Maternal Depression

Vermont’s MCH program was awarded a 5-year HRSA cooperative agreement: Screening and Treatment for Maternal Depression and Related Behavioral Disorders Program. Vermont’s program “Screening, Treatment and Access for Mother and Perinatal Partners” (STAMPP) aims to improve the mental health and wellbeing of pregnant and postpartum women and their families and children. Our objectives are:

1. assess resources, gaps and opportunities in our existing system of care;
2. increase the capacity of Vermont’s health care providers to educate, screen, diagnose, prevent, and treat maternal depression and other related behavioral disorders;
3. increase the capacity of Vermont’s mental health system to diagnose, and treat maternal depression and other related behavioral disorders, including the exploration and implementation of telemedicine and technology innovations;
4. increase the capacity of the human service workforce to screen and support women at-risk for maternal depression and other related behavioral disorders;
5. identify and support innovative financing options to support the screening, diagnosis, and treatment of maternal depression and other related behavioral disorders;
6. ensure access to comprehensive maternal depression and educational information and support and treatment options;
7. develop up-to-date, real-time referral resources at the community level; and
8. conduct a comprehensive evaluation.

STAMPP works collaboratively with the Department of Mental Health, Department of Vermont Health Access (Medicaid and Women’s Health Initiative), Department for Children and Families, VCHIP, UVM Medical Center, Vermont’s designated community mental health centers, Help Me Grow and MIECHV.

Preventive Reproductive Health

The preventive reproductive health program is situated within the Division of MCH. Thus, the Title V Director can leverage reproductive health programming in a collaborative and administratively efficient manner to determine common goals and activities between Title V and funding sources related to reproductive health, such as the Title X Family Planning Program and the Personal Responsibility and Education Program (PREP). This collaborative approach under MCH common leadership supports outcomes such as those reflected in the national and state performance measures addressing women’s preconception health, adolescent birth rates, interpregnancy spacing, intended pregnancy, and prenatal care access/utilization.

The Division of MCH has overseen Title X funded clinical services that are contracted from MCH to Planned Parenthood of Northern New England (PPNNE) and are offered at PPNNE sites statewide for more than 4 decades.  This past year, the Health Department made the decision to relinquish Title X funding due to the Final rule issued by HHS/OPA that would have prevented the health department and our longstanding subrecipient, from providing the full range of family planning and reproductive health care services for Vermonters. In the absence of Title X funding the state replaced these funds as part of contingency planning for FY20 and FY21 to allow for the continuation of these essential services in the absence of federal funding. 

MCH also provides oversight for the Medicaid grant funding to PPNNE via ACA provisions allowing PPNNE to be reimbursed for clinical services to patients with incomes under 200% FPL. This program allows PPNNE to serve uninsured and underinsured low-income clients at the time of the appointment and use the clinic visit to enroll the client in Vermont’s public health care insurance system. MCH is working with our partners in Medicaid eligibility to ensure that patients with incomes under 200% FPL are covered in all health care settings.

The Director of Preventive Reproductive Health, with support from Title V leadership and funding, works to increase services and systems for reproductive health and specifically for women who may be at risk of domestic and interpersonal violence. Title V funding has enabled MCH to renew several long-planned ideas for key improvements in services and systems for women. MCH chairs the Domestic Violence Advisory Group (DVAG) at VDH and participates on the Agency of Human Services’ Domestic Violence Steering Committee, allowing for both cross-departmental and agency-wide approach to addressing domestic violence. This group heightens awareness of domestic and sexual violence by such activities as community education, coordination across state child and adult service systems, monitoring violence related data, updating state policies and procedures to address violence against women, and providing training and resources for state employees. In this past year the Director of Preventive Reproductive Health also provided support for improvements to be made to the State of Vermont required training on sexual harassment prevention.

