Women/Maternal Health

Annual Report Year 2022

 

Priority: Improving women’s reproductive health and promoting equitable access to care

Focus Area: Well-Woman Visit

Preventative medical visits are necessary to promote and maintain health throughout a woman’s lifespan. Visits to a medical care provider primarily focus on providing preventive medical care to women of reproductive age including primary and secondary prevention methods like pap smears, cervical cancer screening, mammograms, vaccines, blood pressure screenings, BMI monitoring, education and counseling, and perinatal health services. It is recommended that women begin attending well-woman exams at age 18. Unfortunately, many women nationwide and in the District do not receive their annual well-woman exam as recommended. In the District, 58% of women aged 18-44 have had a primary care visit in the past year.

 

Several individual and systematic factors result in gaps in care. Some of these factors include a lack of awareness and patient education among women about the annual exam, insufficient access to primary care providers, and limited time during patient appointments for the delivery of preventive services among others[1].

 

 In the District, the prevalence of well-woman visits is higher among: 

• Higher-income women than lower-income women.
• Women who reported a high perceived health status compared to those who reported a low perceived health status. Insured women compared to uninsured women. 

 

Racial stratification increases risk factors for poor maternal health factors. Many Black women lack access to quality contraceptive care and counseling and experience negative physical consequences due to exposure to chronic stress linked to socioeconomic disadvantage and discrimination over their life course, during interactions with the healthcare system.[2] DC Title V has made it a priority to improve women’s reproductive health by increasing awareness and access to services. DC Title V is also focused on addressing the social determinants of health that affect the women of reproductive age (18-44) in the District.

 

Performance Measures:

• National Performance Measures (NPM) 1: Percent of women, ages 18 through 44, with a preventive medical visit in the past year.
• State Performance Measure (SPM) 1: Increase the percentage of women who are Medicaid beneficiaries that received a primary care visit within the past year.
• Evidence-Based or- Informed Strategy Measure (ESM) 1.1: Percent of women that participated in PRAMS and reported attending a preventative medical visit in the past year.

Objective 1: Increase the percentage of women who are patients at a Federally Qualified Health Center (FQHC) that had their annual preventative medical visit from 58% to 63% by 2026.

This objective was recently modified to adequately track the medical needs of this population group. The Title V team intends to evaluate how the implemented strategies at Federally Qualified Health Centers (FQHC) receiving grant funding from the District’s Title V program will contribute towards promoting annual preventative visits for women of reproductive age.  An increase in the proportion of patients at these FQHCs that had their annual preventative medical visit will result in improving the overall health and wellbeing of women residing in medically underserved areas and populations.

Strategies:

• Implement patient reminders and create outreach initiatives for women in the District to increase knowledge, and awareness, and build self-efficacy to attend their well women visits. 

Activities:

To address the reproductive health of women in the District, the Title V Program continued to fund and provide programmatic and technical support to Unity Health Care, Well Woman Project (Unity) in FY22. Unity is an FQHC that provides primary care in patient-centered medical home settings located in Wards 5, 7, and 8 where a majority of the District’s Black population resides. Unity’s community health centers are strategically located in the community to meet patients where they are and play an essential role in providing Black women with basic, reproductive, and maternal health care services. Unity’s mission reaches people wherever they are to provide compassionate, comprehensive, high-quality health care that is accessible to all and advances health equity in the District. Optimal health enables women to thrive in many areas of life, and access to affordable and quality healthcare is a priority at Unity Health Care.  Over 70% of Unity’s patient population are Black African- American and over half of their patients have household incomes that fall below the Federal Poverty Level. Many Black women experience difficulty accessing reproductive health care that meets their needs. Expanding access to interpregnancy care, preconception care, quality prenatal care, and health care over the life course are important strategies in closing the racial gap in birth outcomes. The health of women in the District remains a critical component of women’s economic security and overall well-being of women and infants.

