Women/Maternal Health

Annual Report - FY2022

 

Activities in this domain were carried out by the following MSDH offices, bureaus, or programs during the reporting period:

• Breast and Cervical Cancer Program (BCCP)
• Healthy Moms/Healthy Babies of Mississippi (HM/HB)
• Maternal and Infant Health Bureau (MIHB)
• Family Planning/Comprehensive Reproductive Health
• Division of Dental Services
• Office of Tobacco Control
• Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

 

The following section outlines strategies and activities implemented between 10/1/2021-9/30/2022 to meet the objectives and show improvement on the measures related to women’s and maternal health:

 

PRIORITY: Access to Care (Women, Children, Adolescents, and Families)

 

NPMs, NOMs, SPM, and ESMs:

• NPM 1: Percent of women, ages 18 through 44, with a preventive medical visit in the past year
• SPM 5 - Percent of Women ages 40-64 yrs. old screened for cervical cancer.
• ESM 1.5 - Promote the use of the Mississippi Quitline and Baby and Me Tobacco Free to assist women in quitting smoking during pregnancy.

 

Objective: By September 30, 2020, increase awareness activities related to the Office of Women’s Health programs from 50 to 60.

 

Objective: By September 30, 2020, increase the number of women and infants participating in a case management program (PHRM/ISS) from baseline to by 1%.

 

Objective: By September 30, 2020, increase the number of outside MSDH referrals for the case management program (PHRM/ISS) from baseline to 1%.

 

Objective: By September 30, 2020, the Office of Women's Health will increase the number of users viewing the social media message delivered by MSDH social sites promoting women's preventive health services from baseline to 2%.

 

Strategy: The Office of Women's Health Director, PHRM/ISS Director, Fatherhood Coordinator, and Outreach Coordinators will work with internal MSDH and External MSDH partners to identify opportunities for collaboration.

 

Activities: Office of Women’s Health program staff continue to have a strong visible presence with several community-focused events and collaborative opportunities. These opportunities allow staff to provide information and resource materials regarding the BCCP, Family Planning Waiver, Healthy Moms/Healthy Babies, and Maternal and Infant Health Bureau programs, as well as others under the Office of Health Services, emphasizing services available to both external stakeholders and potentially eligible participants. Throughout the reporting period, the staff across multiple programs collaborated with community organizations, businesses, and other stakeholders statewide. These organizations included FQHC’s, colleges and universities, faith-based organizations, hospitals, MS-BCCP screening providers, social service providers, grassroot organizations, and others in direct contact with the target population. To increase awareness and knowledge of Maternal/Women’s Health programs at the community level, MSDH staff participated in 76 outreach, engagement, or technical assistance activities throughout this reporting period. These activities included onsite and virtual training, conferences, community forums, roundtable discussions, workshops, and other events. Several staff in the Office of Women’s Health are cross trained to provide outreach for multiple MCH programs, public awareness activities are rarely exclusive to a single program. Often, multiple programs are represented when an outreach activity is executed. Some of these activities are detailed as follows:

• October 2021 – Worksite Wellness promotional table on the MSDH Campus and Jackson Medical Mall across multiple dates– 88 participants (BCCP, Family Planning)
• December 7, 2021 – Virtual Lunch-n-Learn hosted by Mary Bird Perkins Cancer Center – 11 participants (BCCP)
• January 11, 2022 – Virtual meeting with Magnolia Medical Foundation to discuss partnership (BCCP, Family Planning)
• January 11, 2022 – Virtual presentation for the Community Health Advisory Network (Pearl, MS) – 7 participants (BCCP, Family Planning)
• January 19, 2022 – Virtual meeting with Boat People SOS (MS Gulf Coast) to discuss partnership (BCCP, Family Planning)
• January 2022 – Virtual subgrantee orientations/technical assistance with Delta Health Center and Mary Bird Perkins Cancer Center (BCCP)
• February 2022 – Virtual subgrantee orientations/technical assistance with Plan A Health, Singing River Hospital (BCCP)
• February 3, 2022 – Virtual Lunch-n-Learn hosted by Mary Bird Perkins Cancer Center – 11 participants (BCCP)
• February 9, 2022 – Virtual outreach presentation to Harbor House Chemical Dependency Center – 3 participants (BCCP, Family Planning, HM/HB)
• February 16, 2022 – Virtual presentation to Institute for the Advancement of Minority Health – 11 participants (BCCP)
• March 2022 – Virtual subgrantee orientation/technical assistance with Family Health Care Clinic (BCCP)
• March 5, 2022 – 19th Annual Hope Conference (Virtual) “Lighting the Way to Cancer Survivorship” – 257 participants (BCCP)
• March 14, 2022 – Virtual Lunch-n-Learn hosted by Mary Bird Perkins Cancer Center – 18 participants (BCCP)
• March 18, 2022 – Onsite technical assistance to Plan A Health – 6 participants (BCCP)
• March 21, 2022 – Canton Community Health Action Network – Virtual presentation by St. Dominic’s Hospital Patient Navigator on breast and cervical cancer screening, diagnostic, and treatment resources – 16 participants (BCCP)
• March 23, 2022 – Outreach planning meeting with Flowood Women’s Facility Chaplain (BCCP, Family Planning)
• March 26, 2022 – UMMC See, Test, and Treat – 31 uninsured patients with abnormal screening mammogram or pap results were referred to the BCCP table and given a provider in their county to schedule diagnostic follow-up with a BCCP provider (BCCP)
• March 29, 2022 – Mississippi HPV Summit (Virtual) – 140 participants (BCCP, Family Planning)
• April 4, 2022 – MSDH Public Health District IV (Virtual) Provider technical assistance training – 39 participants (BCCP)
• April 21-22, 2022 – MS Perinatal Quality Collaborative (Virtual/Onsite) – (BCCP, Family Planning, HM/HB, MIHB)
• May 10, 2022 – MSDH Public Health District VI (Onsite) Provider technical assistance training – 14 participants (BCCP)
• June 1, 2022 – Jackson Free Clinic (Virtual) Partnership Discussion – 5 participants (BCCP)
• June 15, 2022 – Virtual Lunch-n-Learn hosted by Mary Bird Perkins Cancer Center – 18 participants (BCCP)
• July 12, 2022 – Technical assistance site visit with Jackson Hinds Comprehensive Health Center – 14 participants (BCCP)
• July 15, 2022 – HM/HB Program Rebrand Kick-Off – 98 participants (BCCP, Family Planning, HM/HB, MIHB)
• July 20, 2022 – UMMC Medical Residency Students – resource awareness presentation – 14 participants (BCCP)
• July 30, 2022 – Community Resource Day at MS Department of Corrections Satellite Facility in Flowood, MS – 161 participants (BCCP, Family Planning)
• August 12, 2022 – Making Strides Against Breast Cancer Luncheon – 300 participants (BCCP)
• August 20, 2022 – UMMC See, Test, and Treat –uninsured patients with abnormal screening mammogram or pap results were referred to the BCCP table and given a provider in their county to schedule diagnostic follow-up with a BCCP provider (BCCP) – 19 participants referred to BCCP
• August 25, 2022 – Partnership planning meeting with MS Public Health Institute re: collaboration on MCH programs, services, and activities (BCCP, Family Planning, HM/HB)
• September 1, 2022 – Virtual Lunch-n-Learn hosted by Mary Bird Perkins Cancer Center – 9 participants (BCCP)
• September 1, 2022 – UMMC Medical Residency Students – resource awareness presentation – 9 participants (BCCP)
• September 16, 2022 – New BCCP Provider Orientation with Jackson Free Clinic (Virtual) – 10 participants (BCCP)
• September 22, 2022 – Susan G. Komen Organization – 2022 Navigation Nation Summit – all BCCP staff participated

 

Note: Strategies and activities for attending professional conferences, meetings and engagement with providers continued to be hampered in this reporting period because of COVID-19 impacts. Many events were conducted virtually, which did not allow for the same level of engagement as onsite interactions. 

 

Strategy: The PHRM/ISS program promotes a 2 to 4 weeks post-partum medical visit with all women and discusses inter-conception care with parenting women.

