Annual Report Fiscal Year 2018: This section provides a summary of Federal Fiscal Year 2018 (FFY18) activities, accomplishments, and challenges related to National Performance Measures (NPMs) and State Performance Measures (SPMs) (2016-2020) for the Women/Maternal Health Domain.

In spring 2015, the MCH Unit selected Improve Access to and Promote Use of Effective Family Planning as one of its 2016-2020 priorities. There is no available NPM for this priority. Healthcare access in a rural and frontier state can be challenging, and this is especially true for family planning services. Contraception choices can be limited when the nearest family planning clinic is hours away, and some clinics may not be equipped to offer a full range of contraceptive options. Access to effective family planning not only decreases unintended pregnancy rates, but helps women attain healthy birth spacing, delay pregnancy when desired, and promotes the well-being and autonomy of women. Wyoming women face a number of barriers to widespread family planning access. Long-acting reversible contraception (LARCs) such as intrauterine devices (IUDs) and implants are the most effective form of birth control available, but are often not accessible or offered to women as a contraceptive choice. According to program partners, stakeholders, and current work in the state, the bundling system for payments in federally qualified healthcare centers (FQHCs), Rural Health Clinics (RHCs), IHS, and hospitals is the primary barrier to accessing LARCs. The current reimbursement structure disincentivizes providers to offer LARCs due to little or no reimbursement for the procedure or the device.

The Wyoming Pregnancy Risk Assessment Monitoring Survey (PRAMS) aggregate data from 2012 - 2015 show that 31.2% of live births in Wyoming were the result of unintended pregnancies and 15.8% of women indicated that they were not sure what they wanted. 

Strategy 1: Provide technical assistance to Wyoming hospitals implementing immediate post-partum (IPP) LARC protocols

The WIHP, MCH Epidemiology Program, Wyoming Medicaid, and a provider champion participated in the Association of State and Territorial Health Officials (ASTHO) Learning Community on Increasing Access to Contraception from 2016 to 2018. During that time, the Wyoming team partnered with a local hospital to pilot a project aimed at reducing barriers to IPP LARC insertions, with the support of a local physician champion and hospital leadership. This project helped identify primary barriers to implementation in a hospital setting in Wyoming. These barriers include hospital stocking, Medicaid reimbursement for device outside of the bundle, and provider uptake. Although many barriers must be addressed to reduce barriers to LARC use, the reimbursement challenges were greatest. At least one provider in the pilot hospital successfully billed Medicaid for IPP LARC; however, the workaround was not sustainable and not a possibility for all providers. 

Strategy 2:  Develop IPP LARC Toolkit

Efforts to unbundle LARC in hospital settings are on hold as DRG (Diagnosis Related Grouper) implementation continues. Wyoming Medicaid requests that the project team delay efforts to unbundle IPP LARC until at least 9-12 months after the DRG goes live. In the meanwhile, the project team will focus on reimbursement of LARCs as part of the postpartum, outpatient global fee.

Strategy 3:  Complete a cost analysis on LARC versus unintended pregnancy in Wyoming; Strategy 4: Change Medicaid policies related to LARC reimbursement in hospitals, RHCs, FQHCs, and IHS.

In order to further focus efforts on the reimbursement challenges of LARC, the WIHP applied for a State-Level Initiatives to Expand Access to LARC grant funding opportunity offered by the National Institute for Reproductive Health. WDH received a $25,000 grant to refocus LARC work in the state in early 2019. This grant opportunity will fund a cost analysis on the use of LARCs versus the cost of an unintended pregnancy in Wyoming. The cost analysis will be used to demonstrate the need for unbundling the cost of LARC devices in FQHCs, RHCs and hospital settings under both public and private insurance. Due to the barriers in the hospital setting, WDH will focus its efforts with Wyoming Medicaid to unbundle the LARC device and procedure fee in FQHCs and RHCs first. This will improve contraceptive access in the states most rural and frontier locations. The MCH Unit has partnered with the Wyoming Primary Care Association (WYPCA) and Wyoming Medicaid on this project, and has obtained the support of the WYPCA as a project partner and grant subrecipient.

