Overview of State Action Plans

The following state action plans provide comprehensive information—including objectives, strategies, and performance metrics—on Michigan’s Title V MCH priority areas. Per Title V requirements, the state action plans are organized within five population domains: women/maternal health; perinatal/infant health; child health; adolescent health; and children with special health care needs (CSHCN). Michigan also created a new measure within the optional cross-cutting domain. Within these population domains, the state action plans for FY 2021 focus on the following National Performance Measures (NPMs) and State Performance Measures (SPMs):

• NPM 2 (Low-risk Cesarean Delivery)
• NPM 4 (Breastfeeding)
• NPM 5 (Safe Sleep)
• NPM 9 (Bullying)
• NPM 12 (Transition)
• NPM 13.1 (Preventive Dental Visit—Women)
• NPM 13.2 (Preventive Dental Visit—Children)
• SPM 1 (Childhood Lead Poisoning Prevention)
• SPM 2 (Immunizations—Children)
• SPM 3 (Immunizations—Adolescents)
• SPM 4 (Medical Care and Treatment for CSHCN)
• SPM 5 (Intended Pregnancy)
• SPM 6 (Developmental/Behavioral/Mental Health)

These NPMs and SPMs were chosen based on Michigan’s five-year needs assessment completed in 2020. States are also required to provide FY 2019 annual reports on all “retired” and “continuing” measures from the previous five-year cycle. Therefore, FY 2019 annual reports are provided for the following NPMs and SPMs:

• NPM 1 (Well-woman Visit)
• NPM 3 (Risk-appropriate Perinatal Care)
• NPM 4 (Breastfeeding)
• NPM 5 (Safe Sleep)
• NPM 10 (Adolescent Well-visit)
• NPM 12 (Transition)
• NPM 13.1 (Preventive Dental Visit—Women)
• NPM 13.2 (Preventive Dental Visit—Children)
• SPM 1 (Childhood Lead Poisoning Prevention)
• SPM 2 (Immunizations—Children)
• SPM 3 (Immunizations—Adolescents)
• SPM 4 (Medical Care and Treatment for CSHCN)

Annual reports are based on previous state action plans and may contain different objectives and strategies than current plans. Domain overviews are also provided to give a broader context to the overall population domain. Lastly, methodologies for determining the NPM annual objectives are included in the Supporting Documents.

Women/Maternal Health Overview

The health of women and mothers is a key focus of the Division of Maternal and Infant Health, which oversees the Reproductive Health Unit and Michigan’s Title X program. Title V funds directly support several programs and services designed to improve women’s pre- and inter-conception health, particularly family planning. Title V funds are also used to understand and address women’s health issues more broadly, especially as they relate to maternal mortality and factors such as race, class, and gender inequity that drive disparities. For example, Title V funding supports Michigan’s Maternal Mortality Surveillance activities and PRAMS. To address additional health needs of women, Michigan leverages other federal funds, such as the Preventive Health and Health Services Block Grant (CDC), and partners with the chronic disease, cancer prevention, substance abuse prevention, and injury and violence prevention programs within MDHHS. Additional partnerships that impact women’s health include local health departments (LHDs), the Michigan Council for Maternal and Child Health, Family Planning service providers, and the Michigan Primary Care Association.

At the local level, LHDs expended Title V funds on activities to support well-woman visit (NPM 1), oral health for women (NPM 13) and former SPM 3 (Depression across the Life Course). Six LHDs expended approximately 4.8% of total LMCH funds on NPM 1 by providing gap-filling direct services for reproductive services, cancer screening, STD testing and reproductive education. LHDs also completed outreach, media campaigns and surveys to community partners related to postpartum visits. Two LHDs expended 0.2% of LMCH funds on oral health services for women by educating clients on oral health benefits and referring for services. LHDs expended 1.7% of funds on mental health initiatives including staff development and gap-filling depression screening for women.