MCH also oversees the CDC Rape Prevention and Education (RPE) grant, that supports the expansion of primary prevention efforts related to sexual violence within the statewide domestic and sexual violence coalition, with their member agencies, and community partners. Based on an extensive stakeholder engagement process in the previous year, a 5-year state action plan and evaluation plan were developed.  The 5-year plan aims to prevent sexual violence (SV) perpetration and victimization by using a public health approach to decrease SV risk factors and increase SV protective factors; selecting, implementing and evaluating prevention strategies based on the best available evidence across multiple levels of the Social Ecological Model (SEM), with an increasing emphasis on community-level strategies; and through partnerships and linkages that support using strategies to address shared risk and protective factors across multiple forms of violence. The plan also supports local level efforts in key focus areas:

1. Partnering with youth and support their leadership in implementing individual & relationship level programs and initiatives
2. Growing youth activism, leadership and voice, leveraging existing programs and resources.
3. Equipping adults to support and partner with youth to prevent sexual violence, utilizing the Youth Thrive and WholeSomeBodies frameworks.
4. Implementing an Askable Adults social norms campaign to engage adults in sexual violence prevention.

The focus populations outlined in the plan are:

• Youth ages 12-18, with a focus on youth of color, LGBTQ youth, youth with disabilities and youth living in poverty; and
• Adults engaged with youth

The Director of Preventive Reproductive Health is also a member of Vermont’s Domestic Violence Fatality Review Commission. The purpose of the Commission is to collect data and conduct in-depth reviews of domestic violence-related fatalities in Vermont with the goal of making policy recommendations to prevent future fatalities. The Commission’s report includes data on children killed in a domestic-related-incident and refers these cases to Vermont’s Child Fatality Review Team (Division of MCH ensures representation on Child Fatality Review Team, see Child Health Domain). MCH has worked closely with injury prevention surveillance staff over the past  two years to provide support to the Chair for the DV Fatality Review Commission to make recommendations for changes to the structure and format of the annual report, as well as with data reporting, preparation of tables and graphs, etc., to make the findings and recommendations more meaningful and impactful. This work is ongoing.

Another critical advancement has been a newly created position within the Agency of Human Services, the Director of Trauma Prevention and Resilience Development, which sits within VT’s health care reform initiative. MCH leadership represent the health department on an agency-wide team that will work closely with the new director to help set priorities and identify and plan activities related to workforce development needs across AHS related to trauma and resilience.

The Director of Preventive Reproductive Health supervises the MCH Adolescent Health Program Manager (formerly the PREP Coordinator), as well as the MCH Injury Prevention Coordinator, which supports increased alignment of efforts across these interconnected areas of work. PREP awards are granted to community organizations to educate young people on both abstinence and contraception to prevent pregnancy and STIs, and covers three adult preparation topics: healthy relationships, healthy life skills, and adolescent development. The program targets youth ages 10 to 19 who are homeless, in foster care, live in rural areas or in geographic areas with high teen births, or come from racial or ethnic minority groups. The program also supports pregnant and parenting youth under 21. Three of Vermont’s eleven PREP sites serve only or mostly pregnant and parenting youth. The Adolescent Health Program Manager was originally hired to serve as the PREP Coordinator, but this position has expanded to include broader adolescent health work and youth development. More recently, the Director of Preventive Reproductive Health’s position was changed to Director of Adolescent and Reproductive Health.

VT PREP went through an extensive curriculum review and adopted 2 new curricula: Making Proud Choices and Be Proud, Be Responsible, Be Protective, which emphasize building knowledge, attitudes, and skills. The curricula provide youth with information they need to understand the issues; the cognitive skills that will allow them to examine their beliefs about risks and consequences and analyze behaviors; the intrapersonal skills to understand and manage feelings and thoughts; and, the interpersonal skills to define and exercise behaviors that reduce risk. There has been extensive training on both curricula in the current reporting period which was provided by nationally recognized experts in the field from GCAPP (Georgia Campaign for Adolescent Power and Potential). The VT PREP program has also received technical assistance from national partners, Advocates for Youth, related to supporting PREP facilitators’ knowledge and skills in the areas of gender and sexual identity and using inclusive practices across VT’s PREP programs.

The MCH reproductive health workgroup had several successes, including addressing some of the recommendations outlined in our most recent 3-year Title X Needs Assessment. This workgroup has been essential in informing our strategies related to promoting women’s and maternal health and to collaborating across the system to reduce redundancies and ensure coordination of services. It has also helped to enhance partnerships. Membership includes: primary care and family practices, Ob/Gyn, Title X (Planned Parenthood), FQHCs, Maternal and Child Health Coordinators from the Office of Local Health, an adolescent medicine specialist, Vermont’s Child Health Improvement Program (VCHIP) and other state agencies addressing reproductive health (Medicaid, Agency of Education). Some of the outcomes of the workgroup have included creating a contraceptive referral form (more below); collaborating with Medicaid to improve rates of post-partum insertion of LARC by establishing an add-on payment, which was further advanced by Medicaid in the current reporting period to include an add on payment that covers the full cost of the device; and collaborating with the Blueprint for Health, Vermont’s health reform initiative, on the Women’s Health Initiative (WHI), to enhance psychosocial screening for women and to improve access to LARC in women’s specialty practices (OB/Gyn and PPNNE). The Reproductive Health Workgroup was paused this past year as many members also served on the Blueprint Women’s Health Initiative’s Steering Committee and wanted to avoid redundancy. 

