WOMEN’S/MATERNAL HEALTH DOMAIN

Nebraska Annual Report for the 2017-2018 Year

 

In this section, Nebraska MCH Title V reports on the accomplishments and activities in the Women’s/Maternal Health Domain for the period October 1, 2017 to September 30, 2018.  The numerical sequence of headings used below references the new narrative format found on page 35 of the Title V MCH Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report, Eighth Edition.

 

The Nebraska Priorities in the Women’s Maternal Health Domain with 2017-2018 NPM, SPM, and ESM statements are as follows:

• Sexually Transmitted Diseases among Women of Childbearing Age.

NPM: Percent of Women with a past year preventive medical visit.  

ESM: The percent of Title X Family Planning female clients under age 25 who were screened for chlamydia and gonorrhea infections as a component of a comprehensive visit.

 

• Improved Access to and Adequacy of Prenatal Care.

SPM: Percent of Women who initiated prenatal care in the first trimester.

ESM: None

 

1. Context: the State of this Population Domain

Title V has a particularly lean infrastructure to draw on in the area of sexual health for women of childbearing age, and much depends on collaborative and aligned efforts across programs in DHHS, including the Title X Reproductive Health Program, the Women’s Health Initiative, STD prevention program, the programs of the Maternal Child Adolescent Health Program, as well as Women’s and Men’s Health programs. Additionally, Title V leverages the expertise of external partners, such as local health departments and the Women’s Fund of Omaha.  Within the universe of existing resources and programming dedicated to sexual health, Title V is working to find its unique niche in growing system capacity.

 

In 2017-2018, Nebraska’s Title V efforts in the priority area of sexually transmitted diseases among women of childbearing age, focused on the feasible data relationships between the Title V MCH epidemiology program, and the Nebraska Reproductive Health program, and collaborative relationships to develop health-literate messaging about well-woman care.  However, in early 2018, an opportunity emerged for the Title V MCH epidemiology coordinator to become involved in a data sharing agreement between Nebraska Medicaid and vital statistics reporting.  Through this new data sharing innovation, the opportunity to match birth data with health services utilization data from Medicaid opened new opportunities in 2018-2019 to better understand the root causes for poor birth outcomes.

 

In the priority area of Access to and Adequacy of Prenatal Care, the most promising activities during the reporting period involved building strong collaborative relationships with the state’s three Medicaid Managed Care Organizations.  In 2015, Nebraska Medicaid launched a statewide system transformation toward providing services through three Managed Care Organizations.  This change has brought a significantly greater population health perspective to Medicaid, and has resulted in opportunities for Title V to collaborate with the MCOs in 2017-2018.  Quality improvement practices are part of the contractual requirements of the MCOs and the three work collaboratively on the QI projects.  Two areas in which the Title V Maternal Infant Health program has made contributions are Tdap dose in the third trimester of pregnancy, and 17-P for prevention of prematurity.  These particular topics represented unexpected opportunities, created by the quality performance processes set by Medicaid, for Title V to shine as a public health partner.

 

In the spring of 2018, Nebraska Title V began efforts to revitalize a maternal mortality review committee.  This involved moving the process back in-house to DHHS from a contractor; undertaking process improvement activities to reflect current national best practices; and engaging dedicated professionals with expertise to serve on the review committee. Progress has been significant.  At this time, the committee has formed, met, and reviewed process and historic data.  Case reviews have begun.  Title V staff have trained in the areas of abstracting and use of a national data system.   

 

During this period, Nebraska Title V also went through a period of assessment on the use and delivery of the Healthy Mothers Healthy Babies helpline, a resource and referral service available for statewide use through a dedicated 24-hour toll-free helpline.  The contractor for this service, Nebraska 2-1-1, was performing adequately but the dedicated phone line was not being used.  The matter was not fully resolved by the end of this reporting period, September 2018.  As a result of the transition, Nebraska Title V has a stronger relationship with Nebraska 2-1-1 and receives data on all maternal health related calls to Nebraska 2-1-1, making an overall much more effective use of funds compared to the separate dedicated 800-number previously in use.