Michigan’s approach to women’s health emphasizes improving access to health services for this population, including reproductive and oral health services, based on the concept that access to care can be preventative across a variety of health needs. In 2018, Black mothers in Michigan experienced nearly twice the risk of severe maternal morbidity (277.5 per 10,000 delivery hospitalizations) than White mothers (144.3 per 10,000) (MDHHS, 2018). Similarly, maternal mortality (11.5 per 100,000 live births, MDHHS, 2016) is lower in Michigan than the national average (16.9 per 100,000, CDC, 2016) but the risk among Black women (20.4 per 100,000) is much higher than among White women (8.6 per 100,000). The disparity in the rate that Black and White Michigan mothers undergo low-risk cesarean births has moved from parity (in 2013) to 11% higher in Black mothers (MDHHS, 2018). Black mothers were also 1.8 times as likely as White mother to report their most recent pregnancy was mistimed or unwanted (PRAMS, 2018). These disparities have led Michigan to place greater focus on understanding and addressing the conditions that place non-Hispanic Black women at greater risk for adverse health outcomes, including disease and death before and after childbirth.

Although surveillance data tends to focus on indicators of a healthy pregnancy and healthy infant, wellness in pregnancy and at birth reflect women’s health status prior to conception. While 8.3% of US infants (NVSS) reported in 2017 were born with a low birth weight, 14.6% of babies born to non-Hispanic Black mothers in Michigan had a low birth weight. Similarly, while 10.2% of US infants (NVSS) reported in 2017 were born preterm, the percentage was much higher among Michigan’s non-Hispanic Black mothers (14.8%) (MDHHS). These data suggest that Michigan is far from achieving equity in health among women; improving women’s health status must focus on addressing the conditions that lead to disparate outcomes for Black women and their infants. Another trend in Michigan is the dramatic rise in rates of infants born with neonatal abstinence syndrome, which increased from 2.0 per 1,000 in 2008 to 7.6 per 1,000 in 2016 (which represents a slight decline from the 2015 peak of 8.5 per 1,000) (MDHHS). Partners at the state and local level have been designing and implementing strategies to understand and address this crisis.

Well-Woman Visit (FY 2019 Annual Report)

In 2019, MDHHS focused on strategies to improve the quality of family planning counseling and access to long-acting reversible contraceptives (LARC) through provider/practitioner professional development and outreach. The Michigan Collaborative for Contraceptive Access supported six hospitals with implementing best practices for peripartum contraceptive care, increasing LARC access for approximately 350 post-partum moms. During FY 2019, MDHHS held a clinical practicum on the insertion and removal of Paragard, a LARC, with 11 local providers, increasing network access to a highly effective reversible non-hormonal method.

MDHHS worked with family planning providers to improve quality of services and access to women in need. Family Planning collaborated with state and local programs to promote the evidence-informed PATH counseling model for pregnancy intention assessment and preconception counseling across a diverse array of providers and public health practitioners. During the FY 2019 Open Enrollment Period, local Family Planning agencies assisted and enrolled clients in Medicaid or Medicaid Health Plans or the Marketplace or referred clients to an entity with the capacity for enrollment assistance. Local agencies continued to connect Family Planning clients to primary care providers within the community, as needed. MDHHS continued to find opportunities for local Family Planning agencies to foster relationships with Medicaid Health Plans. The Family Planning Program engages consumers by soliciting their feedback through state and local client satisfaction surveys and participation on state and local Advisory Boards. Youth voice is incorporated into policies, programs, and practices by collaborating with Michigan Youth Voice, a statewide youth council coordinated by the Michigan Organization on Adolescent Sexual Health. During 2019, 98% (n=701) of statewide survey respondents strongly agreed (85%) or agreed (13%) the Title X services provided met their needs at the time of their visit. The quality of contraceptive care is assessed by monitoring local agency quality assurance mechanisms (e.g., abnormal pap follow-up) and improvement efforts (e.g., PDSA cycles).  