The purpose of Unity’s well women project is to improve access to preventive health services for women of reproductive age 18-44. Their primary project goal is to increase the number of reproductive age women engaged in well-women visits from 52% to 55%. Unity’s project goal and mission is in alignment with Title V’s selected NPM 1: Well-woman visits (percent of women, ages 18 through 44), with a preventative medical visit in the past year, the corresponding elected Objective 1: Increase the percent of women ages 18-44 who engage in a preventative care service in the past year from 58% to 63% by 2026. Unity’s mission and goals are also in alignment with DC Health’s Framework for Improving Community Health objective to increase the percent of women ages 18-44 who have had a primary care visit in the past 12 months and strategy for community-serving organizations to disseminate information about their ability to provide contraception and other reproductive health services.

 

To increase the number of reproductive aged women engaged in well-women visits, Unity utilized evidence-based strategies to improve appointment rates. They developed and implemented a targeted e-messaging campaign for outreach to women of reproductive age to re-enter their wellness program. They intended to capture women who were not seen in the health center over the last year, women who did not have an updated cervical cancer screening, or did not have a pregnancy intention screening. Due to staffing challenges and data limitations, there was a need to redesign their outreach plans. Unity’s population health specialist reviewed patient records due for cervical cancer screening, sent letters to addresses on file encouraging them to call her directly to schedule their appointments, followed up with patients by phone, and monitored the scheduling system for patients who did not show or canceled their appointments. Redirecting efforts to focus solely on this targeted population reduced demands on t the scheduling center department’s capacities. Through this strategy, Unity reached 1,602 patients with abnormal pap smear outreach.

 

The Districts Title V program also continued to fund and provide technical oversight and evaluation support to La Clinica del Pueblo’s Mujeres Saludables (Well-women) Project (La Clinica) in FY22. La Clinica is a Federally Qualified Health Center (FQHC) with a primary care facility in DC that is strategically located between historic Latino neighborhoods. While La Clinica serves residents of the District at large, most of their clients reside in Wards 1, 4, and 5. This trend corresponds to neighborhood demographic composition, where these three wards alone account for 50% of the Latino concentration in the city. La Clinica’s patient population is 91% Latino, 84% are best served in a language other than English, 36% are uninsured, and approximately 89% have an income at or below 200% of the Federal Poverty Level.  Many factors contribute to disparities in Latino immigrants’ overall health and access to care, including poverty, language barriers, and immigration status. Barriers to healthcare significantly reduce Latino immigrants’ access to preventive care. For women, a unique set of health disparities and barriers further reduce preventive care utilization. These barriers include financial accessibility, real or perceived discrimination, language, and communication barriers, lack of proper documentation for obtaining services in the District, inadequate health literacy skills, lack of information, and embarrassment. Provision of a safe protected environment that is rooted in culturally concurrent care is pivotal to enhancing the wellbeing of the District’s Latino population.

 

La Clinica targets its services to low-income, immigrant Latina women of reproductive age (18-44), residing in DC. La Clinica’s program, Mujeres Saludables (well-women), aims to increase the percentage of women in their MCH target population that attend a preventive medical visit (or well-woman visit) by 10% annually for a cumulative increase of 46% during the 5-year project period. Their overall mission aims to increase the utilization of preventive services among female patients of reproductive age and decrease no-shows for well-woman appointments.  Mujueres Saludables employ a family practice model of care rooted in a holistic approach aimed at eliminating barriers to care. There is a gap in the availability of culturally and linguistically appropriate resources for the Latino community in the District. Clients at La Clinica report experiencing increased immigration discrimination, xenophobia, racism, and fear of deportation. La Clinica is specifically unique in its ability to offer culturally and linguistically appropriate care to its patients. Their ability to provide staff that can impart this care is immeasurable. Supporting the efforts of La Clinica will continue to be a priority for the District's Title V program. La Clinica’s project goal and mission are in alignment with Title V’s selected NPM 1: Well-woman visits (percent of women, ages 18 through 44), with a preventative medical visit in the past year, the corresponding elected objective 1: Increase the percent of women ages 18-44 who engage in a preventative care service in the past year from 58% to 63% by 2026. La Clinica’s mission and goals are also in alignment with DC Health’s Framework for Improving Community Health objective to increase the percentage of women aged 18-44 who have had a primary care visit in the past 12 months and strategy for community-serving organizations to disseminate information about their ability to provide contraception and other reproductive health services.