 

2. Summary of programmatic efforts and use of EBP to address priorities

 

Priority: Decrease Sexually Transmitted Diseases among Women of Childbearing Age

2017-2018 Objectives and Strategies:

• WM1a.  By 2020, improve knowledge and attitudes among providers regarding well-woman benefits and preventive care. 

 

Summary of programmatic efforts: Collaborative activities between the Nebraska Reproductive Health program and the Nebraska Women’s Health Initiative investigated the current nature and success of recall strategies for routine preventive well-woman visits following an STD or contraceptive visit. A small group explored best practices contributing to success in routine return visits, especially for women using long-acting (multi-year) contraceptive methods.  The Title V Maternal Infant Health program developed and expanded web-based material for consumers on preconception health and healthy pregnancy, including prevention of STDs, using readability and literacy standards. This included launch of the “Healthy Pregnancy” webpages in July 2018 and dissemination of the “Importance of the Postpartum Visit” and the “My Life, My Choice” flyers via website and directly to Managed Care Organizations, birthing hospitals, federally-qualified health centers, and family planning locations statewide, in both English and Spanish.  (See: http://dhhs.ne.gov/Pages/Pregnancy.aspx )

 

In May 2018, program partners took two steps back to collaboratively develop a logic model (driver diagram; theory of change) in order to re-visualize the connections between the priority (reducing STDs among women of childbearing age) and the National Performance Measure (NPM - increasing use of preventive health care) and understanding where a niche for Title V working with others might be. This helped mobilize an activity to understand better the information passing from provider to patient on well-woman care.  A team member in the Women’s Health Initiative stepped forward to lead a workgroup to develop messaging for providers to hand off to women about preventive care.

 

• WM1b.  By 2020, increase by 10% the percent of women who return for a subsequent preventive care visit following a contraceptive or STD visit.

 

Summary of programmatic efforts: MCH epidemiology collaborated with the Nebraska Reproductive Health program to derive baseline and trend measures of visits to family planning clinics including those receiving STD services. This activity was captured as the percent of women under age 25 screened for chlamydia when presenting for a comprehensive visit at a family planning clinic, and represents an important data outcome of a collaborative relationship between Title V and Nebraska Reproductive Health.  The alignment and collaboration between Title V and Nebraska Reproductive Health has continued to develop in fruitful ways.  The project measures of Family Planning clients screened for chlamydia are as follows:

2016: 74.3%

2017: 78.6%

2018: 80.1% 

The increase in screening rates is encouraging, however the complexity of the landscape involving multiple system partners working on the issue means that it is challenging to attribute the success to any one particular intervention.

 

In May 2018, a diverse ad hoc workgroup convened to re-develop a theory of change model to describe the relationship between STD reduction and the NPM on well-woman preventive care, and identify opportunities for Title V to make improvement.  The use of effective recall methods for return visits took on new focus: the communication of providers to promote and engage women in their preventive health care.  The behavior of the clinician in terms of teaching points delivered during the contraceptive or STD visit regarding the value to the woman in returning for preventive medical care, as well as the clinician including one or more aspects of teaching about well-woman care during the contraceptive or STD visit, represent two opportunities that can be applied to preventive care.  The partners are working to offer a consumer-friendly, health literate message tool for women which, held in the hand of a provider, offers a convenient reminder and at-a-glance points to emphasize for the provider to educate on or emphasize, then hand to the woman.  Work on this continued from June 2018 into the following MCH program year.

 

Use of Evidence-based Practice in this Priority Area:

The ESM selected for this priority is the percent of Title X Family Planning female clients under age 25 who were screened for chlamydia and gonorrhea infections as a component of a comprehensive visit. Data for 2016 provide a baseline for this ESM.  With a denominator of 9,196 clients, and a numerator of 6,830 clients tested, the baseline indicator (2016) is 74.3%.  A well-woman or preconception visit provides a critical opportunity to receive recommended clinical preventive services, including screening, counseling, and immunizations, which can lead to appropriate identification, treatment, and prevention of disease to optimize the health of women before, between, and beyond potential pregnancies.  This rationale links the priority with the NPM, yet limited to the self-selected population of women who utilize family planning clinics for primary care.  While this is an important population, more should be done to encourage all women to become more proactive about self-care including preventive medical visits in the first place, if no STD or contraceptive need is present.