In 2019, MDHHS staff spent considerable effort implementing the 2019 Title X Final Rule, which escalated physical and financial separation requirements for abortion providers, prohibited disclosure of abortion providers and referrals, and tightened mandated reporting policy and documentation requirements. Due to these regulatory changes, Michigan’s largest Title X sub-recipient, Planned Parenthood of Michigan (PPMI), exited the program in September 2019. Within Michigan, PPMI was the sole Title X provider in five counties and the City of Detroit and worked in tandem with another Title X sub-recipient in 10 counties to serve 42,000 clients. To address this challenge, MDHHS staff conducted numerous outreach presentations and held meetings with interested providers. MDHHS successfully recruited three new providers for two counties (Oakland and Washtenaw) and the City of Detroit. MDHHS has focused on outreach to other healthcare providers across the state to fill contraceptive access gaps left from Planned Parenthood’s program exit.

Objective A: Increase the percent of females aged 15 to 44 who use a most or moderately effective contraceptive method from 81% to 84% by 2020.  

Having access to a broad range of effective contraceptive methods allows each woman the opportunity to choose the method that is right for her to successfully delay or prevent pregnancy. In 2019, 77% of female Family Planning clients aged 15 to 44 years old chose a most (i.e., sterilization, vasectomy, or LARC) or moderately effective (i.e., pills, patch, ring, cervical cap, or diaphragm) method, with 16% choosing LARC. Most or moderately effective (MME) method use peaked at 86% for Family Planning in 2016 and has declined approximately two percentage points each year while LARC use (12%, 2016) has increased by the same amount each year for this age group. To increase contraceptive access to individuals at greater risk of unintended pregnancy, a number of local agencies have integrated their Family Planning and STD clinics, which has resulted in more comprehensive services for men and women. At the same time, this has also resulted in an increase of females aged 15 to 44 who report male condoms as their primary method of contraception. In FY 2019, MDHHS worked toward increasing access to MME methods while balancing individuals’ contraceptive needs and preferences.

To promote Michigan’s Title X network, MDHHS implemented a statewide outreach/media campaign from January 2019 to April 2019. The statewide media campaign was designed to raise awareness of Family Planning clinics and to direct individuals to MDHHS’s Family Planning website to find a clinic location near them. The campaign was administered in high infant mortality communities (above the state rate) and targeted low-income, uninsured, men and women aged 20-35 years old, with an emphasis on reaching Latinx and African Americans. Multiple modalities were used such as audio streaming (e.g., Spotify), Digital (e.g., mobile web/Hispanic mobile), and Google Adwords. Based on Google Analytics, MDHHS’s Family Planning website traffic increased significantly during the campaign period. The click-thru-rate for most of the modalities exceeded industry standards. Over 80% of clicks were from women 20 to 24 years old.

From April 2018 to September 2018, MDHHS facilitated a Contraceptive Access Learning Collaborative (CALC) with six local agencies to measure performance and conduct quality improvement (QI) on two contraceptive care measures (i.e., most or moderately effective methods and LARCs) endorsed by the National Quality Forum. Evaluation results from Michigan’s CALC project demonstrated a 16.7% increase in LARC use among females aged 15 to 44 from baseline (6%) to endpoint (7%) for participating sub-recipients. The four agencies that provided LARC on-site experienced a 37.5% increase from baseline (8%) to endpoint (11%) and the two agencies that provided LARC by paid referrals maintained 3% LARC use from baseline to endpoint. During this project, one of the sub-recipients that offered out-county paid LARC referrals learned none of the providers within their community performed LARC insertions, including hospital systems. As a result, LARC access has been elevated as a county-wide need. Lessons learned and success stories were shared with the network at the 2018 Family Planning Update (September 2018) and during the 2019 Coordinators meeting (June 2019). The Family Planning Program has chosen not to replicate this project at this time, as all sub-recipients with the capacity to provide LARC on-site do so now.