 

Activities: The Mississippi State Department of Health (MSDH) implemented the Perinatal High Risk Case Management Program (PHRM/ISS) in every county of MS for over 34 years. The program provided clinic and home-based perinatal case management to pregnant women and infants, using a multi-disciplinary team of a nurse, social worker, and nutritionist. This case management program was largely sustained by program revenue generated from billing Medicaid for eligible patients. Following amendments to the Medicaid Administrative Code for Maternity Services, Part 222, Chapter 2: Perinatal High-Risk Management and Infant Services in 2020, the program has subsequently revised its model to a nurse-led case management model. Effective July 2022, the historic perinatal case management program was rejuvenated and rebranded as the Healthy Moms/Healthy Babies Program of Mississippi (HM/HB). This new family support program’s mission is focused on partnering with families and communities to ensure all Mississippi moms and babies have a safe birthing experience and healthy infant development. The program aims to decrease preterm births, improve maternal health, decrease infant mortality, and support infant physical and mental development.  Its target population remains high risk pregnant women through 60 days post-partum and high-risk infants through 12 months old.

 

The HM/HB program partners with the medical home and community to provide care coordination and home visiting services to assist expectant women of all reproductive ages and infants up to one year of age who have identified health risks. HM/HB provides comprehensive and coordinated maternity and infant targeted case management services aiming to reduce the maternal and infant mortality and morbidity rates in the state of Mississippi. The care management model consists of assessment, education, empowerment and support, linkages to other services, management of high-risk behavior and response to the social determinants of health (SDOH) that may have an impact on birth outcomes. Patients and families shall receive culturally sensitive, compassionate, non-judgmental care and services in the HM/HB program. HM/HB exists to address the following:

 

• Ensuring that all HM/HB staff and HM/HB Extended Service Providers are trained in maternal early warning signs, post-birth warning signs, and postpartum depression.
• Ensure that HM/HB patients and families are connected to social services and mental health services for psychosocial support and/or substance use treatment.
• Ensure that HM/HB patients and their families feel heard and empowered about how to advocate for their health.
• Ensure that HM/HB patients are educated about maternal early warning signs (dangers in pregnancy), post-birth warning signs, and postpartum depression.
• Ensure that HM/HB patients have a medical home and follow up on appointments.
• Ensure that HM/HB patients are screened for social stressors including any social determinants of health.
• Ensure HM/HB patients/caregivers are educated about family planning and are connected to resources as needed.
• Ensure that pregnant women, caregivers of infants and their families are educated about the risks in pregnancy and in infancy.
• Ensuring that HM/HB patients are assisted in receiving access to insurance coverage.
• Educate pregnant women and parents about the benefits of breastfeeding and connecting them to lactation support as needed.
• Promoting smoking cessation and encouraging patients and families to reduce secondhand smoke exposure.
• Provide safe sleep education to pregnant women, parents, and families and refer to safe sleep resources as needed.

 

Strategic planning began in August 2021 to develop provider specific training and orientation to new and existing staff. Protocols were developed and evidence-based strategies are in the implementation stage to revamp a program that has been in existence at the health department for over 30 years. The HM/HB program developed a recruitment strategy to address the shortage of nurses within the program. The overall goal is to increase capacity, training, and accountability to better serve pregnant women and infants in the state of MS.

 

To combat the growing maternal and infant health crisis in the state of Mississippi, the MS State Department of Health, Healthy Moms/Healthy Babies program wanted to equip their staff and internal partners with the resources and training needed to assist pregnant women and their families. From October 2021 to January 2022, HM/HB partnered with the MSDH Maternal and Infant Health Bureau to offer a Maternal and Infant Health virtual training series. The first training was the Maternal and Infant Health Training Session 1- Getting to Know our MCH Teams. This training gave an opportunity for HM/HB, the Maternal and Infant Health Bureau, and The Maternal Child Health Block Grant Team to provide introductions, talk about the purpose of their programs or bureaus and how the systems can collaborate. Session 2 was called Maternal Morbidity and Mortality in Mississippi. This session provided information about the drivers for maternal mortality and its disparities. Also, maternal mortality definitions were provided as well as a discussion on the maternal mortality review process. Session 3’s topic was Infant Mortality in MS which included discussions on infant morbidity and mortality data, definitions, and description of the child death review panel. Session 4’s topic was Maternal Hypertension-What Every MCH Professional Should Know. Session 5 is Predicting and Preventing Preterm Birth in MS and the last training, Session 6, was Supporting the NICU Graduate. The training series had an average of 60 participants in each training session. All sessions were recorded. And videos can be found on Health Stream, MSDH’s learning management system.

 

In prior years, PHRM/ISS program utilized a data management system to capture required performance measure data including information on the participants, interventions, and birth outcomes, which allowed for real-time analysis of service delivery, quality assurance, and research analysis. The database was developed for each individual county health department site throughout the state and structured to collect demographic information for participants and their infants, including age, race, ethnicity, contraceptive/birth control choices, information concerning the number and types of referrals and direct services provided, and other programmatic information monthly. The database was updated June 2020 to include a data point exclusive to interconception care. Starting in 2021, the former data system became obsolete and was replaced with the MSDH electronic health record, which allows for data extraction when a case manager has input information for discrete data fields. Unlike the prior data system, there presently is not a single data point in the EHR exclusive to the HM/HB program where data can be reliably extracted for analysis of the postpartum home visit and medical visit. Instead, there are multiple points at which this data can be entered, including narrative progress notes, which makes for less reliable reporting. The program is prioritizing improvement in this area for the remainder of CY2023.

 

Strategy: The PHRM/ISS case management program develops relationships with external partners to increase referrals to the program.

 

Activities: The HM/HB program experienced a major downward turn in referrals and new enrollments throughout the COVID pandemic. Starting in January 2022, the HM/HB program had 402 enrolled patients. In February 2022, there was increase in HM/HB central office program staffing that helped equip the resources needed to re-launch the program. In March 2022, branding and collateral work began with MSDH Communications Department to develop marketing information and brochures. By May 2022 the program branding was completed with a new logo, vision, mission, and values. The month of May was also a crucial time to where HM/HB was able to kick of nurse recruitment for HM/HB case management. The Healthy Moms/Healthy Babies of MS held an all-day program convening on July 15, 2022, in Raymond, MS. The purpose of the convening was to kick-off the new program, share the new promotional materials, reveal visions and goals and to provide training to staff. It was MSDH’s way of unveiling its new strategy for addressing maternal child health in the state of Mississippi. The agenda for the convening included 4 guests representing the Voice of MS Families discussing their challenges with pregnancy and with birth of infant and development. The MSDH State Health Officer and CDC Epidemiology Assignee presented on the “State of Maternal and Infant Health in MS”. The HM/HB program director discussed HM/HB New Program and New Practices which included the incoming State Health Officer sharing his vision for MS. Lunch guest speakers included: a Pediatrician, OB-GYN, and Public Health Nurse to discuss topics and solutions concerning Maternal and Infant Health. Breakout sessions included topics about patient- centered care to Social Workers, Nurses, and Nutritionists. Birthing doulas also came with some of their clients and discussed the services they provide. Over 100 participants registered and participated including some who attended virtually. Staff testimonials included that the convening was refreshing, gave them hope, and a new perspective on maternal and infant health. Afterwards, HM/HB teamed up with a veteran perinatal social worker to prepare to provide 10 training courses to HM/HB staff about maternal and infant case management and mental health. And HM/HB also teamed up with the MS Public Health Association to develop Nurse training modules for HM/HB nurse case management team. During the convening, the HM/HB director encouraged MSDH staff to “Give Me 5…For the Next 5 Months”. This included: 5 to 10 minutes every morning to set your day and focus, 5 to 10 new enrollments each month, 5 days to provide first contact attempt, and 5 community/provider outreach each month. HM/HB new enrollments jumped from 38 for July 2022 to 120 in August of 2022. For the rest of the year of 2022, MSDH saw an increase in participants of HM/HB. This number of enrolled patients steadily climbed month-to-month reaching 596 by the end of September 2022.

 

Throughout the reporting period, the Office of Women’s Health program staff networked and collaborated to leverage additional formal and informal partnerships for programmatic referrals and continuity of care with community health centers/FQHCs, delivering hospitals, OB/GYN offices, pediatricians, and managed care organizations, in addition to community-based, faith-based, and other youth-serving organizations. The program tracks several referral sources sent to the program administrative office for recording and processing.

 

During the reporting period, there were 1,266 referrals processed across these multiple referral sources, returning the program to pre-COVID referral numbers. While referral numbers have improved over the past year, there is still much work to be done on enrolling patients. Most referrals do not result in an enrollment into the program. Internal quality improvement initiatives are underway to improve this.

The following table shows the numbers of patients served by fiscal year, as well as the number of professional visits recorded related to PHRM/ISS – HM/HB. The program will continue monitoring and reporting to MSDH Senior Leadership and the Division of Medicaid on a monthly basis for the foreseeable future.

