II.E.2.c Women/Maternal Health: Annual Report (FY20 10/1/2019 - 09/30/2020)

State Priority:

Infant Mortality

State Performance Measure #1 (2016-2021):
Percent of Women that receive prenatal care in the first trimester.
 

Home Visiting
MCH continues to partner with state agencies in the coordination of home visiting services within other systems. Specifically, MCH invests in Nurse-Family Partnership (NFP), with state and federal funding, including the Maternal Infant and Early Childhood Home Visiting (MIECHV) Program. The overall vision of Indiana’s investment in home visiting is to improve health and developmental outcomes for children and families. Nurse Family Partnership is an evidence-based community health program with years of evidence showing significant improvements in the health and lives of first times mom and their children. The NFP model engages women early in pregnancy aiming to improve pregnancy outcomes through engagement in preventive health practices, improve child health and development, and improve families’ economic self-sufficiency. Implementation of NFP began in 2011. As of 9/30/2020, approximately 4,700 families have been served through four active implementing agencies covering 42 of 92 counties. Indiana has a total funded NFP capacity of approximately ~2,000 through 78.5 registered nurses.

The COVID-19 pandemic became a factor beginning March 2020 (2nd Quarter). In April 2020, the NFP NSO strongly recommended all licensed independent agencies not under policy mandate from funders to deliver in-person home-visiting begin delivering the model via 100% telehealth platform. Safety measures were instituted, while addressing the concerns of providing critical resources to our clients. NFP was challenged to quickly adopt new processes for consents and visitations. 

In FY20 Title V directly supported the NFP Lake County implementation which served a total of 255 clients. Specifically, of the 255 families, 120 were newly enrolled and 135 were continuing in the reporting period.

My Healthy Baby
IDOH, in partnership with FSSA and DCS, are working to establish a perinatal navigation system directly impacting the home visiting system. As stated in the legislation passed May 2019, the state department of health ‘shall establish a perinatal navigator program for the purposes of engaging in early prenatal care and providing referrals to pregnant women for wraparound services and home visiting programs in the local communities.’ A perinatal or OB navigator is a home visitor who provides personalized guidance to a woman during her pregnancy and at least the first six to twelve months after her baby is born.

A structure for coordinated intake process to identify of pregnant women, share data, and use of a brief screen to determine the optimal home visiting program referral based on available services and perinatal needs. The vision is for every pregnant woman in Indiana to be supported by a navigator or home visitor. In 2020, the state will start working with women who are insured by Medicaid and of childbearing age.

Existing home visiting programs are leveraged as part of the infrastructure for this framework.  The programs could include: Early Head Start home-based, Healthy Families Indiana, Nurse-Family Partnership, Parents as Teachers, workforce specific models such as community health workers, doulas, paramedics, or others.  

In the first year, MCH launched the referral system in 22 counties, These counties were chosen based on health outcomes and readiness for participation. From January – July 2020, 1,658 women were identified as potential clients for My Healthy Baby, of which 33.5% were successfully contacted. Of those successfully contacted and screened (n=571), 58% accepted a referral to home visiting. In the upcoming year, MCH plans to conduct quality improvement projects that increase the number of people who answer the phone and then go on to convert to home visiting services. Preliminary data suggest that home visiting providers are appreciative of the referrals sent their way from MCH communication specialists. IDOH will be employing deliberate marketing strategies that include social media advertising, internet ads, billboards, radio spots, and a landing page which provides the opportunities for self-referral.

In 2019 and 2020, MCH will expand its current data source (presumptive eligibility applications) to include existing Medicaid applications, landing page/self referral clients, data from the Indiana Health Information Exchange (IHIE), and WIC.

Early Start

During the reporting period, IDOH continued to provide funding to four organizations across Indiana to implement and expand Early Start, a program that provides community outreach to engage women in early prenatal care. Women deemed as high risk are fast-tracked into a qualified provider for care. These programs are still essential for serving women as the state initiative, My Healthy Baby, launches and expands around the state.
 

Safety PIN

To combat poor trends in both infant and maternal morbidity and mortality, Indiana passed the Safety PIN – Protecting Indiana’s Newborns Grant Program, IC Section 16-46-14. This legislation allowed non-reverting appropriated funds to be granted to organizations in the efforts to reduce infant mortality.

The Indiana Department of Health’s Maternal and Child Health Programs Team has released a request for grant application (RFA) on an annual basis for these funds. Throughout the life of the Safety PIN Fund, the department has seen different types of programs that benefit women including utilized using doulas, expanding home visiting, tobacco cessation programs, parent education and more.

IPQIC/OTHER

IPQIC continued to serve as the convener for clinical providers and public health practitioners throughout the year. In 2019-2020 IPQIC focused heavily on implementation of the Perinatal Levels of Care (PLoC) rules, as well as developing expectations for perinatal centers. However, as PLoC transitioned from theory to practice, IPQIC staff and volunteers were  able to refocus on other critical maternal health issues such as the development of AIM hypertension bundles and other clinically focused toolkits.

