforts were greatly diminished, resulting in a decrease in the number of overall clients served by MICHC programs. Due to the relative convenience of conducting remote visits, CHWs were able to stay in more frequent contact with existing clients, resulting in almost double the number of contacts with MICHC clients. However, maintaining CHW staffing levels during a pandemic were challenging.
By design and definition, the MICHC program is centered on improving perinatal and infant health outcomes and reducing health disparities in communities that are disproportionately impacted by disparities and is staffed with CHWs that are “indigenous to the communities they serve.” Meaning, oftentimes, CHWs are also disproportionately impacted by these disparities. The COVID-19 pandemic proved no exception, with many MICHC CHWs having to resign from the program due to illness or death in their family, or contracting the virus themselves, or from the stress and exhaustion of balancing the remote schooling of their children and lack of childcare options while maintaining a full client caseload. Given these challenges, MICHC agencies were limited in the number of new CHWs they were able to hire in the CHW Expansion awards. In addition, as response efforts to the pandemic increased, more CHWs and MICHC supervisory staff across the state were diverted to COVID-19 efforts; particularly for those MICHC projects based in local health departments. With staff deployed to activities, such as contact tracing, testing coordination, and call centers, the scope of MICHC services decreased in these areas. Staff working on call centers were able to refer eligible prenatal and postpartum community members for home visiting services. MICHC programs also received increased referrals from public health nursing, as their nursing staff were 100% deployed to the pandemic response.
At the onset of the pandemic, MICHC programs reported an overwhelming need among clients for basic necessities such as food, diapers, toiletries, masks and other PPE, as these items quickly became scarce or increasingly expensive based on supply. To meet these immediate needs, NYSDOH allowed MICHC programs to use a small amount of unobligated funds to purchase emergency supplies for their clients in need. Title V MCHSBG staff also worked with partners in WIC and NYCDOHMH on a statewide effort to distribute emergency supplies to food pantry sites in high-need communities.
Data observations for MICHC in this reporting period include:
- More diverse clients sought MICHC services, with an increase in the percentage of Hispanic and non-Hispanic black clients from 52.4% to 59.2%
- Referrals issued per client increased from 3.4 to 4.6
- Referrals issued for Food Pantry and Clothing/Baby Care Items increased noticeably, largely due to the changing needs of communities impacted by the pandemic
- For prenatal clients, transportation no longer ranked in the top five for needs, presumably due to access to telemedicine and virtual home visiting services. Instead, Family Planning, Family Resource Center and Food Pantry moved up in rank to fall within the top five health care and family and social referrals made
- For postpartum clients, Adult Primary Care and Housing ranked in the top five health care and family and social referrals, replacing Child Primary Care and Home Visiting Services.
To support MICHC program efforts during the pandemic, Title V MCHSBG staff provided MICHC agencies with COVID Maternity guidance documents they developed in support of the NYS COVID Maternity Task Force. (Guidance materials may be found here: https://coronavirus.health.ny.gov/protecting-public-health-all-new-yorkers#pregnancy-guidelines)
Evidence-based home visiting programs (Nurse-Family Partnership and Healthy Families New York) also emphasized birth spacing, importance of the postpartum visit, and effective contraceptive usage. In FY2020 (October 1, 2019 – September 30, 2020), 51.8% of clients enrolled in the Maternal, Infant, and Early Child Home Visiting (MIECHV) programs attended a postpartum visit within eight weeks of their delivery.
Another strategy used to engage more women in health care is the promotion of telehealth. In January 2019, Governor Cuomo launched efforts to promote access to rural telehealth services for perinatal care. This initiative includes four components: 1) providing up to $5 million in capital funds to increase regional perinatal center, rural birthing hospital and private provider access and capacity for perinatal telehealth services; 2) establishing a Perinatal Telehealth Workgroup with national experts including the founders of the successful Arkansas Antenatal and Neonatal Guidelines, Education and Learning System (ANGELS); 3) engaging hospitals participating in the Rural Health Care Access Development Program (RHCADP) to encourage expansion of perinatal telehealth initiatives; and 4) establishing a Project ECHO™ (Extension for Community Healthcare Outcomes) telementoring initiative to engage and enhance obstetric provider skills.