 

Measure	FY18	FY19	FY20	FY21	FY22	FY23
Unduplicated maternity patients served	1,960	2,206	2,190	1,136	794	912
Maternity professional visits received (with nurse, social worker, or dietician)	10,636	8,378	15,395	4,051	2,721	5,065
Unduplicated infant patients served	1,471	1,484	1,454	897	719	495
Infant professional visits received (with nurse, social worker, or dietician)	8,218	5,192	8,544	3,513	2,638	3,245

 

Strategy: The Office of Women's Health will identify similar promotional themes surrounding well woman visits and health exams for internal MSDH and external MSDH partners to promote the social media posting by MSDH.

 

Activities: The MS-BCCP program initiated a cervical cancer awareness social media campaign through the MSDH Office of Communications to run through January 2022. In September 2022, the Outreach Coordinator prepared a work request for a social media campaign to run through October 2022, which promoted breast cancer screening and early detection.

 

During October 2021, the importance of screening and early detection was further promoted by community health partners and participating providers. Many partners used their own internal and organic resources, such as business and organization social media outlets, to encourage uptake of screening services. Southeast Mississippi Rural Health Initiative, Inc., Aaron E. Henry Community Health Center, East Central MS Healthcare, Inc., and Coastal Family Health Center used Facebook as an outlet to bring awareness to the availability of free breast screening services in the month of October 2021. Numerous other providers and health systems across Mississippi took to their own social media platforms and local news outlets to promote screenings and early detection throughout the year, some even referring to MS-BCCP as a resource for women without insurance or other means to pay for services. 

 

Objective: By June 30, 2022, increase screening rates among the African American, Hispanic, Asian and American Indian communities to identify never or rarely screen women and link them to services.

 

Objective: By June 30, 2022, re-engage with the MS Department of Corrections (MDOC) to provide staff and incarcerated women with education on the importance of screenings and resources available.

 

Strategy: Facilitate sub-grant agreements with Health Systems Partners (JHCHC, FHCC) and Community-Clinical Linkage partners (Plan A, Singing River Health Systems, North Sunflower Health System) to support activities that increase screening rates among these underserved groups of women.

 

Activities: A competitive RFP was developed to recruit subgrantee partners for FY2022 and was posted to the website in late August 2021. Seven applications were returned. Reviews were scheduled for early October 2021 and would lead to five competitive proposals being funded through June 30, 2022. The FY2022 subgrantees were located different areas of the state and were strategically positioned and working to reach underserved women. Some activities planned included expansion of patient navigator services to additional sites, addition of community health workers in under-reaching counties, and mobile screening and mobile mammography events in areas of the state with both low MS-BCCP enrollment, increased incidence for cancer, and higher vulnerability. The FY2022 subgrantees were Jackson Hinds Comprehensive Health Center, Family Health Care Clinic, Plan A Health, Mary Bird Perkins Cancer Center, and Delta Health Center. Collectively, these subgrantees enrolled 1,100 unduplicated women residing in 47.5% (n=39) counties in MS-BCCP during the reporting period. These enrollees accounted for 31% of all women enrolled (n=3,569). Among subgrantee enrollees, 49% (n=543) were new (no prior enrollments in any year) to the program. Collectively, these women received a total of 3,564 program-supported breast and/or cervical cancer screening and/or diagnostic activities.

 

For FY2023, the subgrantee request for proposals (RFP) public facing announcement, closed September 30, 2022, and produced 14 applications from organizations from health systems and community-bases partners. A report on these subgrantees will be provided in the next MCH Block Grant report.

 

FY2022 MS-BCCP program data for the reporting period reflects that among 3,590 participants served, 51.5% were Black/African American women, 32.4% white women, 1.9% American Indian/Native Alaskan, Asian, or Pacific Islander women, and 0.5% were two or more races. For 13.7% of participants, no race was indicated, representing a major area for programmatic data quality improvement. Fifteen point eight percent (15.8%) of enrollees indicated their ethnicity was Hispanic, 81.1% non-Hispanic, and for 3% no response was recorded. With the race of nearly 14% and ethnicity of 3% of the participant population undetermined, the program cannot accurately determine its progress in achieving its targets for serving priority populations. However, based on available data, the program presently falls short of targets set in prior years.

 

Strategy: Consult with Institute for the Advancement of Minority Health on strategies and best practices for engaging underserved populations. Explore opportunities for partnership.

 

Activities: There was no activity for this strategy during the reporting period.

 

Strategy: Initiate contact with Flowood Correctional Facility and other minimum-security settings, which house women for brief periods (6-18 months) to explore interest in providing virtual education to staff and inmate population on breast and cervical health and BCCP services. Plan logistics accordingly. Pursue MOU for sustainability.

 

Activities: On March 22, 2022, the BCCP Outreach Coordinator completed orientation at the MDOC Flowood Women’s Facility. This is a requirement for any outside agency who wishes to visit the facility to interact with or provide educational programming to the inmates.

 

PRIORITY: Maternal Morbidity and Mortality

 

Nearly all the strategies and activities for this priority were carried out by the Maternal and Infant Health Bureau (MIHB), which aims to reduce maternal and infant morbidity and mortality by understanding the causes of deaths through surveillance, review, and abstraction of records for infants, children, and women (pregnancy-related). MIHB further utilizes the information and recommendations gathered through review to engage health systems and communities to implement quality improvement initiatives and prevention strategies.

 

MIHB utilizes strategies such as multidisciplinary review teams with guidance and technical assistance from the National Center for Fatality Review and Prevention (NCFRP) and the Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM). Strategies included in the report for the FIMR, CDR, and Maternal Mortality Review Committee (MMRC) are aligned with processes developed and guided by the NCFRP and the MMRC.

 

MIHB utilizes strategies such as quality improvement initiatives with guidance from the National Network of Perinatal Quality Collaboratives (NNPQC) and the Alliance for Innovation on Maternal Health (AIM). NNPQC is a partnership between the CDC and March of Dimes to support state perinatal quality collaboratives in making measurable improvements in statewide health care and health outcomes for mothers and babies. AIM is a national data-driven maternal safety and quality improvement initiative based on proven safety and quality implementation strategies that reduce preventable maternal mortality and severe morbidity. MSPQC utilizes best practices and evidence-based guidance from NNPQC and AIM.

 

It is important to note that 4 of 5 of the former MIHB staff separated from the agency in August through October 2022. It has taken this Bureau months to stabilize with new staff seeking to build on the work of those in former leadership positions. However, there have been multiple challenges to do so, notably due to the inability to plan for succession with the former staff. Additionally, accessing reports and data that would inform this report has been challenging. While certain OWH staff do have access to the former staff members’ emails and have been able to construct information for this report, many strategies would have been better informed by information contained in data files that can no longer be accessed. This has been an important lesson learned and has been shared across the broader MCH workforce. Notably, the Office of Health Services leadership has since provided direction and instruction for all staff related to succession planning, continuity of work during vacancies, and the archival of important records and artifacts for perpetuity in more broadly accessible platforms.

 

NPMs, NOMs, SPM, and ESMs:

• SPM 2 - Reduce Maternal Mortality Rates and Disparities by promoting best practices in clinical care and strengthening the Maternal Mortality Review Committee (MMRC) efforts.
• SPM 4 - Percent of women ages 15-44 years old that use family planning services

 

Objective: By September 30, 2021 increase the percent of cases reviewed by the Mississippi Maternal Mortality and Morbidity Review Committee within one year of maternal death.

 

Objective: By September 30th, 2022, build an infrastructure to address birth equity among Maternal and Infant Health Bureau staff, hospitals participating in MSPQC Quality Improvement Initiatives and the Maternal Mortality Review Committee.

 

Objective: By September 30th, 2022, increase the number of MSPQC hospitals participating the Initiative to Support Vaginal Births caesarean reduction project from 5 hospitals to 9 hospitals.

 

Objective: By May 30th, 2022, conduct at least 2 Maternal Mortality Review Committee meetings.

 

Objective: By September 30th, 2022, increase Maternal Mortality informant interview participation rates for 2019 cases from 60% to 70%.

 

Objective: By August 30th, 2022, conduct at least six community outreach events to address maternal mortality disparities and promote Maternal Mortality Review Committee recommendations.

 

Strategy: Review all deaths potentially related to pregnancy within two years of the date of death. 

 

Strategy: Identify, abstract, and review maternal deaths up to 365 days postpartum.