 

The evidence summary at www.mchevidence.org reads as follows (retrieved 5/20/2019) for increasing well-woman preventive health care benefits (bold emphasis added):

Current evidence has not focused on effective strategies to increase well-woman visits overall. Thus, proxy strategies to increase receipt of two preventive services that could be delivered in the context of a well-woman visit – cervical cancer screening and human papillomavirus (HPV) vaccination – have been reviewed. The following trends have emerged from this analysis.

• There is strong evidence to suggest that patient reminders/invitations are effective, both on their own and in combination with other strategies.
• Other interventions targeting the patient/consumer that appear to be effective are community- based group education and patient navigation.
• Home visits (1-2 total visits) targeting patients/consumers do not appear to be effective.
• On the provider/practice-level, provider reminder/recall systems, provider education, and implementation of a designated clinic/extended hours appear to be effective.
• On the community-level, television media appears to be effective.
• Of interventions targeting payers, expanded insurance coverage appears to be effective.
• Using multicomponent interventions is more effective to increase uptake of other screenings.
• Findings from the literature on components of the well-woman visit can be applied to the implementation of multicomponent interventions that target various audiences.

 

The MCAH program has progressed considerably in the goal to embed quality improvement practices including diverse consumer engagement, CLAS and literacy standards, and PDSA cycles into program methods.

 

Priority: Improve Access to and Adequacy of Prenatal Care

2017-2018 Objectives and Strategies:

 

• WM2a: By 2020, increase by 10% the percentage of women giving birth annually who are provided prenatal care in a maternal medical home practice.

 

Summary of Programmatic Efforts: Initially in the period, a collaborative on maternal medical home was proposed with Medicaid leadership in the quality management program for Managed Care Organizations. This however proved not to be viable at the time, due to changes in Medicaid leadership and the loss of a champion.  Title V did proceed with collaborations in May 2019 with the Nebraska Medicaid Quality Management program subcommittee on some maternal medical home practices, including Tdap immunization of pregnant women in third trimester, and 17-P administration for women with previous premature delivery. In September 2018, Title V initiated collaboration with Office of Rural Health on maternal medical home standards as a quality improvement activity for rural primary care practices. The Maternal Infant Health program transitioned messaging projects related to preconception health/interconception health CoIIN to ongoing program activities: consumer education to improve health during the preconception period, keeping the postpartum visit, and timely access to prenatal care.  Culturally- and linguistically-appropriate and literacy standards were intentionally applied in development of the materials in order to reach priority and disadvantaged groups.  

 

Much more fruitful work on maternal medical home has arisen from the Office of Rural Health-Title V collaboration.  The Office of Rural Health reached out to partners working at the level of clinic service transformation, finding strong alignment between foundational patient-centered medical home approaches, health systems transformation, and now maternal medical home practice.  The collaboration grew into the Office of Rural Health funding a partner to develop a practice-level toolkit for maternal medical home, and a pending application for federal funding for a planning and implementation project between systems partners in rural Nebraska, as of this writing.

 

• WM2b:  By 2020, increase by 10% the percent of patient-centered medical home practices and Managed Care Organizations providing maternal medical home approaches.   

 

Summary of Programmatic Efforts: Attempted collaboration with Medicaid Managed Care Organizations and Nebraska Medicaid Quality Management Committee to promote maternal medical home practices initially seemed promising then faltered due to changes in leadership in Medicaid and the loss of a champion for maternal medical home within Medicaid.  However, the Maternal Infant Health Program lead, Jackie Moline, experienced considerable success in collaboration at the level of Managed Care Organizations and discussions on approaches to incentivizing and encouraging women to keep timely prenatal and postpartum visits.  This in turn contributed to credibility of the Maternal Infant Health Program in conversations about 17-P and Tdap, which were the subject of quality improvement projects of the MCOs.  While the maternal medical home approach has not necessarily been prominent in these more focused collaborations, in late summer 2018, a new collaboration opened between the DHHS Office of Rural Health and Title V to grow maternal medical home practices.

 

• WM2c:  By 2020, increase by 10% the percent of American Indian women starting prenatal care in the first trimester.