The Vermont Department of Health has been a key partner throughout the process of planning the Women’s Health Initiative, and several Title X health centers have been engaged in the initiative since its inception. Through the Women’s Health Initiative, women’s health specialty providers (including Title X), are providing enhanced health and psychosocial screening in clinical settings. New staff, training, and payments support effective follow-up to provider screenings through brief, in-office intervention and referral to services for mental health, substance use disorder, trauma, intimate partner violence, food and housing. The Women’s Health Initiative helps ensure that women’s health providers, Patient Centered Medical Homes, and community partners have the resources they need to help women be well, avoid unintended pregnancies, and build thriving families. The Women's Health Initiative supports practices in building enhanced screenings into regular health care visits. Women identified as at-risk in the areas of mental health, substance use disorder, intimate partner violence, or access to food and housing are immediately connected to an initiative-funded social worker for brief intervention and counseling and referral to more intensive treatment as needed. Each social worker is a member of the Community Health Team and available to connect women with the local network of health, social, economic and community service providers. Women also receive comprehensive family planning counseling and services. Those who tell their providers they do not want to have a baby in the coming year will have immediate and affordable access to a broad range of contraceptive options, including LARC. Women who wish to become pregnant will receive preconception counseling and services.

MCH leadership continues to serve on the WHI Steering Committee and helps to identify key stakeholders and faculty to support learning sessions on topics related to approaches to contraceptive counselling, substance use and mental health screening, brief intervention and referral, and interpersonal violence screening and referral, and food insecurity. At this time, there are 24 women’s health specialty practices, and 22 Patient Centered Medical Homes participating in this initiative. Day long trainings are now offered in collaboration with PPNNE for 10 Best Practices of Contraceptive Counseling, and there are in person Long Acting Reversible Contraception trainings with partners from UVMMC. There are also two monthly ls per month for leadership and for in practice staff for peer support and learning opportunities.

This initiative now includes more than half of the OB/GYN practices in the state and includes all 12 of the state’s Title X health centers, which are Planned Parenthood health centers. In addition, this initiative has helped pave the wave for the introduction of social determinants of health screening in primary care practices and emergency departments. This approach helps health care providers identify risks to their patients’ health and wellbeing, from a wide range of sources including drug and alcohol use, housing and food insecurity, inter-partner violence, and mental health including risk of harm to self and others. When risks are present, trained counselors offer patients support and help them access and navigate the services they need to address risk factors and maintain or improve their health.

As a result of the reproductive health workgroup, and in collaboration with VT’s Title X provider, Planned Parenthood of Northern New England, a contraceptive referral form was created that includes One Key Question as a pregnancy intention screening tool. The Family Planning (FP) Referral Form was designed to (1) streamline referrals for family planning throughout Vermont, (2) provide a visual aid and tools for providers when discussing pregnancy intention and birth control options, and (3) improve care coordination and referral relationships among providers. The FP Referral Form is intended for use by entities compliant with HIPAA—including medical practices and social support organizations—when making referrals to family planning providers who offer the full range of contraceptives, including IUDs and implants. In 2017, One Key Question was moved to the National Campaign to Prevent Teen and Unplanned Pregnancy, now called Power to Decide, so there is a national platform to support this work. MCH has reached out to get direction on how to align with the national effort, obtain materials, and identify TA options for the year ahead. Power to Decide has expanded their training and TA to include working more intentionally with home visiting programs, an area that we will explore in the year ahead.