During FY 2019, MDHHS’s Family Planning Program supported healthcare providers’ and public health professionals’ education regarding Medicaid’s immediate post-partum LARC policy change, which took effect on October 1, 2018. During FY 2019, Title V funds supported the Michigan Collaborative for Contraceptive Access (MICCA), a statewide learning collaborative to assist hospitals with implementing best practices for peripartum contraceptive care, including immediate post-partum LARC. In FY 2019, four of the six participating MICCA hospitals inserted approximately 350 LARC devices during the peripartum period. Of the two hospitals not currently offering LARC, one is finalizing internal procedures and provider training and the other is working through internal concerns regarding the cost-effectiveness. MICCA project staff have supported hospitals by providing ongoing implementation and evaluation support. MICCA plans to recruit an additional three to five hospitals for FY 2020.    

To increase Title X provider professional development, a clinical practicum on the Paragard intrauterine device was held on September 10, 2019 in Traverse City in conjunction with MDHHS’s annual Family Planning Update conference. Eleven mid-level clinicians attended the session. Dr. Brent Davidson, MD, Chief of Women’s Health at Henry Ford Health System and MDHHS Family Planning Program Medical Director, served as the practicum trainer. All 11 attendees agreed the information was relevant, and the trainer was knowledgeable and effective. The advantage of a clinical practicum focused on a non-hormonal LARC is that it broadens the range of contraceptives available in Michigan’s Title X network and improves access to a highly effective reversible method, especially for clients interested in non-hormonal contraceptives. The hands-on component of the practicum supports provider confidence with insertion, which often drives on-site provision.

Objective B: Increase the percent of women who report ever having discussed reproductive life planning during a visit with a doctor, nurse, or other health professional from 64% to 65% by 2020.

This objective is also Michigan’s ESM for the well-woman visit performance measure. Based on data from the Behavioral Risk Factor Surveillance System (BRFSS), Michigan’s FY 2019 reporting data indicates 58.4% of women discussed reproductive life planning during a visit with a doctor, nurse, or other health professional. This was a decrease from the previous reporting year, which was 66.2%, a peak year. To continue to make progress on this objective, the Family Planning Program worked to expand the use of pregnancy intention assessment and preconception health education within state and local programs. Family Planning staff presented to MDHHS’s Behavioral Health Program at their October 2018 staff meeting. The presentation covered all FDA-approved contraceptive methods, medical condition considerations for contraception, and the shared decision-making model for contraceptive counseling. Case manager and client-friendly resources were also included within the presentation. Family Planning staff also assisted the Maternal Infant Health Program (MIHP) in aligning its Family Planning Plan of Care with national standards and contraceptive best practices. The Plan of Care was updated to assess pregnancy intention, discuss future goals (e.g., school, career, lifestyle), and include client-friendly contraceptive resources. MIHP also posted the client-friendly resources on their provider network website.

Family Planning partnered with MDHHS’s STD Program for a Learning Pilot to examine a sub-set of clinics that have integrated both programs. One aspect of this pilot is learning about client identification practices and client fit for pregnancy intention and contraceptive counseling. Pilot findings and program recommendations will be shared through written guidance and at the annual 2020 Family Planning Update conference. Family Planning staff consulted on Medicaid’s Contraceptive Counseling pilot with OB/Gyn and Family Practice clinics where quality improvement methodologies will be used to incorporate or refine pregnancy intention and contraceptive counseling for female clients aged 18 to 44.

During FY 2019, the Family Planning Program was unable to find a clinical conference where pregnancy intention assessment and preconception health aligned with the theme and/or clinical topic area(s) of interest. Rather, this strategy shifted to utilizing MDHHS’s conference platforms as a mechanism to promote evidence-informed PATH questions, developed by Patti Cason, an Assistant Clinical Professor at the UCLA School of Nursing. These questions are one client-centered approach to assessing Parenthood/Pregnancy Attitude, Timing, and How important is pregnancy prevention. PATH can be used with clients of any gender, sexual orientation, or age. PATH is designed to facilitate listening and efficient client-centered conversations about preconception care, contraception, and fertility, as appropriate. Four Family Planning Program staff became Master Trainers. During the 2019 annual Family Planning Update conference, Patti Cason delivered a keynote Patient-Centered Reproductive Goals and Contraceptive Counseling and facilitated, along with three Family Planning Master Trainers, an applied PATH skills practice breakout session. Most session attendees (n=46) agreed the breakout session information was relevant, and the trainers were knowledgeable and effective. To reach a more diverse audience of providers and public health practitioners this counseling model will be a repeated breakout session at MDHHS’s 2020 Maternal Infant Health Summit. The session will be co-facilitated by two Family Planning Master Trainers and a lead teacher from a Detroit community-based organization. This session will explore application of the PATH counseling model within non-Title X clinical settings and programs that serve mothers and infants aged zero to five.