In order to meet the goals of this initiative, Title V MCHSBG staff collaborated with the Office of Primary Care and Health Systems Management (OPCHSM) to integrate the telehealth capital funds into a Statewide Healthcare Transformation Grant.. Additionally, Title V MCHSBG staff have collaborated with the NYSDOH Charles D. Cook Office of Rural Health to provide information and updates for RHCADP participating hospitals.
In May 2019, NYSDOH launched the Rural Perinatal Telehealth Workgroup, which includes representatives from rural birthing hospitals, regional perinatal centers that serve rural communities, rural private practitioners, and representatives from the ACOG-NY, New York State Association of Licensed Midwives, HANYS, Arkansas ANGELS project, and other stakeholders. The first meeting included a presentation from Dr. Curtis Lowery, founder of Arkansas ANGELS, Tina Benton (ANGELS Project Manager), Dr. Thao Doan (Westchester Medical Center Perinatal ECHO Project), and Drs. Heather Brumberg and Edmund LaGamma (Westchester Medical Center RPC).
Finally, in collaboration with OPCHSM, Westchester Medical Center (WMC) launched a pilot Project ECHO™ on perinatal health in June 2019. This pilot project represented only the second perinatal-focused ECHO program in the country since its’ inception in 2003 by the University of New Mexico Health Sciences Center. The WMC Perinatal ECHO Pilot continued into January 2020 with the following presentations:
- Late Preterm Infants – NOT Just “Small” Babies (October 24, 2019) by Dr. Jordan Kase, MD, FAAP (14 attendees from seven affiliate hospitals and private practices)
- Prevention of Preterm Birth (November 7, 2019) by Dr. Desmond White, MD, MFM, FACOG (12 attendees from nine affiliate hospitals and private practices)
- Perinatal HIV (December 12, 2019) by Dr. Nina Arlievsky, MD (seven attendees from seven affiliate hospitals and private practices); and
- Cell Free DNA Prenatal Testing (January 23, 2020) by Dr. Geetha Rajendran, MD (10 attendees from seven affiliate hospitals and private practices).
In addition to addressing women’s physical and reproductive health, NY's Title V MCHSBG program is addressing women’s social-emotional health. Perinatal Mood and Anxiety Disorders (PMAD) have a significant impact on mothers and the social-emotional stability of their children and families. NY’s Title V MCHSBG program is committed to addressing the comprehensive needs of women. In 2014, legislation was enacted requiring hospitals to educate patients about PMADs, maternal depression screening, and referrals. The Title V program, in collaboration with the Department’s OPCHSM, notified all obstetric hospitals of this requirement. Staff also researched and updated resources on the NYSDOH web site and continue to regularly review this information to ensure resources are current and applicable. In addition, the Title V MCHSBG program participated in the MOMD project, convened by the CLASP, with tOMH and other key stakeholders to address strategies to improve maternal depression screening and enhance resources for those women experiencing depression. New York’s goal for the MOMD project is to improve the health and well-being of mothers and children by strengthening state and local policies that identify, screen, prevent, refer, and treat maternal depression and other maternal mental disorders. Finally, legislation was passed mandating that, to the extent depression screening is already a covered benefit, insurers must pay regardless of which health care provider performs the screening.