 

In order to achieve their overall program goal and the goal of the District to increase utilization of well-woman visits, La Clinica’s Mujeres Saludables project uses multiple evidence-based strategies to decrease no-show rates and encourage the appropriate use of preventive services. Their first objective aims to improve the use of patient reminders to schedule annual preventive medical visits. The indicators implemented to track this strategy are 1) documentation of the number of women who received an appointment reminder for their annual preventive service visit and 2) documentation of unique women who completed their well-woman visit. La Clinica served 250 patients through well-woman visits, well over their annual goal of 206. However, La Clinica’s appointment reminder strategy required a change of course regarding their plans for sending out electronic appointment reminders. A new strategy was necessary to determine how to send out reminders through their EMR’s built-in systems without overburdening staff. La Clinica’s Patient Access Team is now reaching out to patients individually over the phone to schedule appointments. The second objective to achieve their primary goal is aimed at increasing staff capacity in preventive care through training on key issues associated with well-woman care, barriers to attendance to preventive visits, and strategies to address missed appointments. The indicator implemented to track this strategy is the training of 25 staff members, including clinical providers. There were 48 staff members who received training in Spanish provided by Planned Parenthood covering Women’s Sexual and Reproductive Rights and Family Planning methods. The staff reported they could better enhance their terminology and skills for educating clients by receiving the training session in Spanish. The third objective to achieve their primary goal was to provide education to women of reproductive age regarding preventive services. The key indicators to reach this objective were to track the number of women with group-based health education sessions (‘Salud integral de las Mujeres’ charlas) and track the number of individuals who participated in health fairs. La Clinca reached 140 women through charlas, surpassing their annual goal of 120. La Clinica also reached 286 people via health fairs, well over their annual goal.

 

La Clinica has been a role model in surpassing their goals and maintaining a reputation as a trusted, high quality, and high-performance health center for the Latino community. However, challenges to accomplish some of their activities did arise. Most challenges fell under the need for additional clinical staff to support activities and daily workflow. The capacity to incorporate the EMR system and workflow was a challenge, and unique activities are necessary to mitigate these barriers. Some actions they are taking include hiring key positions to support their model of care, focusing on recruiting and retention, raising salaries, and providing more training and professional development opportunities.

 

In FY22 Title V continued to fund and support the Pregnancy Risk Assessment Monitoring System (DC PRAMS). DC PRAMS is a surveillance project by the Centers for Disease Control and Prevention and DC Health. DC PRAMS is an ongoing, population-based survey of DC residents who delivered a live-born infant. DC PRAMS collects data on maternal behaviors and experiences from preconception to the postpartum period. DC PRAMS data is used to identify groups of women and infants at high risk for health problems, to monitor changes in health status, and to measure progress toward improving maternal and child health. The PRAMS project’s vision is for all mothers who give birth in the District of Columbia (DC) and their babies to have positive health outcomes. The project’s goal is to make the District of Columbia a place where every person who wants to give birth has the support and resources they need to have a healthy pregnancy and healthy babies. The DC PRAMS mission is to administer an ongoing survey so DC Health is informed of the experience and behaviors of all birthing people in the District and can better assess what strategies are most effective in improving the health of mothers and children. PRAMS data allow DC Health to analyze population-level trends alongside stakeholders to coordinate efforts and improve health outcomes. A better understanding of maternal attitudes and experiences before, during, and shortly after pregnancy allows DC Health to focus efforts on evidence-based approaches to support programs and policies. Particularly, PRAMS has data on the percentage of pregnant women who received preventive care before pregnancy. Preventive care before pregnancy is associated with a healthier pregnancy. This project supports Title V’s priority area of improving women’s reproductive health. DC PRAMS goals and mission are aligned with Title V’s ESM 1.1: Percent of women that participated in PRAMS and reported attending a preventative medical visit in the past year and objective 1: Increase the percent of women ages 18- 44 who engage in a preventative care service in the past year from 58% to 63% by 2026.