The SPM for this strategy--the percentage of women aged 15-44 at risk of unintended pregnancy that is provided a most effective (i.e. sterilization, implants, intrauterine devices or systems (IUD/IUD)) or moderately effective (i.e., injectables, oral pills, patch, ring, or diaphragm) contraceptive method-- was adopted in FFY19 and will be reported in 2020. The MCH Epidemiology Program will also track other contraceptive care measures adopted by the National Quality Forum, as appropriate. 

The WIHP seeks to prevent infant mortality through reducing the percentage of women who smoke during pregnancy. Smoking during pregnancy has been linked to numerous health problems for the unborn infant, including placental issues, low birth weight, increased risk of premature birth, birth defects, and spontaneous abortion.

Strategy 1: Train health care providers in Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) Program

The WIHP partnered with March of Dimes in April of 2017 to attend the train-the-trainer session for Smoking Cessation and Reduction in Pregnancy Treatment (SCRIPT) at the Society for Public Health Education (SOPHE) conference in Denver, CO. The 8-hour training included the fundamentals of SCRIPT implementation, SCRIPT evaluation, and a certification to train others in SCRIPT implementation. The WIHPM provided SCRIPT training at the Wyoming Public Health Association annual conference in September of 2018 on SCRIPT implementation, and eight public health providers, including six public health nurses (PHN), were trained on SCRIPT implementation. As of May 2019, Sweetwater County Public Health has plans in place to implement SCRIPT in their home visitation program, and data on this effort will be collected through the Healthy Baby Home Visitation program through the new PHN electronic health record, WebChart, that was implemented in late 2018. Currently, no MCH staff are trained in SCRIPT. This strategy will be continued after new staff receive training.

Strategy 2:  Promote the Wyoming Quitline with pregnant and postpartum women, with a focus on women served through the Healthy Baby Home Visitation Program.

The WIHP has committed to the ongoing promotion of evidence-based smoking cessation strategies targeted at pregnant and postpartum mothers. Through an MCH services contract held with all counties, MCH requires PHNs to ask about smoking status at every home visit and refer smoking clients to the Wyoming Quitline. The WIHP continues to promote the Wyoming Quitline through distribution of marketing materials in PHN home visiting and PHN offices.

The Wyoming Quit Tobacco Program is focused on increasing the number of pregnant women that call the Wyoming Quitline. The Quitline is an evidenced based strategy for quitting tobacco. Wyoming has an incentive program for enrollment in the program during pregnancy. The ESM for this strategy was adopted in FFY19 and will measure the success of the partnership between the MCH Unit, PHN, and Tobacco Prevention Program in getting women who smoke during pregnancy to enroll in the Quitline services. During FFY18, 18 pregnant women were referred to the WY Quitline. 

(Inactivated) Strategy:  Work with tribal tobacco program to build capacity to implement strategies for smoking cessation during pregnancy

In mid-2017, the WIHPM executed a contract with a licensed clinical psychologist to offer life-history training to healthcare and social service providers on the Wind River Reservation, specifically staff from the White Buffalo Recovery Center. Training topics were to include qualitative interviewing and coding techniques. By increasing capacity to conduct focus groups (and life history interviews), the program expected to learn more about circumstances surrounding smoking (and other risky health behaviors such as substance use) among pregnant and postpartum women use that information to better target information and interventions related to smoking cessation in pregnancy. In FFY18, due to staff turnover at White Buffalo Recovery Center and other barriers, the training was postponed indefinitely. When a new WIHPM begins in Summer 2019, this strategy will be reviewed further to identify if other strategies may be employed with tribal partners to reduce smoking among Native women. 