Building upon NYSDOH participation in the MOMD workgroup, Title V MCHSBG and MIECHV staff developed and coordinated a media campaign to improve public awareness and treatment of PMAD and to direct primary care physicians and OB/GYNs to the OMH Project TEACH. NYSDOH worked with OMH staff to create digital and print messages for both the public and provider arms of the campaign. NYSDOH also partnered with the Postpartum Resource Center of New York (PPRCNY), as well as home visiting clients served by the MICHC, to obtain feedback on draft public messages from those with lived experience with PMAD. The digital public messages directed the public to the NYSDOH PMAD website (www.health.ny.gov/pmad), which was updated to feature gender inclusive language and the phone number for the PPRCNY helpline prominently displayed. Provider messages directed users to the Project TEACH website, where resources on maternal depression, including office hours for consultations with psychiatrists, are posted. The campaign ran from August-November 2020. The public arm of the campaign delivered more than 102 million impressions and delivered approximately 182,000 clicks to the NYSDOH website, with nearly 147,000 new users. The provider arm of the campaign delivered more than 1.7 million impressions which drove over 2,100 clicks to the Project TEACH website. This strategy is measured by ESM MWH-5: Percentage of women enrolled in Medicaid who are screened for maternal depression during postpartum care. The Title V MCHSBG program is monitoring this strategy using PRAMS data effective this past grant year. The collaborative project with OHIP originally reported has concluded. According to PRAMS data from 2016, which is the most recent data available for NYS, 81.6% of women on Medicaid report that a doctor, nurse, or other healthcare worker asked at the postpartum check-up if they were feeling down or depressed. This improved slightly to 83.1% in 2018. While a significant percentage of women are being screened, evidence is lacking regarding use of standardized screening tools, and there is room for improvement in percentage of women screened. Additionally, practitioners often identify lack of treatment services as an issue for women who screen positive.
NY's Title V MCHSBG program is committed to continued work to address this significant health issue for mothers and children. Through the Report on the Status of New York Women and Girls, 2018 Outlook, NYS Governor Andrew Cuomo launched efforts to address maternal depression and reduce maternal mortality. The components of the maternal depression efforts include the NYS Department of Financial Services requiring all health insurance policies to include coverage for maternal depression screening; expediting referrals and treatment, including expansion of Project TEACH (NY’s model for pediatric psychiatry consultation) to connect primary care providers and obstetricians and gynecologists with mental health specialists; enhanced screening and referrals at WIC clinics; increased access to telepsychiatry for those in rural communities; and a media campaign to increase awareness of and decrease stigma about maternal depression.
Title V MCHSBG staff work with OMH staff in increasing awareness of the expansion of Project TEACH for maternal mental health. WIC has added the Patient Health Questionnaire-2 to the screening questions on enrollment into the program. They have also increased training for WIC staff on maternal depression. The NYSDOH promoted awareness through social media and revised the NYSDOH consumer web pages on maternal depression. Social media kits were sent to local MCH providers for use in their social media efforts.
In addition to the above, NYS initiatives addressing PMADs include First 1000 Days on Medicaid (Dyadic therapy and home visiting proposals), HealthySteps grants, the Early Childhood Comprehensive Systems (ECCS) Impact Grant, and participation in the Moving on Maternal Depression learning collaborative with the Center for Law and Social Policy. The NYS Early Childhood Advisory Council (ECAC) identified early identification, prevention, and intervention for maternal depression as a current priority and convened a workgroup to develop and help advance relevant strategies. ECAC members were active in NYS’s First 1000 Days on Medicaid initiative (described elsewhere in this application), advocating for efforts to improve screening and treatment for maternal depression and dyadic therapy. They also are participating in the MOMD learning collaborative discussed below. Title V MCHSBG staff participate in this ongoing workgroup.
Two of the initiatives in the 10-point plan selected under the First 1000 Days on Medicaid initiative (described elsewhere in this application) could positively affect maternal depression. One is for Medicaid to allow providers to bill for the provision of evidence–based parent/caregiver–child therapy (also called dyadic therapy) based solely on the parent/caregiver being diagnosed with a mood, anxiety, or substance use disorder. The second is statewide home visiting, which would include a pilot in three communities and an identification of common programmatic elements that could be reimbursed through Medicaid funding. The first would allow for treatment of mothers identified as depressed and the second would help identify women through maternal depression screening conducted by home visitors. OHIP worked with OMH and Office of Addiction Services and Support (OASAS) to catalogue existing statewide efforts related to dyadic therapy and researching the provision and payment of the benefit. Currently, OHIP is drafting a Medicaid Update article to clarify this benefit that is planned to be released by Spring 2020. The SCAA Home Visiting Workgroup has been convened and parameters for the work established. Title V MCHSBG staff participate on the leadership team for the workgroup and pilot. To develop the pilot, Title V MCHSBG staff have been involved in the Aligning Early Childhood and Medicaid (AECM) initiative, which provides technical assistance to help design the pilot. The AECM initiative has linked OHIP and Title V MCHSBG staff to other states who have aligned Medicaid and home visiting. The pilot was anticipated to begin in Spring of 2020 but, due to the COVID-19 pandemic, has been delayed until Spring 20211.