 

Summary of Programmatic Efforts: The Maternal Infant Health Program lead, Jackie Moline, joined an effort to convene a Tribal grantees Community of Practice on improving pregnancy outcomes.  This began slowly, with initial meetings focused on building relationship and communication, and the meetings were conducted by phone.  Building a reliable infrastructure and practice around the Community of Practice has proven a challenge to sustain.  The plan is to move to more structured workplans and action steps.  The Maternal Infant Health Program successfully described the use of incentives by the three Medicaid Managed Care Organizations to improve compliance with visits pre- and postpartum.  Impact measures are not being considered at this time by any of the three managed care organizations.  

 

Use of Evidence-based Practice in this Priority Area: Efforts to find the most effective strategies for Nebraska Title V to contribute to impact on the state priority of improving access to and adequacy of prenatal care continue to progress and evolve.  Becoming more specifically focused on the topic of maternity care, rather than preventive medical care utilization more broadly, has been important.  In 2016-2017, Title V staff began looking at models and best practices for maternal medical homes, with an eye toward leveraging Nebraska’s patient centered medical home movement toward improving prenatal care. In 2017-2018, after attempts to engage Medicaid in shared leadership on a maternal medical home initiative failed, a new but well-suited partner emerged in the DHHS Office of Rural Health.  Long engaged in the patient-centered medical home movement in Nebraska, the Office of Rural Health has been a partner to rural health services seeking to stay both relevant and viable in increasingly value-based health systems.  In 2018, the Office of Rural Health embraced maternal medical home approach as a quality improvement and value-add initiative useful to keep rural health care relevant and effective in contributing to optimal outcomes of pregnancy.

 

It should be noted that the evidence-base for the patient-centered medical home is still emerging, taking into account costs, outcomes, and satisfaction of patients.  There is an NPM for medical home which, while not assigned to this priority, bears consideration.  At the site, www.mchevidence.org, the evidence summary for medical home reads as “under development” in May 2019.

 

In the current environment, www.mchevidence.org is constructed around a selection of NPMs, in which early and adequate prenatal care is not included.  However, there is substantial evidence available that improved prenatal care reduces risk of low birthweight, and that reducing low birthweight is a significant sign of population health overall.

 

3. Alignment of NPMs, ESMs, SPMs, SOMS with priority needs

 

Priority: Sexually Transmitted Diseases among Women of Childbearing Age

NPM: Percent of women, ages 18 – 44, with a preventive medical visit in the past year.

ESM: The percent of Title X Family Planning female clients under age 25 who were screened for chlamydia and gonorrhea infections a component of a comprehensive visit.

 

In this priority of the Women/Maternal Health domain, it has been especially difficult to determine if efforts should focus on increasing preventive health services utilization, and the STD services that might happen within that frame; or on focusing on women seeking care for STDs, and teaching/recalling them to preventive health care visits.  Focusing on the opportunity for improvement in how providers interact with women of child-bearing age about preventive health care including sexual risk, was helpful in 2017-2018. 

 

Title V seeks to decrease sexually transmitted disease rates for women of childbearing age by increasing the percent of those receiving a preventive medical visit in the previous year. While the ESM suggests a behavior of women to seek screening, in reality the lever of change may be the behavior of the provider who inquires about sexual risk in a non-judgmental fashion in the course of any visit, in a way that leads to education and screening.  The primary tool available to Nebraska Title V in influencing provider behavior is through provider education. 

 

The chlamydia rate within NE continues to steadily increase, while the gonorrhea rate remains stable but high.  Of additional concern are disparities in chlamydia, suggesting disproportional risk for minority groups including African American, Native American, and Pacific Islanders. Reported rates of chlamydia among women are much higher than among men. https://www.americashealthrankings.org/explore/annual/measure/chlamydia/state/NE

 

Performance measures in the Title V block grant framework for this priority include a selection of National Outcome Measures on birth outcomes, which do not explicitly reflect disparities among groups.  The DHHS Office of Health Disparities and Health Equity shows that American Indian women have three times the rate of receiving inadequate prenatal care compared to the average Nebraska woman; Hispanic women experience 2.4 times greater rate of inadequate prenatal care; and African-American women experience an infant mortality rate 2.4 times greater among their offspring compared to the average Nebraska mother. (Source: http://dhhs.ne.gov/publichealth/Pages/Nebraska-Disparity-Summaries.aspx )

 

The challenges of seeing the alignment of the NPM of preventive health care services, with the priority of decreasing STDs, have been discussed.  Raising the visibility of sexual health risk assessment as a normal and important aspect of well-woman care has opened new doors of training with the Community Health Worker workforce by Title V.