Strategy 1: Support hospitals in implementation of AIM safety bundles (e.g.

hypertension, opioids use during pregnancy, low-risk Cesarean delivery)

The WIHP maintains an ongoing partnership with the Utah Department of Health related to their Alliance for Innovation in Maternal Health (AIM) ECHO series. Six Wyoming hospitals participated in Utah’s Severe Hypertension in Pregnancy safety bundle ECHO starting in 2017. This partnership resulted from review of LOCATe results and identified opportunities to improve maternal emergency protocols and drills. Currently, Wyoming is not an AIM state and therefore cannot directly participate in AIM work. The requirements for states to participate as an AIM state are to have established both a maternal mortality review committee and a perinatal quality collaborative. The partnership with Utah allows Wyoming hospitals to participate in AIM despite Wyoming not currently meeting eligibility criteria. Participating hospitals completed pre/post assessments and were permitted to register as AIM facilities and upload data into the AIM portal, thus contributing to data capacity on maternal safety in the hospital setting. Sessions for this safety bundle wrapped up in mid-2018, but plans are in place to offer refresher sessions in 2019. Wyoming facilities will be invited to participate in an in-person close-out meeting.

In late 2018, the WIHP released a survey to Wyoming hospitals to assess interest in future ECHO sessions and to help inform Utah’s choice on their next ECHO topic. Eleven Wyoming hospitals responded. Wyoming survey results indicated an interest in the Support After a Severe Maternal Event safety bundle and Obstetric Care for Women with Opioid Use Disorder safety bundle. Utah selected the Obstetric Care for Women with Opioid Use Disorder safety bundle based on feedback from both Wyoming and Utah hospitals. The WIHPM will continue to partner with the Utah Department of Health to develop the ECHO session content and schedule. The WIHP anticipates increased participation from Wyoming hospitals due to increased hospital engagement in the Wyoming Perinatal Quality Collaborative (WYPQC). 

New FFY19/20 Strategy: Offer provider training on safe prescribing to reduce opioid use/misuse in pregnancy and postpartum periods

In early FFY19, the WIHP, in partnership with the WDH Public Health Preparedness and Response Unit and their Cooperative Agreement for Emergency Response: Public Health Crisis Response funding, started work on a training for healthcare providers related to safe prescribing of opioids during pregnancy and postpartum. The training will be offered in Summer/Fall 2019 and will help providers meet a new legislative requirement of receiving three continuing medical education (CME) hours on safe prescribing every two years. The WIHP worked with partners at tertiary care facilities in Colorado to identify potential trainers who will be Dr. Kaylin Klie from Colorado Children’s Hospital, Dr. Lesley Brooks from the Northern Colorado Health Alliance, and Dr. Ryan Jackman, an Addiction Medicine Specialist from St. Mary’s Family Medicine. The WIHP will continue to work with the Wyoming Medical Society, American College of Obstetricians and Gynecologists (ACOG) and other physicians groups to engage providers who serve pregnant women in Wyoming, to ensure the training reaches a wide audience. It will also be broadcast virtually for remote attendance, and will offer continuing medical education for live attendees.

Through the same partnership with the WDH Public Health Preparedness and Response Unit and their Cooperative Agreement for Emergency Response: Public Health Crisis Response funding, the WIHP will release a Request for Application (RFA) to Wyoming hospitals to implement quality improvement projects that respond to the rising incidence of opioid use in pregnancy and postpartum and neonatal abstinence syndrome. This grant will support Wyoming hospitals in implementation of quality-improvement strategies or projects that prioritize one of the following project options: 