 

Activities: Maternal deaths are identified within a year of the end of pregnancy on a routine basis in collaboration with Mississippi Department of Health Office of Vital Statics. Birth and death certificates are the primary source for identify maternal deaths. The Maternal Mortality Review Committee identified maternal deaths through a structured multistep process including:

1. Pregnancy checkbox on death certificates
2. Death codes and descriptive terms
3. Linkages to birth and fetal death certificates
4. Review of news, social media

 

Once maternal deaths were identified, The MMRC abstractor called the institution or health system to establish a point of contact. Once contact was initiated, a letter describing the records request was sent. An allotted grace period of 7-10 days is given to receive records before follow-up correspondence is initiated. Follow-up correspondence is conducted at least three times before indicating the missing components of the medical record. Once records are completed, they are securely transferred to the MMRC Nurse Abstractor for review of the record and development of the case summaries in preparation for the review meeting. An additional component of the abstraction process occurs with the MMRC Social Worker through the informant interview process. The informant interview process allows additional context on social determinants of health that could have impacted the pregnancy. The MMRC Social Worker utilized the medical records to obtain contact information for families. If case abstraction did not yield usable contact information, MMR Social Worker utilized extensive online searches, online obituaries, social media searches, and utilized information found on legitimate/reputable news outlets. During the CDC ERASE Maternal Mortality reporting period of 4/1/2021 – 3/31/2022, 39 cases of maternal death were abstracted for review. decisions forms are completed during the meetings with input from MMRC members. During the December 2021 MMRC meetings, the use of zoom polls was piloted to capture pregnancy-relatedness, contributing factors, preventability, and the chance to alter outcomes. This assisted with reducing the amount of time spent discussing each case and targeted the discussions on areas where consensus was not reached. The use of zoom polls also provided more time to complete the contributing factors and recommendations for action section of the committee decision form.  Zoom polls were very helpful during uncomfortable discussions about the contribution of racism, where at times during open discussion some members felt silenced by others and the committee leadership could not determine the level of agreement on the decision. 

 

Maternal Mortality Review meetings are conducted with a multidisciplinary member committee consisting of clinical and non-clinical disciplines and organizations with representation from multiple regions of the state, gender, and racial diversity. Meetings are generally hosted quarterly; however, the schedule fluctuated due to the peak periods in COVID-19 cases.

 

MMRC meetings were conducted on:

• December 16-17, 2021
• July 19, 2022
• September 30, 2022

 

Strategy: Document committee decisions consistent with guidance documents no later than two years from the date of death.

 

Activities: Committee decision forms were completed for all cases reviewed during the study period and entered in MMRIA. Completing the committee decisions form in real-time during the meetings was a time-consuming process especially when consensus was not reached amongst MMRC members, and few offered concrete decisions. It is typical for committee members to offer few recommendations as this appears to be an area where committee members struggle the most. Additional facilitation strategies will be employed in future meetings to further reduce the time spent discussing each case and more on developing recommendations for action. 

 

Strategy: Enter all review committee decisions (documentation consistent with guidance) into MMRIA within 30 days of completing the review of death. 

 

Activities: While committee decisions forms were entered for all the cases reviewed, there were delays in entering completed committee decision forms when there was lack of consensus on some points of the form or when recommendations were not provided in the manner requested by CDC (who/what/when).  Existing committee decisions have been revised to meet the requested format and committee members have been educated on the desired format for recommendations. In the future, MMRC administrative support staff will work to enter decisions directly into MMRIA rather than transcribe from a PDF to MMRIA at a later date to ensure complete entry within 30 days.

 

Strategy: Perform data quality assurance checks for completeness within 90 days of completing the review.

 

Activities: While initially performed outside of 90 days, the MMRC reviewed cases for completeness and made corrections based upon those reviews. A special request to the CDC to open closed cases is necessary to make updates, corrections, or modifications, but that process has been fast. All staff who contribute to case abstraction have access to MMRIA and can work together to ensure data completeness and accuracy.  Two additional staff have been trained on MMRIA and now all those contributing to abstraction and analysis have access and work together to ensure completeness and accuracy. Both independently and based upon prompts from the CDC, MIHB has been assessing data completeness within this last quarter.  There are plans to standardize the timing and process of data quality assurance and work closely with the CDC to update locked cases.

 

The Maternal Mortality Report for 2017-2019 deaths was prepared starting in August 2022. However, due to turnover in 4 of 5 positions with the MIHB occurring August through October in 2022, the report could not be completed until January 2023. The most recent Maternal Mortality Report can be reviewed at https://msdh.ms.gov/page/resources/19612.pdf

 

Strategy: Increase the number of informant interviews that assist the Maternal Mortality Review Committee in understanding the family’s perspective of the mother preceding death.

 

Activities: Informant interviews became a formal process of the MMRC in 2020. The MMRC contracted with Therapy Plus, LLC to conduct key informant interviews and outreach to next of kin and families. The completed informant interview case summaries are shared during the case reviews.  Therapy Plus provided a report relative to the informant interviews conducted on 2018 deaths. For 2018 cases, 60% of the cases assigned resulted in a successful Informant Interview. The 40% of cases that were not interviewed, were primarily not completed because of inaccurate contact information for the next of kin, or lack of accurate contact information for surviving family members in the medical record. This often left no viable means of successfully contacting the family. For 2018, Informants were most likely to be a woman. The mother or sister of the decedent was most likely to participate as an Informant. Overall, mothers are more likely to be an Informant, even when the decedent was married at the time of death. For 2018 cases, the contact information listed on the death certificate or in the abstraction medical record had a high probability of being inaccurate. There is an increased likelihood that family members/next of kin could have moved or changed phone numbers within the amount of lapsed time between the death and attempted contact of the next of kin by the MMR Social Worker. Therapy Plus also provided a report on all 2019 death cases related to informant interviews. The participation rate had risen to 82%.

 

The Informant Interviewer shared the following key takeaways:

• Most families with viable contact information in the medical record elected to participate in the informant interview process. Anon-interview was primarily a result of a lack of medical records or inaccurate contact information for the next of kin. Conducting Informant Interviews on cases outside of "real time", continue to present challenges.
• In 2019, participants were overwhelmingly likely to be a female relative. The mother of the deceased was most likely to participate in the informant interview process. These are similar trends observed in 2018 interviews. However, 2019 experienced more male participation from spouses/partners, fathers, and male children of the deceased (versus that of 2018). Also, Informants were most likely to be the caregiver to the deceased's surviving child(ren).
• Cases classified as a homicide continue to be difficult to process for interviews. Several factors contributed to this dynamic for the 2019 group. Of the 2019 homicide cases, many of the family members that were contacted reported that their loved one's case had not yet gone to trial. Due to the pandemic, the Mississippi court system experienced a backlog of cases due to shutdowns and limit setting procedures to prevent the spread of COVID. Many family members expressed fear of retaliation or interference with the pending court case if they participated despite being informed of confidentiality measures.

 

Strategy: Partner with a national organization to provide training, assessments, and technical assistance in building a strategic plan to address birth equity.

 

Activities: MSPQC decided not to enter into a contractual agreement with the National Birth Equity Collaborative to conduct the Birth Equity Assessment, focus groups and interviews during the reporting period. In lieu of conducting these activities, MSPQC is partnering with the Obstetric Initiative to distribute the Labor Culture Survey (LCS) to hospitals to measure the micro culture of labor and delivery units as well as identify opportunities to encourage attitudes around vaginal birth. MSPQC had planned to distribute the Labor Culture Survey (LCS). The Labor Culture Survey is a tool designed to measure individual attitudes and beliefs and labor and delivery unit culture related to cesarean overuse. The LCS tool consists of 29 items and six subscales: Best Practices to Reduce Cesarean Overuse, Fear of Vaginal Birth, Unit Microculture, Physician Oversight, Maternal Agency, and Cesarean Safety. By using the LCS, MSPQC will be able to better facilitate the implementation of the I-Support Initiatives specifically targeting attitudes, unit norms, knowledge deficits, communication gaps, and behaviors. The LCS officially opened for responses in September 2021 and the oversight of the project stayed with MSPQC, which transitioned to being housed and administered by the MS Public Health Institute (MSPHI) in September 2022.

 

Strategy: Provide evidenced based training to MSPQC birthing hospitals to reduce severe maternal morbidity.

 

Strategy: Provide guidance to hospitals on reducing nulliparous, term singleton, vertex (NTSV) caesarean rate.

