NPM 1 - Well-Women Visit:  Percent of women, ages 18 through 44, with a preventive medical visit in the past year.

The four County Public Health Departments (CPHDs) who picked NPM 1 for FFY22 were a good representation of the state’s differing regions and population sizes.  The smallest in population is Petroleum, with only 154 residents in their maternal and child population. Petroleum’s county government contracted with Central Montana Family Planning to provide maternal and child public health services, which was a good fit for implementing activities associated with NPM 1.  Petroleum’s activities included: a quality improvement project for reminders and scheduling of well-women visits for their clients; and an outreach mailing to all women aged 18-44 in the county (approximately 52 women).

Beaverhead CPHD is in the southwest corner of the state, with a MCH population of approximately 3,482. It provides WIC and family planning services for the county.  These services allow for staff to provide education to their clients on the importance of well-women visits.  Beaverhead implemented a quality improvement project for their recall and reminder system for Human Papilloma Virus (HPV) vaccines and cervical cancer screenings.  The project is continuing into FFY23, as they work to establish a baseline by tracking the number of women who receive these services because of the reminders. It includes offering county-specific education on cervical cancer and HPV, which includes information on local resources.  This CPHD faced some staffing challenges during FFY22 due to continued effect from COVID stressors.

Richland CPHD, with a MCH population of approximately 4,764, is on the eastern side of the state next to North Dakota.  They requested to redirect their MCHBG activity funding toward COVID-19 response for FFY22.  As the situation eased, they returned to their planned activities in support of NPM 1 as capacity allowed.  These included four meetings with local stakeholder partners to determine a baseline on the status of well-women visits in the county; and meetings with Family Planning partners for how to handle Title X reductions in funding.

Silver Bow County has a MCH population of 13,167 and is located in the south-central part of the state.  The population qualifies the county to be considered large by Montana standards.  The following information on their FFY22 NPM 1 activities is from their June 2021 Operational Plan, and November 2022 Annual Report:

In FFY23, the FCHB is contracting with three CPHDs who have chosen to focus on NPM 1: Beaverhead, Richland, and Silver Bow.  They are implementing and evaluating at least two community-level activities during the fiscal year.  The FCHB is providing these counties with training, resources, and support on evidence-based/informed or best-practice activities, goal setting, and evaluation.

Montana Obstetrics and Maternal Support Activities

Improving Postpartum Care Affinity Group

During FFY22, Montana Obstetrics and Maternal Support (MOMS) staff addressed NPM 1 most significantly through a partnership with Medicaid to increase the number and quality of postpartum visits.  This partnership resulted in the MOMS and the Medicaid Perinatal Behavioral Health Initiative Program Coordinators submitting a joint application to receive technical assistance by participating as co-leads on the CMS Medicaid and CHIP, Maternal and Infant Health Quality Improvement: Improving Postpartum Care Affinity Group. Montana’s application was accepted, and the Program Coordinators were designated as co-leads and charged with forming a workgroup of four to eight stakeholders from other DPHHS maternal health programs and partner stakeholder organizations.  The workgroup participated in monthly individual technical assistance (TA) calls with CMS and their consultant Mathematica.  They also met monthly for TA and peer sharing with the other states in the affinity group.

This QI affinity group supported the broader Improving Postpartum Care Learning Collaborative, sponsored by the Center for Medicaid and CHIP Services (CMCS). The Improving Postpartum Care Affinity Group seeks to drive measurable improvement on the postpartum care visit rate, and quality of care for Medicaid and CHIP beneficiaries, as demonstrated through improved performance on: the Prenatal and Postpartum Care: Postpartum Care (PPC-AD) measure in the Adult Core Set; improved postpartum care visits for individuals with chronic medical conditions such as diabetes and hypertension; and, reduction or elimination of disparities in postpartum care visits.   

Montana Medicaid supported the OneHealth clinic in Hardin with a mini-grant to participate fully with their care coordinator.  They are implementing plan-do-study-act (PDSA) cycles for a variety of test interventions to improve the rate of attendance by women at the postpartum visit. MOMS program staff provided support on bi-weekly calls with Medicaid and the OneHealth care coordinator for updates on data tracking, strategizing new interventions, and sharing resources to support the work.