The contraceptive referral form has been integrated into the Blueprint Women’s Health Initiative and is being used by the participating practices in the Women’s Health Initiative, mentioned previously. PPNNE has provided family planning referral form learning sessions through the Hub and Spoke model, Vermont’s Opioid Use Disorder Treatment approach, which has included reaching staff at 7 Hubs (1 in New Hampshire and 6 in Vermont). This orientation to the use of the form includes introducing the family planning referral form to staff at the hubs and reviewing resource binders with supplemental materials (including a guide for how to use the form, info about reproductive life planning, birth control options, reproductive justice, and PPNNE/ Title X services). This work has been carried out in consultation with the division of Alcohol and Drug Abuse Programs. We are in the process of exploring how PPNNE can continue to support Hubs’ staff in providing family planning information to clients and increasing access for this population.

Substance Use in Pregnancy

To address Vermont’s high rate of tobacco-use in pregnancy, nurse home visitors, parent educators, and WIC staff regularly screen pregnant women for tobacco use and refer to the Quit Line resources and medical follow up. The IMR Collaborative Improvement and Innovation Network (CoIIN) supported a closer coordination and strategic direction of the prenatal tobacco use cessation activities between MCH and the Health Department Tobacco Control Team, which has sustained. In 2017, we worked with our Rutland District Office and the Rutland Regional Medical Center to bring evidence-based training on prenatal tobacco use (SCRIPT) to health care providers. 100% of the providers were trained and continue to stay engaged. We have also developed a contingency management pilot study in Rutland to provide cessation counseling and incentives (up to $1100) to pregnant women based on national research out of the University of Vermont, which launched in spring 2018. Lastly, we conducted two trainings for community-based agencies on: “Basic Tobacco Intervention Skills for Maternal & Child Health.” These trainings were well attended and support a wrap-around approach to ensure consistent and supportive messaging. Residents and faculty at the University of Vermont Medical Center have been also been trained in SCRIPT, and two more are planned.

Although Vermont has high rates of substance use in pregnancy (Title V Performance Measures), a number of efforts are underway to improve this. In Vermont, when pregnant women are identified with a physical dependence on opioids or an OUD, their newborns often receive an NAS diagnosis code at delivery regardless of number, type or severity of symptoms. This approach allows hospital staff to monitor a newborn for up to four days ensuring that both mother and newborn receive any needed services. Newborns with few or mild symptoms are often discharged from the hospital with treatment continuing on an outpatient basis. Over the past year, Vermont hospitals are making the switch to the “Eat, Sleep, Console” method.

Vermont has a number of activities to support families with substance use disorder (SUD). A few examples include:

• Last year, Vermont MCH along with our partners in the Health Department completed a formative evaluation regarding substance use in pregnancy in Vermont to inform future messaging efforts with prenatal providers and families. We are now in Phase II of this work. The scope of work under this new phase will focus on health care providers, and the provider-patient relationship, supporting the providers’ role in impacting an individual’s behavior change. The desired outcomes of this work are to:

1. Work with identified providers to understand what tools health care providers in Vermont need to educate their patients about substance use in pregnancy, and to make strong recommendations for not using substances while pregnant.
2. Create impactful messages that promote a universal understanding of the clinical guidance related to substance use in pregnancy.
3. Develop communication materials to share these messages with pregnant individuals.
4. Promote Help Me Grow Vermont as an existing resource that can be used to share information and make referrals.