Pregnancy intention and preconception health messages were disseminated on MDHHS’s Facebook and Twitter accounts in FY 2019. Messaging during national health observances such as National Minority Health Month, Maternal Health Awareness Week, National Women’s Health & Fitness Day, and National Birth Control Day was promoted on MDHHS’s Facebook and Twitter accounts. One of the unforeseen challenges with using MDHHS’s social media accounts is the approval process for messages and notification of release days/times, which makes it difficult to notify and/or share content with local agencies. Another challenge is competing health observances and preventive health messaging. While MDHHS has a large reach on Facebook (24,098 followers) and Twitter (13,700 followers), engagement (e.g., likes, comments, retweeting) is typically low on both platforms. With low engagement, it has been difficult to evaluate MDHHS’s social media accounts as a tool for program promotion and community awareness. To assist with mitigating the noted internal and external communications challenges, a Communications Plan has been developed for FY 2020.

Objective C: Increase the percent of women with a past year preventive medical visit from 68% to 85% by 2020.  

This objective is Michigan’s National Performance Measure for the Women/Maternal Health domain. Based on the Behavioral Risk Factor Surveillance System (BRFSS), Michigan’s FY 2019 reporting data indicates that 58.4% of women aged 18-44 years old had a preventive visit in the past year. This was a decrease from the previous reporting year, which was 66.2%. To continue making progress on this objective, in FY 2019 Medicaid outreach opportunities were promoted among local Family Planning agencies. During the Open Enrollment Period, local Family Planning agencies assisted and enrolled clients in Medicaid or Medicaid Health Plans, the Marketplace, and other health insurance plans. For agencies without on-site enrollment, clients were referred to appropriate organizations in the community. Local agencies also participated in enrollment events by distributing health insurance brochures and related educational materials. During 2019, 31% (n=16,897) of Family Planning clients reported utilizing public health insurance such as Medicaid or Healthy Michigan Plans (i.e., Medicaid Expansion).

Local Family Planning agencies were reviewed and monitored on the development of medical and social service referral agreements and collaboration at the local level, as well as their assessment of client needs for primary care or other services. Agencies are required to assess client access to a primary care provider and make appropriate referrals as needed. Of the agencies reviewed during FY 2019, 100% had incorporated asking clients whether they were in need of primary care services into their Electronic Health Record systems and had current referral agreements with primary care providers within their community. Referrals to primary care providers were promoted on an as-needed basis.

During FY 2019, MDHHS used several tactics to assist local Family Planning providers in fostering relationships with Medicaid and Medicaid Health Plans. Local agencies are encouraged to establish formal arrangements with Health Plans. If that is not possible, agencies are encouraged to foster informal relationships. MDHHS also focused efforts on receiving regular Medicaid updates, providing input on Medicaid’s common formulary, and providing 340B prices on medications (i.e., antibiotics and contraceptives) to set reimbursements. In FY 2019, regular Medicaid updates were received during Family Planning’s statewide Advisory Council. Local Family Planning agencies had the opportunity to provide input on the common formulary on a quarterly basis, and 340B medications prices were provided to Medicaid on a quarterly basis.