 

Activities: The Mississippi Perinatal Quality Collaborative (MSPQC) is a statewide partnership that promotes evidence-based quality improvement initiatives at the hospital and community level to improve birth outcomes across Mississippi. MSPQC relies on collaborative data-driven projects to address specific drivers of maternal and neonatal morbidity and mortality. These projects are selected by participating members across the state who work to develop, disseminate, and successfully implement best practices in all clinical settings caring for mothers and infants. Working collaboratively, the MSPQC comprises three divisions: (1) Neonatal, (2) Obstetric, and (3) Family Engagement and Support. During the reporting period, the MSPQC provided monthly technical assistance and training to participating MSPQC hospitals.

 

The Alliance for Innovation on Maternal Health (AIM) is a data-driven maternal safety quality improvement initiative that collaborates with the Mississippi Perinatal Quality Collaborative to implement strategies to reduce preventable maternal mortality and severe morbidity. In prior reporting periods, MSPQC utilized the AIM Severe Hypertension in Pregnancy safety bundle to provide a structured and standardized approach for delivering well-established, evidence-based practices to be implemented with complete consistency, for every patient, every time. After several months of successful implementation with participating hospitals, this bundle was considered “in maintenance.” During the reporting period, the MSPQC’s focus shifted to other AIM bundles, notably the I-Support Reduction of Primary C-Section and I-Support Intended Vaginal Birth bundles. During the reporting period, 36 hospitals actively participated in AIM activities. Patient safety bundles are driven by the findings of the MMRC and the relationship between the MMRC and MSPQC along with the support of third-party payers is critical to the successful implementation of data driven recommendations. 

 

Monthly conference calls/webinars for I-Support Vaginal Births/Reduction of Primary C-Section were led by the MSPQC I-Support Lead, Dr. Janice Scaggs, a certified nurse midwife and nurse practitioner, and were held on the following dates. Due to incomplete data, a report on the number of participants is not immediately available:

• October 19, 2021 – 19 participants
• November 2, 2021 – in lieu of I-Support content, participants received presentation “Promoting Physiologic Humility During Birth and Labor”: participant count unable to be obtained.
• December 21, 2021 – 8 participants
• February 15, 2022 – 34 participants; guest presenter, Dr. Lisa Law
• March 15, 2022 – 42 participants; guest presenter, Dr. Nicole Carson
• April 12, 2022 – 20 participants

 

MSPQC hosted its Annual Conference on April 21-22, 2022. The conference was offered in-person at the Sheraton Flowood the Refuge Center & Conference Center and virtually. Only hospital teams could attend the conference in-person, all other programs and community-based partners were asked to attend virtually due to COVID-19. The conference had educational two tracks: Neonatal and Maternal. The Neonatal track was held on April 21, 2022, and the Maternal Track was held on April 22, 2022. Additionally, a Spinning Babies pre-conference workshop was hosted on April 21, 2022. As part of the conference, a workshop supported by MS Blue Cross Blue Shield entitled “Spinning Babies” was offered to 38 participants. At the event, there were 37 onsite participants and 40 virtual participants. On April 22, 2022, the MSPQC officially announced its statewide launch of the I-Support Intended Vaginal Births AIM bundle. Facilitation of the I-Support Vaginal Births is coordinated in partnership with Blue Cross Blue Shield of Mississippi Provider Partnerships & Health Management. Over the next several months, the MSPQC developed a tool kit, which was sent to all participating hospitals and included labor positioning handouts, badge cards, posters, birthing balls, and other useful tools and resources.

 

Monthly conference calls/webinars for I-Support Intended Vaginal Births were also led by Dr. Janice Scaggs through August 2022. A new lead, Sara Humbert, also a certified nurse midwife assumed the facilitator role in September 2022.

• May 13, 2022 – 11 participants (Statewide Kick-Off)
• June 7, 2022 – 47 participants
• July 5, 2022 – due to inaccessible data file, the participant count is not available
• August 2, 2022 – due to inaccessible date file, the participant county is not available

 

To support AIM bundle implementation momentum, Blue Cross Blue Shield hosted regional meetings with participating hospitals. In these meetings, I-Support bundles and “Spinning Babies” education was offered to participants. These meetings were held as follows:

• July 19, 2022 – Indianola, MS – I-Support (6 hospital teams), “Spinning Babies” (36 participants)
• July 27-28, 2022 – Pascagoula, MS – I-Support (9 hospital teams), “Spinning Babies (32 participants)
• August 4-5, 2022 – Oxford, MS – I-Support (9 hospital teams), “Spinning Babies” (32 participants)

 

MSPQC partners with AAFP to conduct hands-on Advanced Life Support in Obstetrics courses to nursing staff in Mississippi. MSPQC Project Director, Lead Nurse Midwife for the I-Support Project and contract nurse consultant are trained facilitators for this course. MSPQC is working to increase not only the number of nurses trained in the state but the number of ALSO instructors. To improve the response to obstetric emergencies, MSPQC hosted Advanced Life Support in Obstetrics (ALSO) simulation training. ALSO is an evidence-based, interprofessional, and multidisciplinary training program that equips the entire maternity care team with skills to effectively manage obstetric emergencies. Training is conducted with hospitals upon request.

 

Training was conducted with hospitals on the following dates:

• October 12, 2021: 11 participants
• November 5,2021: 10 participants
• January 29,2022: 14 participants (ALSO Instructor Course)
• February 25, 2022:  7 participants and 5 instructor candidates  
• June 23-24, 2022: 10 participants

 

Strategy: Provide education on the treatment of severe maternal hypertension.

 

Activities: MSPQC utilizes the AIM Severe Hypertension in Pregnancy safety bundle to provide a structured and standardized approach for delivering well-established, evidence-based practices to be implemented with complete consistency, for every patient, every time. Conference calls and webinars for Severe Maternal Hypertension are conducted to provide continual guidance, knowledge sharing, and technical assistance to hospital teams. Additionally, one-on-one quarterly calls are held in conjunction with Blue Cross Blue Shield of MS to discuss unique challenges and barriers teams face with implementing maternal safety standards and to provide additional resources.  Conference calls and webinars were held on the following dates:

• February 8, 2022: 72 participants
• February 22, 2022: 43 participants
• March 29, 2022: 42 participants

 

After several months of successful implementation with participating hospitals, this bundle, along with the obstetric hemorrhage bundle, were considered “in maintenance” in March 2022 and no additional specific efforts were dedicated here.

 

During the reporting period, MSPQC partnered with the Preeclampsia Foundation to distribute blood pressure cuff kits to health systems for home monitoring of pregnant and postpartum women with hypertension/preeclampsia. MSPQC purchased and distribute 450 Cuff Kits to 9 clinics and hospitals. Participating clinics and hospitals provided the Cuff Kits to women who are currently pregnant or have given birth within the last 6 weeks and who were unable to purchase a home blood pressure monitor.

 

Distribution of the blood pressure cuffs were prioritized based on highest risk, including a higher medical risk (hypertension, history of preeclampsia, obese plus age over 35, and autoimmune disorders) and population-level risk (Black, Native American, and rural). The cuff kits included automatic blood pressure monitors and a variety of educational tools that explain how and why to take your blood pressure, what the numbers mean, and when to seek help. A REDCap survey was developed to track demographics of individuals receiving Cuff Kits. Additionally, sites were given guidance on how to identify, educate and enter data. During the reporting period, 109 Cuff Kits were disseminated Dissemination of Cuff Kits to women was a slow process. The Preeclampsia Foundation lacked an implementation guide that provided guidance on how to roll-out the Cuff Kit community. MSPQC developed a process and hosted a kick-off webinar with instructions on eligibility, diagnosis, and data entry but some facilities faced greater difficulty creating internal processes to capture and enter the data in REDCap. Out of the 109 participants, 104 were Black, 4 were White, and 1 was left blank. The majority (89%) had Medicaid.

 

DIAGNOSED CONDITIONS AMONG WOMEN WHO RECEIVED

A BLOOD PRESSURE CUFF

RACE	COUNT (PERCENT) N=109
Pre-Eclampsia	51 (46.8%)
Gestational Hypertension	10 (9.2%)
Chronic Hypertension	33 (30.3%)
History of Pre-Eclampsia	19 (17.4%)
Obesity	15 (13.8%)
Cardiovascular Disease	1 (<1%)
Other Diagnosis	5 (4.6%)

NOTE: Participants could choose more than one condition

 

Strategy: Implement community outreach events to address maternal mortality disparities and promote clinical recommendations of the MMRC.