MCH staff members sit on a Reproductive Health Task Force within the Indiana Perinatal Quality Improvement Collaborative (IPQIC) to discuss several local and state-wide initiatives to promote the importance of preconception health and early prenatal care. The taskforce authored several sought after documents including: substance use and breastfeeding guidance; the perinatal substance use practice bundle, LARC resource guide, as well as a safe sleep and breastfeeding guide.

IPQIC hosted its annual transport conference and substance use conference. These day-long events hosted experts in the field and provided invaluable education to clinicians involved in the work.

IDOH helped to promote presumptive eligibility at the local level by collaborating with local organizations, attending stakeholder meetings, including a quarterly neonatal quality subcommittee meeting hosted by our Office of Medicaid Policy and Planning, and exhibiting at statewide community baby showers.

The seventh annual Labor of Love Summit on December 11, 2019, attracted an audience of more than 1500 to the JW Marriott in downtown Indianapolis, making it our best attended Summit. The theme, “Connecting Communities,” focused on ways to reduce Indiana’s infant mortality by creating and fostering partnerships between health care providers, the Department of Health and the community. Morning plenary session keynote speakers included psychiatrist Nzinga Harrison, M.D., who spoke about connecting communities to support maternal substance use and mental health disorders, and pediatrician Dipesh Navsaria, M.D., who spoke of the impact of early life experiences on child development. Morning speakers also included Jack Turman, Ph.D. of the Indiana University Fairbanks School of Public Health with a panel of volunteers who act as  community liaisons for pregnant women/new mothers with social services needs.  Gov. Eric Holcomb provided the welcome and Dr. Kristina Box, Indiana Commissioner of Health, discussed the year in review and our current infant mortality picture. Dr. Box also introduced the State’s new OB/Navigator (home visiting) program. Thirty breakout sessions featured presenters from around the state discussing a range of topics and perspectives on maternal and infant mortality.

State Priority Need:

Alcohol and Drug Use

State Performance Measure #5 (2016-2021): 

The rate of infants born with neonatal abstinence syndrome per live birth.

In 2020, 57 hospitals participated in the perinatal substance use collaborative initiated in 2017. Of the 60,965 births in these hospitals, the cords of 12,336 babies (20.2%) were tested for substance exposure. Of the cords tested, 4,522 (36.7%) tested positive. Of the cords that tested positive, the number of infants receiving a NAS diagnosis was 920 (20.3%). ISDH believes that there is some variability in applying the NAS diagnosis and that the actual number is likely higher. For 2020, the rate of positive cords per 1,000 live births was 74.2 and the rate of NAS per 1,000 live births was 15.1.

The hospitals switched from a standard 13-panel screen to a custom 9-panel screen plus alcohol developed for Indiana by The United States Drug Testing Laboratories (USDTL). The drug panel includes amphetamine, cocaine, opiates, cannabinoids, methadone, benzodiazepines, barbiturates, oxycodone, and buprenorphine. Data is received on a monthly basis and is aggregated to protect the identity of the volunteer hospitals.

In 2018, ISDH implemented a substance use practice bundle developed by the Indiana Perinatal Quality Improvement Collaborative. The bundle includes modules for pharmacologic treatment, non-pharmacologic care, maternal discharge planning, infant discharge planning and follow-up care and transport. ISDH also partnered with the Vermont Oxford Network (VON) to provide educational modules for stakeholders working with families impacted by prenatal substance use. There are 19 modules that will be available to the hospitals for 24 months and provide CNE and CME credits for participants.

Of note: This data is representative of only participating Indiana hospitals, not the entirety of Indiana. We are also limited to the data supplied to us – some hospitals have not submitted data on a monthly basis, so there is some missing data. Lastly, positivity data centered around specific substances or the number of substances is limited to hospitals using USDTL while screening data encompasses all participating hospitals.

State Priority Need:

Smoking

National Performance Measure #14 (2016-2021):

A. Percent of women who smoke during pregnancy.

B. Percent of children who live in households where someone smokes.

ISDH funded 23 sites to implement the Baby and Me Tobacco Free program. Nineteen sites are funded through Title V and three are funded through our sister agency - the Division of Mental Health and Addiction within the Family and Social Services Administration. The remaining site is funded through the Safety PIN grant state funds. ISDH Baby and Me Tobacco Free sponsored programs enrolled a total of 926 participants.

In order to best serve the women and families of Indiana, MCH has decided to stop funding Baby & Me - Tobacco Free Program (BMTF) with Title V funds due to disappointing outcomes. In late 2019, MCH was accepted to participate in the 2020 Centers for Disease Control and Prevention (CDC) & Harvard School of Public Health Program Evaluation Practicum with the focus of starting a formal evaluation of the BMTF program. Unfortunately, as our time in the program came to a close, the COVID-19 pandemic put the formal evaluation process on pause. However, after two years of collecting our own data metrics from funded BTMF sites, the MCH team dissected the data for the past eighteen months, and ultimately found the program ineffective.

The MCH maternal heath team is planning to collaborate with partners to create a new, homegrown program using sound research to better address tobacco cessation and the unique needs faced by Indiana women. In the meantime, MCH will continue to refer women to the Quitline and continue to support evidence-based programs to help participants quit smoking during and after pregnancy and explore how additional services or programming.