In August 2018, NYS was selected to participate in the CLASP 18-month MOMD learning collaborative that aims to advance polices around maternal depression prevention, screening, and treatment. The NYS Team is co-led by OMH and the SCAA and includes members from OMH, NYSDOH, OASAS, American Academy of Pediatrics (AAP), ACOG-NY, Postpartum Resource Center, and the Children’s Agenda. Title V MCHSBG staff participate on the core team and on several subcommittees. NYS has five broad goals: 1) leverage and coordinate existing activity around maternal health and mortality and early childhood health and development, to generate action on maternal mental health; 2) meaningfully engage women with lived-experience into policy/advocacy for maternal depression; 3) develop key metrics/data relating to maternal depression; 4) develop an understanding of the scope, options and location of existing services to treat maternal depression; and 5) integrate policies and information across state agencies and partnerships at the community level.
To build on the work that began in June 2018 at the CLASP learning collaborative, Title V MCHSBG staff have participated on regular calls with the core team, as well as the workforce, equity, and data subcommittees. The data subcommittee is committed to developing a matrix that includes data measures on programs throughout NYS. The equity subcommittee worked to set up two equity webinars to gather input on equity that will help inform the in-person workforce meeting as well as other aspects of our work. The workforce subcommittee has worked to develop a continuum of care that highlights preconception, pregnancy, high-risk, and postpartum activities to address maternal depression. This document will help to inform the core group’s work on addressing maternal depression in NYS.
Addressing the complex needs of NY's women requires interagency partnerships and collaboration among key stakeholders. The NYS OMH supports 17 HealthySteps programs in pediatric medical practices across the state. The HealthySteps model is an evidence-based pediatric primary care program focused on early child development and effective parenting. A child development professional (HealthySteps Specialist) connects with families during pediatric well child visits as part of the primary care team. The NYS initiative provides full-time HealthySteps Specialists in medical practices to provide screening, including maternal depression, parental protective and risk factors, and social determinants of health. The 17 HealthySteps providers are fully operational, engaging new parents to enroll their infants in the HealthySteps program by 4 months of age. Over 5,000 children and their families were served as of September 30, 2019.
HealthySteps Specialists provide screening to include maternal depression, parental protective and risk factors, and social determinants of health. OMH is conducting an independent evaluation. Sites are tracking the maternal depression screening tools utilized, referrals made and/or approaches to care and report challenges to accessing services when making linkages/referrals to supports and services. The 17 sites have administered over 9,000 maternal depression screens for families enrolled in the program and provided over 3,000 maternal depression related referrals and/or services. Data are being analyzed to determine the positive screen rate and disposition of the positive screens.
Other program components include:
- Team-based well-child visits
- Positive parenting guidance and information
- Screening following a periodicity.
- Adverse Childhood Experiences (ACE)
- Parent Education Groups
- Home Visiting at key developmental times
- Access to support between visits
- Connections to resources
- Care coordination/systems navigation
- Early Literacy Reach Out and Read.
In January of 2018, the OMH HealthySteps sites completed a 12-month Learning Collaborative on Building a Trauma-Informed Practice and Integrating the ACE survey into practices in collaboration with technical assistance and training from Montefiore Medical Group’s nationally recognized experts in Trauma Informed Care and Healthy Steps. The sites have completed over 2,300 ACEs surveys.