 

Activities: During this project period, a contract was renewed with Six Dimensions, LLC to conduct outreach events to bring awareness to maternal mortality, disparities, and strategies to prevent maternal deaths. One key process in raising awareness was to identify partners working to reduce maternal mortality. This provided opportunities to leverage resources and deliver consistent messaging to the community. Additionally, it provided opportunities for interacting with women prenatally and postpartum to provide education and create a safe space for women to share lived experiences that further shaped the work and recommendations of the MMRC and the MSPQC. Information pertaining to partners is securely stored in a spreadsheet and utilized to distribute resources and information.

 

During this reporting period, Six Dimension LLC. Partnered with 23 organizations.  Six Dimensions hosted six virtual screenings of the Laboring with Hope documentary. Laboring with Hope is a film created by Six Dimensions, LLC. that talks about loss, grief, and the hope for change. The film addresses maternal morbidity and mortality among Black women and the racial and structural biases that create barriers to health among Black women. Screenings were hosted on the following dates.

• October 26, 2021: 118 participants
• November 15, 2021:  974 participants
• January 26, 2022: 25 participants 
• February 23, 2022: 25 participants

 

A partnership was established with Six Dimensions, LLC to assist with raising awareness on Maternal Morbidity and Mortality issues in Mississippi. During the reporting period the following outreach events and presentations were conducted.

• October 18, 2021: Motherhood 101 Discussion/Presentation with expecting and new mothers - 12 participants
• October 25, 2021: Documentation for Patient Advocacy: (Facebook Live Event) –Reached 1026
• October 27, 2021: Maternal Health Discussion with the MS Worker’s Center for Human Rights -parent & worker circle participants -18 participants
• November 17, 2021: Not Just the Baby Blues (Facebook Live Discussion) - Reached 710
• November 30, 2021: Motherhood Discussion- Labor & Delivery stories, breastfeeding support, and postpartum discussion -14 participants
• December 13, 2021: Mama’s Mental Health Matters Too (Facebook Live Event) - Reached 406
• December 16, 2021: Coping with Holiday Stress & Anxiety Parenting Seminar -Zoom - 40 participants  
• January 25, 2022: Training on Health Equity in Reproductive Health - 20 participants
• January 27, 2022: Supporting COVID-Positive Pregnant and Parent People - 296 participants 
• February 2, 2022: Educational session - 10 participants 
• February 9, 2022: Maternal Health & Medicaid Expansion- Jackson MS Alumnae Chapter of Delta Sigma Theta -356 views
• February 17, 2022: Breastfeeding Excellence Conference-Jackson State University - 78 participants
• February 22, 2022: NICHQ presentation about shared decision making for Black mothers - 80 participants 
• March 5, 2022: Educational and training workshop for doulas -12 participants 
• March 31, 2022: Nutrition education for mothers and expecting mothers -5 participants 

 

During this reporting period the following promotional and educational items were developed by Six Dimensions in part using support from MS MMRC subawards. 

• Pregnancy Journal
• Actions Steps Visual  
• Let’s Talk Motherhood Graphic Recording Part 1
• Let’s Talk Motherhood Graphic Recording Part 2
• Laboring with Hope Screening & Discussion Graphic Recording 

The pregnancy journal and the Actions Steps Visual are specific products that were developed to address the needs of mothers, based on their feedback. 

 

During the reporting period, MIHB renewed a contract with Mom.ME, a non-profit community-based organization to provide maternal support services to pregnant and postpartum women.  Mom.ME provided the following eCalsses and workshops during this reporting period. 

• October 30, 2021: OctoberFest Community Health Fair - 105 participants 
• January 13, 2022: Car Seat Safety Class - 8 participants 
• January 19, 2022: Labor & Delivery Class - 8 participants
• February 23, 2022: Promising Partnerships to Address Maternal Mortality Webinar (presented on HRSA Region IV webinar)
• April 14, 2022 – “Building for Liberation Centering Black Mamas, Black Families, and Black Systems of Care” Black Maternal Health Conference – 24 participants
• October 1, 2022 – “The Art of Storytelling” – partnership with the Aerial View

 

Mom.ME also conducted peer mentor trainings for mothers wanting to take an active role in offering support to women enrolled in the Mom.ME. Cares pilot program. Peer mentors are recruited and identified through outreach and participation in the Mom.ME Cares program. Two peer mentor training courses were conducted during the reporting period. Five women were trained on how to answer the Mom.ME Peer Support phone line that is available 24 hours. The warm line offers individuals an opportunity to talk to someone who truly understands their struggles. Participants were trained on how to keep all calls confidential unless given permission to disclose information to Mom.ME staff, actively listen to the callers, be empathetic of their issues, empower the individuals, and how to share their story and journey to help encourage them on their path to wellness and recovery. On February 19, 2022, an additional training was hosted to discuss how to communicate with mothers enrolled in the Mom.ME Cares program, identify when a mother is in crisis, and processes for scheduling meetups with mothers and families. Four women received this training.  Mom. ME also sponsored a professional training that was facilitated by Postpartum Support International (PSI) on Perinatal Mood Disorders: Components of Care. The training was held on June 8-9, 2022. The two-day course provided guidance and assisted individuals with building skills to assess and treat perinatal mood disorders.  Additionally, Mom.ME staff and volunteers have participated in a variety of trainings to continually improve and provide appropriately tailored services to pregnant and postpartum women. During the reporting period, Mom.ME staff and volunteers have participated in the following trainings: 

• October 2-3, 2021: Champions for Change Summit hosted by the Voices and Preeclampsia Foundation 

• October 6, 2021: Lactation Conference 
• October 26, 2021: Mother-Infant Attachment: Promoting Connections in the Perinatal Period 
• February 21, 2022: A Maternal Mental Health Crisis: PMADs in the Pandemic Seminar

 

Cohort Two started October 1, 2021. At the end of this project period, Mom.ME Cares has received 35 referrals from medical providers and successfully enrolled 11 women in the program. As of March 2022, 15 support group meetings had been held with 8-10 mothers attending each session. 

 

During the reporting period, Mom.ME also expanded its reach in partnering with Plan A Health and the Diaper Bank of the Delta to provide community-based mobile and mental health screenings, postpartum care, baby weight and length measurements, and tangible high-need items at “birth2baby” events. These events were held on:

• May 13, 2022 – West Point, MS

 

Mom.ME hired a web designer to assist with rebranding the website. The redesign made the website more user friendly and a one-stop shop for pregnant and postpartum women setting assistance. The website went live May 21, 2021, with an integrated referral system for any provider, community worker, etc. to refer women to Mom.ME Cares program, support groups, and workshops.   Rebranding and redesign incorporated a referral system for providers, community, etc. to refer women to Mom.ME Cares program and other services.  Mom.ME worked with its web designer throughout the reporting period on a provider directory that will showcase practitioners referring to the Mom.ME Cares program. This update is anticipated to be completed and added to the website by June 2022. Further, Mom.ME. hired a production company to develop a video to bring awareness to Perinatal Mood Disorders.  In efforts to appropriately capture the lived experiences of women, those participating in the Mom.ME Cares pilot program were encouraged to share their story and how they benefitted from the program. Six women agreed to participate in the development of the video, however, only two of the six stories were utilized due to the narrative and length of time.  Mom.ME edited the video to make a PSA to share across social media platforms and other media outlets to raise awareness about maternal mental health. Mom.ME also released the PSA on television as a commercial. The PSA aired for 45 days within a 50-mile radius of Jackson, MS. 

 

Objective: By March 2022, Title X clinics will increase the number of family planning and preventive health services users by 5.35% (37,000 users) from baseline of 35,120 users CY 2019.

 

Objective: By March 31, 2022, the Family Planning Program will establish formal partnerships with at least 20 community-based and faith-based organizations to increase utilization of family planning services.

 

Strategy: Collaborate with MSDH regional staff to develop promotional strategies to increase family planning users.

 

Strategy: Collaborate with partners to provide reproductive health training to the community.

 

Activities: During the Title X project grant period (April 1, 2019 – March 31, 2022), MSDH served as the sole Title X grantee in Mississippi. During that timeframe, MSDH contracted with Federally Qualified Health Centers (FQHCs), also known as delegate agencies to increase community awareness of access to the MSDH Family Planning program services offered. The delegate agencies included Aaron E. Henry Community Health Centers (5 sites), G. A. Carmichael Health Centers (3 sites), Northeast Mississippi Health Care Centers (3 sites), Family Health Care (5 sites), Jackson State University, Jackson Hinds Comprehensive Health Centers, Open Arms Healthcare Center, Dr. Arenia C. Mallory Healthcare, Southeast Mississippi Rural Health Inc, East Central Mississippi Healthnet and University of MS Medical Center. At the local level, community partners are more likely to be a referral source or provide in-kind or low-cost services to family planning patients in need. The contract with delegate agencies ended when the MSDH Family Program was no longer a Title X grantee and entered in the No-Cost Extension cycle which began on April 1, 2022, and ended March 31, 2023.