 

Priority: Improved Access to and Adequacy of Prenatal Care

SPM: Percentage of women who initiated care in the first trimester.

ESM: None

 

For the state priority of improving access to and adequacy of prenatal care, Nebraska has adopted the State Performance Measure (SPM) of the percentage of women who initiated prenatal care in the first trimester.  Early identification of maternal disease and risks for complications of pregnancy or birth are facilitated by early entry into prenatal care.  Women with complex problems or chronic conditions may be more likely to receive optimal management.  In the Nebraska vital statistics report for 2016, the most recent year available, data show that 15.6% of all women giving birth in Nebraska received inadequate prenatal care as measured by the Kotelchuk Index. The Kotelchuk Index measures adequacy of prenatal care (adequate, inadequate, intermediate) by using a combination of the following factors: number of prenatal visits; gestation; and trimester prenatal care began. 

 

Another priority for this domain is increasing access to prenatal care and increasing the number of women who begin prenatal care early on in pregnancy.   Vital statistics (2016) for Nebraska show 72.5% of infants were born to women who received prenatal care beginning in the first trimester.

 

This SPM is strongly aligned with the state priority of increasing access to and adequacy of prenatal care.

 

4. Progress in achieving established performance measure targets along with other programmatic impact

 

At the programmatic level, Results Based Accountability measures are employed to measure progress toward achievement in numerous priority areas of Title V in Nebraska.  In this priority area, five RBA measures were set with reports of achievement on all.  A weakness is in measurement of audience numbers in a convenient way, particularly during tests of message.  When educational materials are considered, Title V staff are charged with assuring messages are readable, reflect diverse society, are translated, and are tested with appropriate audiences prior to dissemination. 

 

2017-2018 Results Based Accountability (RBA) measures Decrease Sexually Transmitted Diseases among Women of Childbearing Age
	Planned for 2017-2018	Achieved 2017-2018
How much did we do?	# educational materials and activities for providers or consumers re: well woman topics.	3 - Postpartum Visit and My Life My Choice; Tdap in pregnancy
How well did we do it?	# and % of materials developed using CLAS and health literacy standards.  # materials developed and/or educational activities involving minority consumers and/or providers.  # and % of total audiences reached who are of minority or disadvantaged groups.	3 – 100%   3 - 100% Tdap in pregnancy tested in practices   Medicaid-enrolled audience reached through MCO Tdap collaboration, no count.
Is anyone better off?	# and % of audiences reporting materials developed or education provided was useful and respectful of their needs or cultures.	Postpartum Visit and My Life My Choice materials received feedback at Minority Health and Current Practices Maternal BH Conferences.  Tdap materials tested with providers, not consumers, for their Medicaid clients, no count.

 

In the priority area of improving access to and adequacy of prenatal care, the RBA measures for 2017-2018 are below.  In this priority area, there were nine measures set in 2017-2018, the second year of working with RBA measures in the Nebraska Title V plan.  Six yielded some meaningful response.  The measures of numbers of individuals participating in message testing were not captured, nor was race/ethnicity of the testers.    This has been resolved with better record retention.

 

2017-2018 Results Based Accountability (RBA) measures Improve Access to and Adequacy of Prenatal Care
	Planned for 2017-2018	Achieved 2017-2018
How much did we do?	# of Nebraska MLTC Quality Management (or subcommittee) meetings attended during period.   # of Measures of Impact of maternal medical home best practices identified.   # Educational materials disseminated,   # educational events for consumers given on preconception/interconception health.   # Meetings with MCOs re: implementation of maternal medical home strategies.	4 meetings       4 - Measures of Impact:     0 dissemination of materials     0 consumer events delivered   6 meetings regarding implementation: Rural Health
How well did we do it?	When new materials are reviewed: # and % reviewers from minority groups.  # materials translated to non-English languages.      # of new collaborations or partnerships formed to gain knowledge about barriers/motivators to entering prenatal care in 1st trimester, keeping prenatal appointments, and postpartum appointments among underserved groups.	Tdap materials selected from existing resources, with translations. Tested in clinic settings.  No measurement of race/ethnicity of reviewers.   New partnership included Tribal grantee Community of Practice, with Omaha, Santee, Ponca, and Winnebago tribes participating.
Is anyone better off?	# and % total women giving birth provided maternity care in maternal medical home practices;   # and % from minority groups.	Maternal Medical Home prevalence not measured.   2016 Vital statistics in NE record 26,594 births; 23% non-White and 18% Hispanic.