To further enhance supports and services, the Title V MCHSBG program successfully collaborated on the development of an ECCS Impact grant with the Council on Children and Families (CCF). The grant supports collaborative quality improvement projects in three high need counties (Erie, Niagara and Nassau) to improve maternal depression screening and follow-up as well as developmental screening and follow-up for young children. CCF is working closely with NYSDOH on this grant which was initiated in 2016. With leadership from Dr. Kuo, Associate Professor and Division Chief for General Pediatrics at the University at Buffalo, the Erie/Niagara team organized a learning collaborative and designed a universal referral algorithm and form for families with young children to use in six local pediatric practices to make referrals to Erie County and Niagara County Early Intervention and local community supports. At the other end of the state, under the leadership of Dr. Elizabeth Isakson, the Nassau team has used ECCS activities to support the implementation of Help Me Grow Long Island. Help Me Grow Long Island offers free developmental and social emotional screens and provides free, virtual, ongoing support to families with young children on Long Island who have concerns such as their child's development or behavior, navigating service systems, or locating baby items. In addition, at the state level the ECCS initiative is connected to various technical assistance initiatives and statewide workgroups and committees such as the OHIP’s First 1000 Days on Medicaid initiative, the New York Strengthening Infant/Toddler Policies and Practices, the NYS Parenting Education Partnership, and workgroups on the NYS Governor’s Early Childhood Advisory Council and the Governor's Child Care Availability Task Force.
In an effort to improve coordination and bi-directional referrals between home visiting programs and local WIC sites, the Title V MCHSBG program collaborated with NYS WIC and OCFS. Title V staff met with OCFS and NYS WIC to determine how best to improve coordination between home visiting programs and local WIC sites and how to improve referrals from local WIC sites to home visiting programs. State WIC indicated that the home visiting referral forms were lengthy and asked for more information about the WIC participant than the WIC staff were willing to share. State-level collaboration led to the creation of a universal referral form for the local WIC sites to use to refer to MICHC, Nurse-Family Partnership, and Healthy Families New York home visiting programs. In July 2020, Title V MCHSBG and MIECHV staff presented at a quarterly WIC call on home visiting programs and the new universal referral form. Referral data is being reviewed quarterly to determine if the universal referral form is having an impact on referrals to home visiting programs and to assist in determining next steps in efforts to improve collaboration and bi-directional referrals between home visiting programs and local WIC sites.
The Title V MCHSBG program also collaborated with CCF on the Preschool Development Birth through Five (NYSB5) project ($13.4 million in federal funding for the next three years) to strengthen and build new partnerships, coordinate the NYS early childhood care and education system, improve transitions, expand parent choice and knowledge and promote equity with a focus on vulnerable populations. The grant also seeks to institutionalize parent voice, align and strengthen interdisciplinary professional development, expand access to high quality early care and education programs and identify strategies to maximize and coordinate funding. Title V MCHSBG staff have been collaborating with the CCF on several NYSB5 project activities. To complete the NYSB5 Needs Assessment, OHIP provided data about Medicaid usage for young children and regularly attended the NYSB5 bi-monthly partner meetings. Title V MCHSBG staff participated in the NYSB5/NYS ECAC Strategic Plan Development over the course of several months. Collaboration with CCF is further strengthened through work with the First 1000 Days on Medicaid Infant Mental Health and Home Visiting Work Groups. The NYSDOH is also included as a partner on the NYSB5 Parent Portal (www.nysparenting.org) with links to NYSDOH resources and a searchable chart for NYS home visiting programs. NYSB5 launched a statewide Talking Is Teaching Media Campaign in collaboration with the NYSDOH, OpAD, and the NYS Office of Child and Family Services (OCFS), which translated posters in six languages (Spanish, Russian, Chinese, Haitian-Creole, Korean, Bangladeshi). NYSDOH and CCF also worked closely in the development of a Family Resource Guide to Early Childhood Services – Prenatal through Age Five. The resource includes programs and supports available to families with children 0-5 like home visiting, childcare, early intervention, Head Start, prekindergarten and preschool special education. Title V MCHSBG staff presented at the first annual NYSB5 Technical Assistance Alignment Summit and worked with NYSB5 partners to establish an understanding of the technical assistance resources in NYS and begin discussion around ways to maximize resources, reduce redundancies, address technical assistance gaps and improve effectiveness.