 

Title X family planning program provided services to:

• 35, 120 unduplicated users from 01/2019 – 12/2019
• 30,891 unduplicated users from 01/2020 – 12/2020
• 13,623 unduplicated users from 01/2021 – 12/2021
• 20,839 unduplicated users from 01/2022 – 12/2022

 

These reported data show a decrease in users for 2020, 2021 and 2022 from 2019 due to COVID-19 and changes in clinical operations for MSDH and Title X delegates.

 

During the reporting period and through March 2022, efforts were made to involve additional FQHC clinic sites as 20 delegate agencies. The Title X program manager, responsible primarily for work with delegates agencies, developed an efficient process to monitor FQHC quarterly reports to ensure compliance. The program Nurse consultant continued to provide clinical staff technical assistance on proper documentation needed for family planning visits in EPIC. Program staff met with the Office of Communicable Disease, which includes the STD/HIV program to ensure that Title X patients received Family Planning Waiver information and condoms funded by the Title X services.

 

Telehealth has a great potential for expansion of access to Family Planning services, particularly in areas that are more likely to experience reproductive health disparities. Conditions under COVID-19 provided an added incentive to introduce telehealth as an alternative healthcare solution. In March 2020, MSDH initiated the COVD-19 Guidance for patient care. This included screening via telephone for the corona virus, then assessing family planning needs, offering either a scheduled face to face appointment or providing immediate delivery of birth control supplies via curb side (in parked car). The COVD-19 Guidance for patient care continued to be used at MSDH county health departments. Telehealth protocols were developed specifically for Family Planning to include both MSDH health departments and Delegate Agency Health Clinics. Several Telehealth meetings were conducted in the process to get the Family Planning program onboarded with MSDH’s EHR, EPIC. The program worked with the EHR to develop a telehealth tool within the EHR to identify program’s telehealth visits.

 

Family Planning continued to collaborate with STD/HIV services by providing Family Planning Waiver materials and condoms as requested by that program. Continuous efforts were made to ensure the integration of literacy, age appropriate and cultural/ linguistic materials are included in all preconception health messages and outreach activities. Educational materials were translated into other languages and disseminated to each county health department and Title X delegate agencies to provide clinicians with tools to better educate the clients served.

 

MSDH continued to train MCH/FP Coordinators to ensure the understanding of preconception health care and how to best emphasize the benefits of family planning services throughout the life span of the client. Every client (female and male) of reproductive age received education and counseling around preconception and inter-conception care along with information about all forms of contraception that is consistent with their reproductive life plan and risk of pregnancy. The orientation process for new clinic staff is managed at the district/regional clinic levels. The program staff provided technical assistance to ensure clinic staff receive appropriate annual updates. MSDH Family Planning staff attended monthly program meetings. Each meeting included education and information on various Title project program topics, updates, and staff training, allowing staff to stay up to date on program and professional information and changes as needed.  The Family Planning program continued to partner with local non-profit organizations and FQHCs to expand family planning services across the state.

 

The MSDH Title X FP program ended on March 31, 2023. The program continued to operate under No Cost Extension (NCE) funds from April 1, 2022, to March 31, 2023. Under the NCE funds, the program continued to provide family planning services to all MSDH Title X clients and work on improving the overall management and administration of the Family Planning program. Areas of improvement included improving administrative functions, fiscal oversight and responsibility, contraceptive access, high quality family planning services and increasing collaborations and partnerships.  As the NCE period has closed, MSDH continues exploring possibilities and opportunities to partner with Converge, the current Title X grantee for Mississippi since April 1, 2022. This includes supporting patients who need the enhanced services and protections offered under Title X to gain access to provide within Converge network. Further, MSDH clinics have been aggressively implementing a statewide project known as “Operation Going Gold” since August 2022. Under this project, MSDH clinic staff have been trained in the most efficient and effective processes to support patients in applying for the Family Planning Waiver. Since August 2022, all MSDH clinics have provided patients with direct, one-on-one assistance to make application for the waiver, and have provided intentional patient-level follow-up, reminders, calls, etc. to assure patients are linked and enrolled in this important resource to allow them to continue receiving family planning services at no out-of-pocket cost to them.

 

PRIORITY: Oral Health

 

NPMs, NOMs, SPM, and ESMs:

• NPM 13.1 - Percent of women who had a preventive dental visit during pregnancy
• NOM 14 - Percent of children, ages 1 through 17, who have decayed teeth or cavities in the past year
• NOM 19 - Percent of children, ages 0 through 17, in excellent or very good health NOM 17.2 - Percent of children with special health care needs (CSHCN), ages 0 through 17, who receive care in a well-functioning system 
• ESM 13.1.1 - Number of pregnant and postpartum women who received oral health education

 

Objective: By September 30th, 2022, increase the number of pregnant women who have a dental visit during pregnancy from 29.5% to 45% (by 10.5%).

 

Strategy: The MSDH's Offices of Oral Health and WIC will collaborate to offer oral health education to WIC participants by Regional Oral Health Consultants (ROHCs).

 

Activities: The Office of Oral Health worked with the WIC team to ensure harmony in maintaining the oral health services currently being offered. During the grant reporting period, our office provided oral health services to several WIC sites throughout Mississippi as well as hygiene kits, finger brushes, training brushes, and brochures in both English and Spanish. The Office participated in routine WIC regional meetings to update WIC team members on program updates. Additionally, throughout this reporting period, ROHCs participated in quarterly WIC nutritionist meetings to share program updates and trouble shoot any region specific challenges. In September 2022, the Program Director also shared updates with the WIC team, including staffing updates of ROHCs and the new referral system in SPIRIT and REDCAP provided through their team.

 

Additionally, since this reporting period, we have updated the documentation tools in the WIC SPIRIT portal to allow the WIC nutritionist or clerk to identify if the participant received oral health education or if a hygiene kit was disseminated. This was needed with the extended virtual certification of WIC participants. These new tools and data from them will be shared in the next annual report.

 

 

 

Strategy: Provide oral health education to expectant mothers on the importance of proper oral health during pregnancy and postpartum.

 

Activities: Over this reporting period, Oral Health personnel continued to amplify messages on the safety and importance of seeing a dentist during pregnancy. In working with our WIC participants, Healthy Moms-Healthy Babies program, community baby showers hosted by faith-based entities and local insurance carriers, we provided oral health education to 1186 expectant mothers and/or those who were post-partum.  We utilized educational materials from the Healthy Smiles from the Start, Dental Care Tips for Mom and Baby brochure launched by the Alliance of the American Dental Association, American Dental Association and the Henry Schein Cares program.  Additional resources shared were those from the National Maternal and Child Oral Health Resource Center.  With these educational materials, each mother was given toothbrush aids for herself (toothbrush, floss and toothpaste) and age-appropriate toothbrush aids for infants and toddlers (finger brushes/scissor brushes or teething ring toothbrushes).

 

Strategy: Provide regionally specific dental referral names and phone numbers to expectant mothers of dentists in the community where they can schedule routine exams and dental procedures during and after pregnancy

 

Activities: While our agency does not provide direct dental services at local county health departments, we have dental hygienists with the office of oral health located throughout the state to assist with our oral health promotion, oral disease prevention, dental care coordination and oral surveillance efforts over a lifespan.  During this reporting period, the program director shared updates to the regional oral health consultant map (which details the counties each ROHC serves) and introduced our dental care coordination process to maternal child health staff throughout the state (at several meetings). Generally, the regional oral health consultants do not have access to the patients seen in the various departments and are not apart of the electronic health record, EPIC, where this information can be captured.  As such, we rely heavily on internal and external team members to share this information with our dental care coordinator or local ROHC for follow up with the patients.  We are waiting for oral health questions and assessments to be rolled out through all agency programs by way of EPIC; however, we are unsure of when this will take place.  In the interim, an excel spreadsheet is utilized to capture dental referrals (internally and externally) and document outcome of the follow up with the patients.  The below graphs depict this process:

 

Strategy: Work with Physician Assistants (PA’s) to provide screenings, varnish, and develop a systematic referral system to ensure dental visits for preventive care.