 

Learning from RBAs

Overall, the RBA framework provides a constructive way for staff to set and deliver achievement goals in priority areas of the Title V block grant, and feel the satisfaction of a results-based framework for success.  In the Women/Maternal Health domain, a total of fourteen RBA measurements were planned for the period 2017-2018, and eleven (79%) yielded some statements of results.  The team is learning that many RBA measures are not needed to reflect and measure significant performance, but a few key RBA measures are useful for keeping focus on the intent of the strategy.  (For example, to voice commitment to CLAS standards and not be diligent about identifying and recording race/ethnicity of message testers is an easy course correction.)  RBA measures stated in a meaningful way are needed so designated reporters readily understand, remember, count, and record results. 

 

5. Challenges and Emerging Issues

It has been a challenge to connect the logic between women’s preventive care (the NPM) and reducing STDs (the priority).  A refreshed logic model in autumn of 2018 is has helped strengthen the approach. 

 

In Nebraska, the political environment for sexual health, particularly as involve state government entities, is extremely sensitive.  The atmosphere is often stressful and challenging.  However, as noted above, the environment of many external partners with existing networks and programming approaches offers a way to ensure successful outcomes through alignment, coordination, and collaboration.

 

As with other states, the health care workforce is changing, representing refreshed potential for addressing some persistent health access issues including the priorities in this domain.  Nebraska has a growing Community Health Worker (CHW) workforce, and Title V is engaged with stakeholders, CHWs, and advocates to assure a quality workforce capable of addressing MCH population health priorities, including women’s preventive health care (and sexual health risk assessment).  Nebraska has also granted full practice authority to advance-practice registered nurses, reducing barriers to practice at full scope of licensure for these mid-level providers. 

 

A nuanced challenge to Nebraska Title V has been to keep focused on the priority of improving access to and adequacy of prenatal care, and addressing STDs, among the most disadvantaged and underserved women.  It is often the default tendency to keep efforts trained in the “mainstream” and attend to the perspectives and experiences of the average or majority population.  Educational messaging tends to reach and be taken up by those populations who already are attentive or at least aware of self-care and medical care opportunities.  In order to achieve equity in birth outcomes, the challenge is to tune efforts to those not reached by typical communication channels, and to consider the needs and preferences of those experiencing differential outcomes.

 

In this domain, Nebraska Title V has a very lean, multi-tasked infrastructure.  As a result, achievement of objectives involves Title V working as a catalyst for engagement of other aligned program areas to collaborate on the Title V priority topics.  The Title V team, along with stakeholders, collaborators and partners, constantly seek approaches that can by synergized or accelerated by systems partners.

 

Title V efforts during the period 2017-2018 were characterized by a distinct turn to more inclusive collaboration and engagement of internal assets of DHHS in Title V work.  More partners began working collaboratively to have input on the theory of change model and continued working on message development. Now engaged much more actively, the alignment between Title V and multiple programs has helped amplify the diversity and the impact of efforts.

 

Working together, the Reproductive Health Program, Title V, the STD program, and the Women’s Health Initiative can explore levers and drivers around the experiences of women in Nebraska’s Family Planning Clinics that may contribute to the likelihood of a woman returning for comprehensive preventive care well-woman visits, following a visit for contraception or an STD concern. 

 

6. Overall Effectiveness of Strategies and Approaches: Addressing Needs and Promoting CQI. 

 

The formation of strategic partnerships to address the priorities in this domain have been strategic and fruitful. The partnerships provide not only a means to accelerate and amplify work, but also provide dissemination channels and networks for sharing and receiving feedback for quality improvement purposes.