• Vermont’s new HRSA funded initiative described above: Screening and Treatment for Maternal Depression and Related Behavioral Disorders Program aims to increase screening rates for maternal depression, anxiety and substance use and test innovative referral and treatment strategies
• Vermont is participating in ASTHO’s Opioid Use, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative (OMNI) Learning Community and is currently developing an action plan to address postnatal support for families with SUD, which will include more streamlined referral into services such as evidence-based home visiting and early intervention
• Vermont is one of three states to implement DULCE (Developmental Understanding and Legal Collaboration for Everyone). Project DULCE is a national demonstration project in pediatric practices, sponsored by the Center for the Study of Social Policy in Washington D.C. DULCE is an innovative intervention through which pediatric primary care clinical sites proactively address social determinants of health, including SUD, to promote the healthy development of infants from birth to six months of age and provide support to their parents. A key feature of the DULCE intervention is a Family Specialist, who is a member of the pediatric team, and connects families to resources based on parents’ needs and priorities. DULCE employs the Medical-Legal Partnership model to provide families more intensive assistance obtaining concrete supports, when needed. The DULCE intervention incorporates a Strengthening Families Protective Factors approach and provides optional home visits.
• The Improving Care for Opioid-exposed Newborns (ICON) project at VCHIP partners with the Vermont Department of Health and the University of Vermont Children's Hospital to improve health outcomes for opioid-exposed newborns. Improved health outcomes are achieved by provision of educational sessions on up-to-date recommendations and guidelines to health care professionals who provide care for opioid-dependent pregnant women and their infants.
• Hub and Spoke is Vermont’s system of Medication Assisted Treatment, supporting people in recovery from opioid use disorder. Nine Regional Hubs offer daily support for patients with complex addictions. At over 75 local Spokes, doctors, nurses, and counselors offer ongoing opioid use disorder treatment fully integrated with general healthcare and wellness services. This framework efficiently deploys opioid use disorder expertise and helps expand access to opioid use disorder treatment for Vermonters. Pregnant women are a priority population in Vermont’s system.
• Vermont's CHARM (Children and Recovering Mothers) Team, led by KidSafe Collaborative, is cited as a case model for collaboration in working with pregnant women with an opioid abuse history in this new SAMHSA publication. KidSafe convenes this team in partnership with UVM Medical Center, UVM Children's Hospital, Howard Center, LUND, VT Department of Health, VT Department for Children and Families - Family Services Division, and others.

Partnerships

Vermont’s tobacco control programming sits within the Division of Health Promotion and Disease Prevention. We work closely with them on tobacco-use in pregnancy strategies. Likewise, we work closely with our Office of Local Health and the regional MCH Coordinators.

For more than 10 years, a monthly Primary Care and Public Health Integration meeting convenes the leadership of MCH, VCHIP, VT AAP, VT AAFP, Planned Parenthood, ObGyn physicians, and primary care internal medicine providers, to coordinate various projects that cross borders. This group is and will continue to be a strong partner in advancing women’s and maternal health in Vermont.

The American Congress of Obstetricians and Gynecologists (ACOG) can be an exceptional partner in moving these strategies forward. In the past, Vermont’s Chapter of ACOG was not well coordinated or integrated with public health. Over the past two years we have worked closely with ACOG members to assess their needs to strengthen the state ACOG chapter. As a result, a quarterly webinar series was developed to support members connecting with each other and with public health colleagues across both clinical and public health topics. Topics included presentations on screening and referral for domestic violence, an update on the Blueprint for Health’s Women’s Health Initiative and how to get involved, smoking and alcohol use during pregnancy, maternal depression, among other important public health topics.

As described throughout this report, a key partner across all population domains is the Vermont Child Health Improvement Program (VCHIP). VCHIP is a population-based child and adolescent health services research and quality improvement program of the UVM.

For a fourth year MCH is partnering with Dr. Gibson, a pediatrician and adolescent medicine specialist to provide training and technical assistance to Vermont’s PREP program to further enhance the training opportunities for program facilitators who implement evidence-based curriculum. In addition, MCH has worked collaboratively with the health department’s division of Alcohol and Drug Abuse Prevention (ADAP) to incorporate activities into the scope of work to include a focus on decreasing prescription drug misuse and abuse among Vermont’s youth, and increase awareness of safe use, storage, and proper disposal of prescription medication. These activities aim to heighten the awareness of the dangers of prescription drug misuse among youth and increase the role and skills of pediatric and primary care practices and community youth-serving agencies in reducing access to prescription drugs among vulnerable youth.

To date, PREP facilitators have received training on topics related to cultural sensitivity, transgender youth care, and HPV, and a demonstration of a comprehensive approach to introducing sexual health education in the classroom. Dr. Gibson has also visited health care practices as part of this area of work. These efforts include disseminating a wide range of health department materials on substance misuse prevention, including promoting Parent Up, an online resource for parents and adult caregivers. MCH expanded this work in the reporting year to include having Dr. Gibson train medical residents as well as afterschool professionals as part of a collaboration between MCH and VT Afterschool Inc. a public-private statewide partnership dedicated to supporting and sustaining innovative learning opportunities that extend beyond the school day for all Vermont’s children and youth. Activities are directed toward increasing the quality and availability of education programs during non-school hours.

Title V works collaboratively with WIC and Vermont’s MIECHV program staff and families to ensure that preconception health planning and pregnancy spacing counseling is incorporated in client visits. Likewise, we plan to work closely with leadership of Vermont’s other home visiting programs to disseminate this messaging.