Addressing the opioid epidemic is a public health priority in NYS, mirroring the national experience. In 2014, Governor Cuomo established the Heroin and Opioid Task Force and signed the Combat Heroin Legislation which established a multi-faceted response to the opioid epidemic, with a focus on prevention, harm reduction, treatment, recovery, and law enforcement. In response to the Task Force and legislation, NYSDOH developed an interagency opioid surveillance workgroup that consists of various state agencies and stakeholders with an interest in addressing this public health priority. The workgroup developed a comprehensive website for opioid-related data in NYS to improve the timeliness of reporting opioid-related data to key stakeholders. This site provides the most recent data (NYS Opioid Annual Report 2019) and trends over time on opioid prevalence, healthcare utilization (emergency department visits, hospitalizations) and mortality at state, regional and county (County Opioid Quarterly Report for NYS) level, where available. The NYSDOH created an interactive Opioid Data Dashboard that is a visual presentation of opioid related indicators tracking fatal and nonfatal opioid overdoses, opioid prescribing, opioid use disorder treatment and the overall opioid overdose burden. Title V MCHSBG staff share the reports and dashboard links, as well as other resources such as webinars and educational materials, with NYSDOH NYSDOH-funded perinatal programs, hospitals involved in perinatal quality improvement efforts for maternal Opioid Use Disorder/Neonatal Abstinence Syndrome and other stakeholders across the state. Access to these data and other resources allows agencies and stakeholders to more easily identify priority areas to target to address the opioid epidemic, help tailor interventions, and show improvements in NYS.
NY’s Title V MCHSBG Program is also working collaboratively with state agencies and stakeholders to increase understanding of and develop strategies to address NY’s opioid epidemic. Since Spring 2016, Title V MCHSBG staff participated on an interagency work group, led by OASAS, to address pregnant and parenting women with opioid use disorders. OASAS received an in-depth technical assistance grant from the National Center for Substance Abuse and Child Welfare, focused on women with substance use disorders and their substance exposed infants in Onondaga, Warren and Washington counties. This was a two and a half-year pilot (6/2016 – 2/2019) and the core team, which includes Title V MCHSBG staff and agencies in the three pilot counties, aimed to establish universal screening, increase treatment access, develop peer services, and address the Comprehensive Addiction and Recovery Act (CARA) amendment to the Child Abuse Prevention and Treatment Act (CAPTA). As part of the initiative, participating counties assessed how pregnant women who use opioids would negotiate the health care and support systems in their respective counties. They identified areas of disconnect that they are working to improve, e.g., lack of communication between health care providers. NYS OASAS has issued a Local Services Bulletin to its providers with instructions on how to work with pregnant women in relation to Plans of Safe Care. NYS OCFS and NYSDOH Title V MCHSBG staff are collaborating to identify how best to work with hospitals on reporting.
Title V MCHSBGstaff in collaboration with other NYSDOH offices, including the OHIP and OQPS staff have been co-leading an analytic project to conduct two studies of maternal opioid use and neonatal abstinence syndrome (NAS). The workgroup met four times during this reporting period to develop consistent methodology on study inclusion and exclusion criteria, exposure definition and categorization, morphine milligram equivalent (MME) calculation and other analytic points. The data analysis planning team, comprised of Title V MCHSBG staff and other state agency representatives, has been addressing questions and concerns that arise throughout the study period. The studies are on hold indefinitely due to competing needs for analytic resources.
Further, the NYSPQC, in partnership with ACOG-NY, HANYS and GNYHA, and with support from NICHQ, is leading the NYS Opioid Use Disorder (OUD) in Pregnancy & Neonatal Abstinence Syndrome Project. This learning collaborative, which kicked-off in September 2018, was piloted in 17 birthing hospitals, and seeks to identify and manage the care of pregnant people with OUD, and improve the identification, standardization of therapy, and coordination of aftercare of infants with NAS. To date, topic areas of focus have included: verbal screening related to substance use for all pregnant people during the prenatal period and on admission to the birth hospitalization; trauma informed care; improved communication between obstetrics and pediatrics; reducing stigma; training clinical staff on the signs and severity of NAS; improving both pharmacologic and non-pharmacologic care for infants with NAS; Eat Sleep Console as a method of treatment for infants with NAS; considerations for breastfeeding for women who use substances; and linkages to care. The statewide project expansion, originally planned for Spring 2020, was delayed to September 2020 due to COVID-19. The NYSPQC is participating in the national Alliance for Innovation in Maternal Health (AIM) through this initiative.