 

DC PRAMS data informs FQHC’s and other necessary stakeholders in their policy and program implementation, specifically in the areas of preventive care and implicit bias. DC PRAMS estimates that 67.0% of mothers who gave birth in 2021 had a health care visit for a regular visit with an OB/GYN and 51.6% had a health care visit with a family doctor in the 12 months before pregnancy. DC Health will work with health systems in the District to implement strategies to increase preventative care among reproductive aged women.

 

In FY22 Title V continued to support DC’s Primary Care Office (PCO) housed in DC Health’s Community Health Administration.  The mission of PCO is to ensure that every resident in the District of Columbia engages in equitable, comprehensive, patient-centered, quality health care services. PCO is tasked with identifying geographical areas in DC that have a Health Professional Shortage Area (HPSA) related to the medical, dental or mental health provider workforce. A shortage is identified when the population in the HPSA does not have enough access, be it by capacity or providers of a specific discipline, to meet the needs of the residents within a defined geographic area or insurance payment type. It is critical for women of childbearing age to have access to quality care. It is imperative to work with the PCO to address the workforce needs and improve engagement of care.

 

With a population whose diversity extends to culture, language, income, and more, the District’s healthcare workforce needs additional training and support to meet the needs of residents. For example, according to 2022 DC Board of Medicine (BOM) Licensure Survey data, among the District’s physician workforce, approximately 17% identify as Black or African American and 5% as Hispanic or Latino, compared to 41% and 11% of District residents, respectively. Statistics like these highlight the need for sustained focus on building and sustaining cultural and linguistic competence among the District’s healthcare workforce. The PCO conducted a primary care needs assessment (PCNA) utilizing Medicaid data from 2015 - 2016 and 2018 – 2020. Medicaid claims were used to analyze primary preventative care utilization patterns for DC Department of Health Care covered beneficiaries. Among women of child-bearing age, 18–44 years old, there are 175,807 women residing in DC  equating to 26% of the city’s population. The DC Department of Health Care Finance (DHCF) provides healthcare coverage through Medicaid for 66,769 of those women between the ages of 18–44 in DC. According to DC Department of Health Care Finance data, the utilization rate for primary or preventative care services for women in this age grouping is 54%.

 

In FY22 PCO aimed to increase women of reproductive age who engage in preventative care by: 1) developing a baseline understanding of workforce related needs, satisfaction, and wellness, which would inform a program in 2023 to improve workforce retention; 2) enhancing the health professional licensure process to capture data on workforce, which would inform programs in future years to address workforce needs; 3) launching a funding opportunity which supported a community health worker pilot, to test models of care that improve health outcomes amongst low-income populations; and 4) redesignating health professional shortage areas, to ensure local and federal resources could be directed accurately to recruit/retain healthcare providers to shortage areas.

 

PCO coordinates two major programs (Health Professional Loan Repayment Program and J-1 Visa Waiver Program) which help recruit/retain providers to health professional shortage areas or for providers that address the District’s leading causes of death. The Health Professional Loan Repayment Program (HPLRP) repays healthcare provider loans in exchange for providing clinical care in shortage areas. The program is open to primary medical, dental, and mental health providers. The J-1 Visa Waiver Program coordinates sponsorship of the physician to work in an underserved area, or to address the District’s leading causes of death, in exchange for a three-year waiver of the requirement to return to the physician’s home country. There were 82,686 visits served to people by HPLRP and J-1 participants for primary care in FY22. Additionally, 51 4 of HPLRP and J-1 participants were OB/GYNs in FY22.

 

PCO also oversees a Community Health Worker Pilot. The Improving Chronic Disease Outcomes: A Community Health Worker Pilot integrates Community Health Workers (CHWs) as a part of the primary medical care team at two grantee organizations (Community of Hope and Whitman-Walker Health), to provide CHW services to low-income District residents enrolled in Medicaid with uncontrolled hypertension.

The goals of this program are to promote engagement with care, address social needs, and improve health outcomes for patients with uncontrolled hypertension (and as applicable, patients with comorbid Diabetes Mellitus and/or other identified chronic conditions); this may include adolescents and women of child-bearing age.