1. Obstetric Care for Women with Opioid Use Disorder Patient Safety Bundle developed by the Alliance for Innovation in Maternal Safety (AIM)
   1. Overview:  This project is being offered by the Utah Department of Health in conjunction with the University of Utah and the Utah Perinatal Quality Collaborative. Wyoming hospitals are invited to participate.  For more information, visit safehealthcareforeverywoman.org.
   2. Requirements: 
      1. Twelve-month commitment to attend AIM Project ECHO sessions. Sessions are offered bi-weekly, and funded hospitals must commit to attending no less than 75% of offered sessions. ECHO sessions will be offered using Zoom video conferencing software. Anticipated start date of this ECHO series will Fall 2019.
      2. Execution of a required data-use agreement between the awarded hospital and AIM.  Hospitals must report all required project data. 
      3. Attendance at optional in-person launch meeting (Fall 2019) and project wrap-up meeting, both of which will take place in Salt Lake City, Utah.
      4. Required project updates and summary reports provided to the WYPQC, including updates at quarterly WYPQC meetings.
2. Colorado Substance Exposed Newborns (CHoSEN) Hospital Learning Collaborative
   1. Overview:  This project is offered through a partnership with the Children’s Hospital of Colorado, Illuminate Colorado, and the Colorado Perinatal Care Quality Collaborative.  For more information, visit https://www.illuminatecolorado.org/sen. 
   2. Requirements: 
      1. Development of a project aim and selection of key drivers.
      2. Implementation of a comprehensive quality improvement project.
      3. Execution of a required data-use agreement between the awarded hospital and CHoSEN.  Hospitals must report all required data into the RedCAP system.
      4. Attendance at optional in-person CHoSEN summit in Fall 2019. 
      5. Required project updates and summary reports provided to the WYPQC, including updates at quarterly WYPQC meetings.

Additional WIHP Activities:

The Maternal High Risk (MHR) and Newborn Intensive Care (NBIC) Programs ensure high-risk pregnant women and high-risk infants have access to care coordination services and limited gap-filling financial assistance to enhance perinatal outcomes.  Promotion of these programs further support efforts to improve risk appropriate perinatal care, especially for families that require out-of-state care at a Level III and Level IV facilities. Referrals for these essential gap-filling programs come from providers around the state, as well as from our tertiary care facilities that are attending high-risk births from Wyoming mothers.

Maternal Mortality Review

In FFY18, stakeholders engaged in the development of a WYPQC identified maternal mortality as a topic of interest.  Specifically, several group members (including past Wyoming ACOG Chair) expressed an interest in supporting the development of a maternal mortality review committee. The MCH Epidemiology Assignee provided multiple presentations to interested stakeholders on current maternal mortality and morbidity data and TA and support was provided by the Centers for Disease Control and Prevention’s (CDC) Division of Reproductive Health.

Over the past year, the MCH Epidemiology Assignee closely evaluated Wyoming’s maternal mortality data, including evaluating the use of the pregnancy check box and developing a plan for case finding. The MCH Epi Assignee is a member of a CDC-led case finding workgroup. Wyoming now identifies cases through linkage of birth and fetal death certificates to mortality data, rather than just the pregnancy check box. This change has improved the quality of data that are submitted to CDC’s Pregnancy Mortality Surveillance System. Data linkages are planned to further complement case finding. 

In 2018, the topic of maternal mortality received significant national attention leading to the passing of the Preventing Maternal Deaths Act of 2018 which provides for establishing and supporting maternal mortality review committees (MMRCs) to review pregnancy-related and pregnancy-associated deaths. In March 2019, the CDC released a funding opportunity for existing MMRCs. Wyoming currently does not have a MMRC.  The lack of in-state specialists, lack of needed legal protections for committee members, and small numbers provides a challenge for starting an independent MMRC at this time. While not an impossibility long-term, it is not a feasible option at this time for Wyoming to start a separate MMRC.  For that reason, Wyoming did not apply for the funding separately. Instead, partners at the Utah Department of Health generously offered to include Wyoming in their application for CDC MMRC funding and include a budget to support Wyoming efforts. This partnership will significantly increase Wyoming capacity to prevent maternal mortality and allow nearly immediate review of Wyoming deaths as part of the longstanding Utah Perinatal Mortality Review Program.