During the reporting period, the NYSPQC continued participating in the Association of State and Territorial Health Officials (ASTHO) Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative (OMNI) Learning Community. The purpose of the learning community is to provide technical assistance, build capacity, and disseminate strategies and best practices to support program and policy implementation on substance use disorder (SUD) among pregnant and postpartum women and infants prenatally exposed to opioids, including NAS. Agencies and organizations convened as part of this effort include ACOG-NY; HANYS; GNYHA; Northwell Health; NYSDOH OHIP, AIDS Institute, and Office of Drug User Health; OASAS; NICHQ; and Community Health Care Association of New York State (CHCANYS). The overarching goal of the NYS OMNI team, in alignment with the NYS OUD in Pregnancy & NAS Project’s goal of increasing the percent of pregnant women screened for SUD with a verbal screening tool, is to train prenatal care hospital staff on standardized screening, develop provider resources for screening and referral, and connect diverse work happening across the state.
In addition, NYSDOH’s Growing Up Healthy Hotline (GUHH), NY's Title V 24/7 phone line provides information and referral in English, Spanish and other languages via the AT&T language line. Any New Yorker can call the GUHH for information on a wide range of programs and services and is used in public health media campaigns. From October 1, 2019 to September 30, 2020, GUHH responded to 13,692 calls, which included calls requesting referral and information related to prenatal care, health insurance and Medicaid, and perinatal depression, among other priority MCH needs.
This NYS priority is tracked through NPM #1: Percentage of women with a past year preventive medical visit; data are obtained through Behavioral Risk Factor Surveillance System (BRFSS). In 2018, 79.6% of women interviewed had a past year preventative visit as compared to 78.3% in 2019. This is steady in NYS and exceeds the national measure of 72.8% in 2019. SPM 1: The percentage of women age 18-44 years who report ever talking with a health care provider about ways to prepare for a healthy pregnancy which is also calculated from BRFSS data showed an improvement from 35.3% in 2016 to 43.1% in 2019. This priority is also monitored through SPM 2: The percentage of women age 15-44 years and enrolled in Medicaid using the most effective, or moderately effective methods of contraception, which is calculated using Medicaid claims data, declined from 27% in 2015 to 24.5% in 2016. Due to data access issues, this measure was calculated using more recent BRFSS data similarly finding that values have been declining from 55.2% in 2017 to 49.5% in 2019.
The National Outcome Measures (NOM) that align with this priority are as follows: NOM #2 Percent of delivery or postpartum hospitalizations with an indication of Severe Maternal Morbidity (SMM). NYS exceeds the national measure of 77.5 incidents of SMM per 10,000 delivery hospitalizations as reported in Healthcare Cost and Utilization Project (HCUP) data in 2018. For the same time period, NYS is reported to have 89.5 per 10,000 delivery hospitalizations. For NOM #3 Maternal mortality rate per 100,000 live births, NYS increased from 17.8 deaths per 100,000 live births in 2014-2018 to 18.4 in 2015-2019, which is higher than the national average of 17.8 in 2015-2019. NYS also demonstrates significant success in NOM #7 Percent of non-medically indicated deliveries at 37, 38 weeks gestation among singleton deliveries without pre-existing condition continued to decline, decreasing from 2.0% in 2015-2016 to 1.0% in 2016-2017, which is lower than the national average of 2.0%. Finally, for NOM #11 The rate of infants born with neonatal abstinence syndrome per 1,000 hospital births, NYS continued to fall below the national average with the NYS rate 4.2 vs the national average 6.4 in 2015.
The application for activities in FY22 (October 1, 2021- September 30, 2022) continues to reflect ongoing efforts to address these priority public health issues to achieve selected targets.
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