To achieve these goals, home-visiting CHWs hired under the grant will provide services to patients and families focused on 1) improving clinical care coordination (e.g., including medical information flow, patient and family engagement in care, healthcare system navigation); 2) identifying and addressing social needs and social determinants of health impacting health outcomes (e.g., screening, referrals, and linkages to internal and external social support services and resources); and 3) improving chronic disease self-management (e.g., patient and family health education, coaching, and social support).

Grantees were awarded in August 2022, with the last two months FY22 serving as a development period for grantees to begin standing up the program and preparing for deployment of CHWs (e.g., protocol development, hiring, equipment purchases, etc.). This will be followed by a two-year implementation period (FY23 and FY24), during which each grantee is expected to provide CHW services to at least 500 District residents who are enrolled in Medicaid.

There is no data available for the CHW program during this reporting period.

Performance Measures:

• ESM1.2: Reduce the percent of women that reported experiencing implicit bias or discrimination in PRAMS.

Objective 2: Reduce the percent of women who reported implicit bias and discrimination while receiving healthcare services from 12.6% to 10.2% by 2026

Strategies:

• Assess the quality of care received by women who are Medicaid beneficiaries and identify and address barriers to increasing the use of preventative services among reproductive aged women in the District.
• Create opportunities for implicit bias and racial equity training for providers. The strategy to improve the perceived treatment of women in the District while receiving medical services is to train those providing services, to provide an environment where their patients feel heard, appreciated, and empowered.

Activities:

The District of Columbia Hospital Association (DCHA) created the District of Columbia Perinatal Quality Collaborative (DCPQC) in collaboration with DC Health.  The DCPQC serves as the Healthy Start Community Action Network (CAN) for the District of Columbia and continued to be funded through the District’s Title V program.  The DCPQC/ CAN serves as the District’s champion for reducing maternal mortality, improving maternal and infant health outcomes and narrowing racial and place-based disparities in maternal health. More on the DCPQC can be found in our Perinatal and Infant Health Domain.

 

In FY22 the DCPQC implemented specific program goals aimed at moving the needle addressing objective 2: Reduce the percent of women who reported implicit bias and discrimination while receiving healthcare services by 2026. In FY22 the DC PQC executed a racial equity and respectful care education and engagement series. The three-part series is offered to each hospital team as a group to encourage group collaboration and action in follow up to each session and ongoing. Content included the following: A foundational session led by national experts exploring individual and implicit bias including tools to disrupt patterns of bias and engage at an individual level; a follow up session in partnership with the DC Primary Care Association and led by DC mothers on respectful care and local context with a series of checklist tools designed to assist hospitals in assessing their current practices and environments; a session on shifting to focus on how to facilitate action in a broader context with tools to foster change at an organizational, institutional, and community level. Combining the three sessions, a total of 143 Labor and Delivery staff attended and were impacted by the training. Based on the pre and post evaluation, there was a 45% increase from the pre to post evaluation stating “in the last six months, I have taken an action to understand my own biases”, a 70% increase from pre to post evaluation stating, “In the last six months, I have changed one thing about the way I interact with Black patients to address bias” and a 33% increase from the pre to post evaluation stating, “In the last six months, I have spoken to a co-worker or supervisor about addressing microaggressions and/or bias in my place of work.”

 

As mentioned above DC PRAMS data informs FQHCs and other necessary stakeholders in their policy and program implementation, specifically in the areas of preventive care and implicit bias. DC PRAMS estimates that 12% of mothers felt that they were treated unfairly during a healthcare visit due to race, age, language, or any other reason. About 5% felt they were treated unfairly due to their race or Ethnicity. Data from PRAMS can support programs by the DC Department of Health to address areas of discrimination in health settings and move the needle on ESM1.2: Reduce the percentage of women that reported experiencing implicit bias or discrimination in PRAMS. Part of DC Health’s framework is to promote respectful care practices and standards through training and technical assistance to healthcare organizations and to encourage health systems to implement policies to help sustain a culture where bias is not acceptable, and all people receive respectful care.

 

DC Health is committed to utilizing data and the voice of the women in the District to decrease the implicit bias and discrimination they receive while interacting with the healthcare system.