 

Activities: Physician Assistants have been one of three non-dental provider types (nurse practitioners, medical webdoctors) we have worked to recruit for our Cavity Free in Mississippi program where we train providers on the importance of oral health assessments and fluoride varnish application in medical settings.  As an incentive, these provider groups received additional reimbursement from Medicaid for the oral assessment and fluoride varnish application on children 0-3, if they are not reimbursed based on an encounter rate.  While we have had some difficulty recruiting physician assistants, we have worked with medical doctors and nurse practitioners to train on the Cavity Free in Mississippi program.  During the grant reporting period, Cavity Free in Mississippi trainings and supplies were provided in Smith County and Wayne County at Family Health Center of Laurel (15), in Wayne County at Waynesboro Family Medicine (5) in Jones County at Calhoun Medical Clinic (3) in Clarke County at Deloach Family Clinic (1), in Bolivar County at Healthy Living Medical Center LLC (3), in Clay County at West Point Children Clinic (6) in Harrison County at Lighthouse Pediatrics, in Franklin County at Caring Hands Children’s Clinic-Meadville, in Lawrence County at Caring Hands Children Clinic-Monticello, in Lincoln County at Milestones Pediatric Clinic, in Simpson County at Pedz Clinic, and Hancock County at Children’s International Pediatrics A total of fifty-four54 medical providers and staff were trained, representing twelve counties.

 

Additionally, medical providers received fifty (50) .25 gram of 5% sodium fluoride varnish, educational pamphlets on fluoride varnish, and a list of dental suppliers and products. During the grant reporting period, at least two thousand and seven hundred (2, 700) .25 grams of 5% sodium fluoride varnish were provided to non-dental providers implement this program in their clinics.

 

Also, as a part of our provider recruitment efforts, folders were created and provided to non-dental providers. These folders included a flyer about the program, a letter from the program director sharing the importance of oral health assessment and fluoride varnish in the medical home, a white paper on fluoride varnish in the primary care setting by the American Academy of Pediatrics, and billing information. We hope to gain more data from the providers going forward on implementation efforts and impact.

 

Strategy: Monitor provider patient utilization to track Fluoride varnish, utilization, provider participation, number of referrals, and number of follow-up care to dental homes.

 

Activities: One of our strategies towards increasing the number of children receiving oral health assessments and fluoride varnish in a primary care setting was to increase the number of persons trained on our Cavity Free in Mississippi Curriculum.  As part of this collaboration, we evaluated the training tool, documents associated and created an evaluation tool to follow up with the trainers of the curriculum for feedback and monitoring of program implementation.  We also incorporated a cold call tracker log where Regional Oral Health Consultants document when they reach out to a provider (office) and what feedback they receive.  Ultimately, we were testing whether updates to the training log and training tools would provide ease of documentation and tracking with follow up by the ROHCs to providers who participated in the training.  Increasing follow up was hoped to generate more opportunities to assist providers with challenges of implementing the process to perform the oral assessment and fluoride varnish.

 

The Office of Oral Health hopes to utilize this centralized tool to follow up with providers over time to better address their training needs and implementation progress of the oral health assessment and fluoride varnish application in their healthcare system.

 

As part of the Advancing Prevention and Reducing Childhood Caries initiative we participated in, teams were given training on oral health drivers and change ideas that could further our efforts:

Our Aim Statement for this project was:  By December 31, 2022, the Magnolia state will increase fluoride varnish applications by non-dental providers for Medicaid and CHIP beneficiaries ages 1-5 to 18, 128 by assisting non dental providers in primary care settings with incorporating an oral health assessment and fluoride varnish application during EPDST screenings.

 

We utilized this framework and learned the following lessons from PDSAs of our training process and tools:

(1) A change in the Cavity Free in Mississippi Training Tracker log that provided a tab per ROHC as opposed to all ROHC entries being on one spreadsheet, was helpful to the ROHC team in keeping up and inputting their information about non dental provider recruitment efforts.

(2) Some recommendations were made regarding the training itself and it was updated to reflect provider and ROHC feedback.

(3) The Cavity Free in Mississippi flyer and medical provider application was reviewed by our pediatric consultant. 

(4) A cold call log was created and used by ROHCs to document follow up with non-dental providers in their counties of coverage.

(5) Providers trained don’t often report back on data of those trained, so we will be updating the medical provider application which asks for preliminary office demographic data.  The staff will be trained in its use.  Our dental director drafted a letter to send to each provider and these are used with other information in recruitment efforts.

 

We now have a better system to monitor which providers not only had the training but those who have implemented it.  We continue to have some challenges with retrieving data back from those providers trained on the number of constituents benefiting from the program.  We are exploring ways to enhance these efforts.

 

Strategy: Build connections and strengthen opportunities with state programs, dental schools, dental hygiene programs, private practice and community-based organizations

 

Activities: Our office continues to build relations throughout the state with various stakeholders to strengthen our work in the community we serve. We received notification from the National Maternal and Child Oral Health Resource Center that our state oral health program was selected to participate in the Integrating Oral Health Care and Primary Care Learning Collaborative:  A State and Local Partnership. In this collaborative, The Office of Oral Health has been working to better integrate the interprofessional oral health core clinical competencies within a local community health center who provides prenatal care to its patients (G A Carmichael Family Health Center). May 2022, we begin working with GA Carmichael Family Health Center. The purpose of this collaboration is to expand access to integrated preventive oral health care for the maternal and child health population by providing high quality oral health technical assistance, training, and resources.  Mississippi is one of 9 states participating in this learning collaborative. As a framework, we are utilizing the Interprofessional Oral Health Core Clinical Domains:  Risk assessment, oral health evaluation, preventive interventions, communication, and education and interprofessional collaborative practices as defined in the US Department of Health and Human Services, Health Resources and Services Administration, Feb 2014 white paper “Integration of Oral Health and Primary Care Practice”.

 

Project measures are:

 

Domain 1:  Risk Assessment

• Percentage of pregnant women who received an oral health risk assessment during a first or second trimester visit by a primary care team member.

 

Domain 2: Oral Health Evaluation

• Percentage of pregnant women who received an oral health screening during a first and/or second trimester visit by a primary care team member.

 

Domain 3: Preventive Intervention

• Percentage of pregnant women who received a fluoride varnish application during pregnancy by a primary care team member.

 

Domain 4: Communication and Education

• Percentage of pregnant women who received oral health education during pregnancy by a primary care team member.

 

Domain 5: Interprofessional Collaborative Practice

• Percentage of pregnant women who received a dental referral during a first and/or second trimester by a primary care team member.
• Percentage of pregnant women who received a dental referral for urgent needs during a first and/or second trimester visit by a primary care team.
• Number of pregnant women who received a documented dental referral who had an initial oral health visit during the month.
• Number of pregnant women who received a documented dental referral for urgent needs who head an initial oral health visit during the month.

 

We are monthly tracking GA Carmichael’s progress having created oral health assessment tools, identified oral health education to disseminate and refining a process of referral form the OB/GYN team to the dental.

 

This is just one example of how our work at the local and state with GA Carmicheal to improve systems of care for the integration of oral health with the OB/GYN department is impactful to the community in reducing oral health disparities and championing the need for comprehensive dental benefits for all ages.

 

Strategy: Increase oral health awareness by distributing educational materials geared towards public and health professionals.

 

Activities: In January of 2022 we expanded our work with the Office of Preventive Health to assist with their efforts in the GO NAPSACC and MS Better Together Program. We have maintained rich relationships with the MS Head start Association and other private daycare centers in the state for decades. Go NAPSACC's provider tools guide childcare providers through 5 simple steps to make healthy changes to their programs. These steps include Assess, Plan, Take Action, Learn More, Keep it Up.

 

The model focuses on seven easy to use modules that address topics that are essential to the health of young children:

• Child Nutrition
• Breastfeeding and Infant Feeding
• Farm to ECE
• Oral Health
• Infant and Child Physical Activity
• Outdoor Play and Learning
• Screen Time

 

During this reporting period, Regional Oral Health Consultants completed the training to provide technical assistance to centers who do not have policies in place at their facilities regarding oral health inclusion and best practices.  We have distributed information about this program at conferences with Head start and Daycare centers, community events and the like.

 

Additionally, during this reporting period, we attended conferences like the 35th Community Health Association of Mississippi where we participated as a vendor and our program director presented on Dental Provider Roles in Providing Vaccination and Social Assessment Use in Dental Clinic Settings.

 

Similarly, our ROHCs participated in numerous meetings, health fairs and community outreach opportunities where they shared literature on the importance of oral health to overall health and well-being. Some topics highlighted included:  the benefits of community water fluoridation; oral health and diabetes, oral health and cardiovascular disease, oral health and aging, oral health and pregnancy, and oral health and substance abuse and misuse (opioids and vaping).