Interventions that OneHealth tested include: conversations with women at their 30-week gestation prenatal appointment about the importance of the postpartum care (PPC) visit, with handouts and videos sent as a follow-up, using the 4th Trimester Project and March of Dimes resources; utilizing peer support specialists to educate patients on the importance of PPC; educational campaign, with flyers and videos for partner providers and patients; follow-up outreach and feedback from other providers, such as WIC and Indian Health Service; and meetings with care coordinators at the birthing facilities where their patients deliver. OneHealth did see increases in the rate of attendance by their patients to their postpartum visits, but it varied with the capacity of their care coordinators to do the outreach.

The MOMS Program contracted with the University of Montana Rural Institute for Inclusive Communities (UMRI) for data collection and analysis, evaluation, and research services. Their staff launched several research studies during the reporting period to gather more information on maternal health, focusing on the experiences of pregnant people and providers within the health system. The provider survey: Understanding and Improving Barriers to Treatment and Care of Postpartum Depression aimed to identify provider bias related to the treatment and care of pregnant women with substance use disorder. The study, Facilitators and Barriers to Seeking Postpartum Care aimed to identify risk and protective factors associated with seeking care for postpartum depression symptoms among Montana women who use substances.

UMRI also utilized a Maternity Experiences Survey to gather information on patient experiences interacting with the healthcare system before, during, and after pregnancy to identify unmet needs.  The information from these surveys was used for the Year 4 MOMS Strategic Planning in June 2022 that included staff representing Billings Clinic, UMRI, the MOMS Program Coordinator, and the Title V Director/MCHC Supervisor.  Additionally, the results are being considered as a part of the ongoing Title V needs assessment data collection.

MOM Mini-Grants

During the reporting period, through a partnership with UMRI, the MOMS Program solicited applications to distribute MOMS funds via mini-grants to organizations working to achieve MOMS objectives to improve maternal health care delivery and outcomes.  These organizations included: local hospitals, clinics, health departments, foundations, and non-profits. Preference was given to Primary Care Health Professional Shortage Areas (HPSA), with funding to be spent on training, programming materials, education resources, equipment, and other innovative responses to improve maternal health and well-being. Award amounts could be up to $20,000 per applicant.

Through supporting a variety of programming, the mini-grant activity was able to promote innovation in education; provide training opportunities for doulas, lactation counselors, clinical staff, health department staff, and expand community resources. This project allowed for necessary support services to meet postpartum people’s needs by providing postpartum resources (such as postpartum kits, gas vouchers to attend appointments, respite care, etc.) and bereavement services.

There were six CPHDs among the organizations that received MOMS mini-grant funds. Big Horn CPHD enhanced education programming and resources by purchasing birth education materials that included: Understanding Birth PowerPoint; yoga mats, birth balls, and rebozos; newborn care education video and workbooks; class handouts; positions video; dilation models; and an Antenatal PowerPoint.

The Gallatin CPHD invested in workforce development by helping to fund wages for: a Spanish-speaking Home Visitor; a Community Health Worker; and a Behavioral Health Consultant. This program was particularly helpful to enable the CPHD to better serve their Spanish-speaking population that has grown significantly over the past three years, and it led them to an opportunity to pilot technology used by the United Nations for real time translation.

The Richland CPHD used funds to purchase items that would address high rates of anemia in their population: postpartum education materials; prenatal vitamins and education; office supplies; testing materials for postpartum Hgb checks; and outreach postcards. Valley CPHD purchased education resources on: infant and postpartum maternal health; mental health; substance use; heart disease; diabetes; weight control; infectious disease prevention; and outreach media to promote the resources.

The Lewis & Clark CPHD invested in workforce development by receiving training and certification for a Breastfeeding Peer Counselor, who received a combo training of birth doula, postpartum doula, breastfeeding counselor, and childbirth educator. They also used funds for a WIC Aide and Circle of Security training. Park CPHD used MOMS funds to invest in workforce development by attending a two-day Postpartum Support International training on perinatal and postpartum mental health.