 

Performance Measures:

• NPM 1: Percent of women, ages 18 through 44, with a preventive medical visit in the past year.
• SPM 1: Increase the percentage of women who are Medicaid beneficiaries that received a primary care visit within the past year.

 

Objective 3: Increase the percentage of women receiving a well-woman’s visit at an FQHC who was screened for SDOH from 55% to 70% by 2026

Strategies:

• The major factors of poverty and race, along with food insecurity, concerns about safety and violence, and housing all affect the ability to reach one’s full potential. These factors and other social and economic needs of women affect access to quality health care. The District has made it a priority to support programs and initiatives that address the social determinants of health and in turn, will positively influence our priority to improve women’s reproductive health.

 

Activities:

La Clinica de Pueblo’s Mujeres Saludables , Well Woman Project (La Clinica) instituted activities in FY22 to achieve their secondary goal to expand La Clinica’s capacity to address woman’s holistic health needs by addressing social determinants of health (SDOH). La Clinica’s project goal and mission is in alignment with Title V’s elected objective 3: to increase the percentage of women receiving a well-woman’s visit at a FQHC who was screened for SDOH. With their efforts to achieve their secondary goal to expand their capacity to address women’s holistic health needs by addressing SDOH, La Clinica instituted important evidence-based activities. The first activity included a key indicator to screen 50% of women attending a well-women visit for SDOH using their PRAPARE Tool Kit. PRAPARE is an acronym for the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences. PRAPARE is both a standardized patient risk assessment tool as well as a process and a collection of resources to identify and act on the social determinants of health. The toolkit provides interested users with the resources, best practices, and lessons learned to guide implementation, data collection, and responses to social determinants needs. La Clinica screened 55% of women attending a well-women visit during FY22. La Clinica provided referrals and follow-up services that include food assistance (i.e., SNAP, food vouchers, food pantries), AIDS Drug Assistance Program (ADAP) application assistance, health insurance application assistance, interpretation, transportation, pro bono legal services, and lactation support. For this grant year La Clinica reported that of the women who were screened with the PRAPARE tool, only 20% were referred to their respective services needs, falling short of their 60% goal. This lower percentage is most likely due to the lack of a system in place to appropriately follow up with and track these referrals. La Clinica is working on quality improvement activities with their data team to create a seamless tracking system to meet their goal and the needs of their patients.

 

Unity Healthcare, Well Woman Project (Unity) instituted activities in FY22  in alignment with Title V’s elected objective 3: to increase the percentage of women receiving a well-woman’s visit at an FQHC who was screened for SDOH. Unity’s partnership with WIC is a priority to ensure their patients are connected to resources to meet the needs of their families and themselves.

Unity has worked with their data team to integrate WIC referral integration into their EMR systems, accompanied by training to maximize the utilization. See Figure 1 below.

 

 

 

 

 

 

 

 

 

Figure 1.

 

Additionally, Unity utilizes their Care Coordinators to ensure their patients are connected to all the resources they need. The Care Coordinators provide patients with navigation services and outreach support if patients did not maintain appointments. Unity Care Coordinators and Case Management teams ensure their patients are seamlessly able to be connected to social services and address their social determinants of health.  Finally, Unity has maintained its external partnership with The Patient-Centered Outcomes Research Institute (PCORI). PCORI is an independent, nonprofit research organization that seeks to empower patients and others with actionable information about their health and healthcare choices. Unity utilizes the PCORI external collaboration to ensure all pregnant women can address their mental health and well-being needs.

 

Federally Qualified Health Centers (FQHCs) in the District are critical to providing healthcare to patients that need them the most. DC Health is dedicated to elevating its presence and uplifting its ability to provide holistic care for its patients.

 

 

 

[1] Stolp H, Fox J. Increasing Receipt of Women's Preventive Services. J Womens Health (Larchmt). 2015 Nov;24(11):875-81. doi: 10.1089/jwh.2015.5552. Epub 2015 Oct 8. PMID: 26447836; PMCID: PMC4643365.

[2] https://www.nationalpartnership.org/our-work/health/reports/black-womens-maternal-health.html