Well-woman and preventive health messages were disseminated on MDHHS’s Facebook and Twitter accounts in FY 2019. Messaging during national health observances such as Cervical Health Awareness Month, Teen Health Week, STD Awareness Month, Sexual Assault Awareness Month, Men’s and Women’s Health Weeks, and National Breast Cancer Awareness Month was promoted on MDHHS’s Facebook and Twitter accounts. The messaging challenges noted above also applied to well-woman and preventive health messaging.

Oral Health – Women (FY 2019 Annual Report)

The MDHHS Oral Health Program (OHP) provides population-based oral health prevention efforts and effective utilization of the dental workforce in implementing and improving oral health access. With the increased awareness of the impact of oral health to overall health, the OHP has continued to increase its collaborations with community partners to improve oral health through prevention activities and direct access programs. This remains evident in the activities of NPM 13 in FY 2019.

Objective A: Increase the number of medical and dental providers trained to treat, screen, and refer pregnant women and infants to oral health care services.

During FY 2019, the Perinatal Oral Health Action Plan continued to be implemented to support better health status for women and girls. A main strategy continued to be the training and education of Michigan health professionals, particularly those who practice in and serve communities and women adversely impacted by health disparities. The ESM for this NPM is the number of medical and dental professionals who receive perinatal oral health education through MDHHS. In FY 2019, the Perinatal Oral Health Program trained 401 health professionals in the medical and dental fields through lectures, webinars, conference calls and other training events. This number does not include the hundreds of additional professionals trained by partners and coalitions. Michigan-specific Perinatal Oral Health Guidelines continue to be promoted, along with other educational materials. A partnership to teach a lecture on perinatal oral health to Nurse Midwifery and Nurse Practitioner students continues with the University of Michigan School of Nursing, with lectures occurring each semester as part of the curriculum. This course contains a hands-on component as well as practical application in how to integrate oral health within your future practice. In addition, an interactive piece called “Why is Grace in the Emergency Room” helps initiate discussion on the social determinants of health and health equity. Positive student feedback continues to be measured at 99% with over 325 advanced practice nurses trained to date.

Objective B: Increase the number of pregnant women receiving oral health care services.

In FY 2017, MDHHS awarded grant funds to the University of Detroit Mercy (UDM) School of Dentistry to implement a dynamic medical dental integration program. The project officially launched in FY 2018 and established itself with expansion in FY 2019 through funds from external partners. This partnership with the University of Detroit Mercy School of Dentistry, the Michigan Primary Care Association (MPCA) and the OHP has expanded from 6 sites to 10 sites across the state. This model of care, which places a dental hygienist directly within an OBGYN unit in an FQHC has provided 14,255 encounters during this reporting period. These services include 4616 education visits by the hygienist and 1208 cleanings for pregnant women. Evaluation began in 2019 with key informant interviews as well as interviews with participating patients and consumers. Additional efforts are underway to utilize electronic medical health records to track referrals and determine if the “referral loop” is being closed. Due to this project occurring within federally qualified health centers, a diverse population is being serviced in both rural and urban areas and includes women and children of all ethnicities and socioeconomic backgrounds.

In FY 2019, the wichealth.org module was utilized not only in Michigan but other states that participate with wichealth.org. Wichealth.org provides stage-based, client-centered, WIC nutrition education and an anticipatory guidance model in which WIC clients could complete educational lessons in English or Spanish to receive their WIC benefits. During the FY 2019 reporting period, 3,232 lessons were completed within Michigan with thousands more nationwide. WIC serves a diverse population and targets those within a lower social economic demographic. By developing education in partnership with WIC, the Oral Health Program has been able to reach populations that may have the most need and may experience the most health disparities. The module has also been developed in Spanish to better serve WIC clients and continues to be utilized by Spanish speaking clients.

In FY2019, customizable promotional materials were developed to inform the public of the new Medicaid dental benefit for pregnant women. These materials were posted online and distributed to the participating Medicaid health plans for their use. In addition, health departments and other clinics were also given the materials to customize for their use. Other educational efforts to promote this benefit included presentations with health departments and home visiting organizations. These materials featured plain language and simplistic but attractive format to reach all audiences.