Perinatal and Infant Health – State Priority #2: Reduce infant mortality and morbidity.
Addressing factors that lead to infant mortality continues to be at the forefront of all NYS's maternal and child health initiatives. Overall, infant and neonatal mortality rates are declining in NYS and are below the Healthy People (HP) 2020 thresholds. NYS’s infant mortality rate was 4.5 per 1,000 live births in 2016, compared with 4.6 per 1,000 births in 2015. The number of infant deaths was 1,045 in 2016, 314 fewer than in 2008. From 2008 to 2016, the infant mortality rate declined 9% for non-Hispanic Whites to 3.45 per 1,000 live births; 28% for non-Hispanic Blacks to 7.85 per 1,000 live births; and 3% for Hispanics to 3.6 per 1,000 live births. Non-Hispanic Asian and Pacific Islanders had the lowest rate in 2016 at 2.87 per 1,000 live births, representing a 13% decrease since 2002 for this group. From 2008 to 2016, the neonatal mortality rate declined by 19% to 3.0 per 1,000 live births, while the post-neonatal mortality rate declined 17% to 1.5 per 1,000 live births.
Despite improvements, striking disparities exist. The ratio of non-Hispanic Black-to-White low birth weight rates was 1.9 in 2016, unchanged from 2015. In 2016, the mortality rate for early term infants (37-38 weeks gestation) was nearly twice the rate of full-term infants (39-40 weeks gestation): 2.32 and 1.31 per 1,000 live births, respectively. The three leading causes of infant death in 2016 were prematurity, congenital malformation, and sudden unexpected infant death (SUID). The NYS Title V program is leading statewide efforts with key stakeholders, agencies, partners, and providers to reduce infant deaths and decrease economic and racial/ethnic disparities in infant mortality rates across NY. Through a variety of focused and collective evidence-based interventions, the NYS Title V program is improving the ability of parents/caregivers to raise healthy infants through several strategies. This State Priority is measured through NOM #8 Perinatal mortality rate per 1,000 live births plus fetal deaths. NYS is below the national average at 5.2 per 1,000 live births vs. 6.0 nationally in 2015. NYS is better than the national average based on National Vital Statistics Data for NOM #9.1 Infant mortality rate per 1,000 live births at 4.5 vs. 5.9 in 2015. NYS is also lower than the national average for NOM #9.2 Neonatal mortality rate per 1,000 live births (3.20 vs. 3.88) and NOM #9.3 Post-neonatal mortality rate per 1,000 live births (1.7 vs. 2).and NOM #9.4 Preterm-related mortality rate per 100,000 live births (175.9 vs. 200).
In order to address priorities such as infant mortality on a state, regional or local level, it is imperative to access comprehensive data for identification, implementation and evaluation of public health initiatives. The NYS Title V program developed and implemented an expanded plan for analysis and reporting of infant mortality and selected morbidity data. The New York State Infant Mortality Report, highlighting collaborations and describing trends in NYS’s infant mortality rates between 2002 and 2016, the NYSDOH’s plan to reduce infant mortality was developed and placed in the review and approval process. Additional multivariate analysis was requested prior to final approval and release of the report; this additional analysis is underway.
To monitor progress of improving the health of women, infants, and children and reducing health disparities, Title V staff previously collaborated with the NYSDOH Office of Public Health Practice to develop the Maternal and Child Health (MCH) dashboard that is comprised of National Performance and Outcome Measures as well as State Performance Measures and Objectives. The MCH Dashboard, which was described in the previous annual report) includes 41 unique measures related to NYS Title V application. This dashboard was released in September 2018 and continues to be maintained. The dashboard serves as an interactive visual presentation of available national, state and county data (where available) that can be used by a wide group of public and private partners to identify trends and issues and develop strategies for improvement. The most current data are compared to previous year data to monitor performance. The dashboard integrates data from multiple sources, includes State and county-level, socio-economic, race/ethnicity and historic data. The measures are presented visually as trend graphs, bar charts, maps and tables, and compare change over time and as related to 2020 MCH objectives.
An important factor in improving birth outcomes and reducing infant morbidity and mortality is ensuring access to comprehensive prenatal care. NYS has long supported access to comprehensive prenatal care for all women. Title V staff continued its collaborative efforts with the NYSDOH Office of Health Insurance Programs (OHIP) to ensure quality prenatal care services are available to NY’s Medicaid (MA) population. Services are available to women up to 223% of the Federal poverty level (FPL) and undocumented women, using State only funding. Supports are also provided to women to promote healthy behaviors and foster infant development.
The NYS Title V program is home to the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) initiative that strives to improve the health and well-being of high-risk families and reduce racial/ethnic disparities through 19 evidence-based home visiting programs including eight Nurse-Family Partnership (NFP) and 11 Healthy Families New York (HFNY) in ten high-risk counties. NY MIECHV grantees provided services to 3,060 families in the FY19 (10/1/2018 to 9/30/2019) reporting period. The NYS Office of Child and Family Services (OCFS) receives MIECHV funding through a Memorandum of Understanding (MOU) with the NYSDOH to fund Healthy Families programs. At the start of FY19, on 10/1/18, two Nurse-Family Partnership programs (Public Health Solutions in Queens and Catholic Health Services in Erie) began receiving MIECHV funds as a result of a re-procurement of the State and MIECHV funded Nurse-Family Partnership programs.
The following items are data on the four constructs within the Maternal and Newborn Health Benchmark related to newborn health.
- 11.5% of infants, born during the reporting period, were born preterm
- 42% of infants, with mothers enrolled prenatally, were breastfeeding at six months of age
- 65% of infants received the last recommended well-child visit during the reporting period
- 38.5% of primary caregivers who reported using tobacco or cigarettes at enrollment were referred to tobacco cessation counseling or services within three months of enrollment.
HRSA requires an 85% filled capacity rate for MIECHV programs. To facilitate increasing referrals into MIECHV programs, MIECHV staff developed a media campaign that ran in the counties that have a MIECHV-funded home visiting program. The campaign pointed pregnant and parenting women and families to the new NYSDOH home visiting webpage. NYSDOH contracted with the company OverIt from Albany, NY to conduct focus groups to help develop these messages by understanding the best terminology, imaging, and messaging for use with families to encourage acceptance of home visiting services. Focus groups were conducted in five MIECHV counties (Erie, Bronx, Schenectady, Chemung, and Nassau) across NYS with women ages 18-35 and matched the demographics of the county it was conducted in. During the focus groups, most of the participants commented that the photos used in the mock-ups were overused. In order to get new photos to use in the advertisements, the MIECHV team worked with OpAd to hold a photo shoot with several models to play the part of mom, dad, home visitor, and infant. Using the feedback from the focus groups and the photos from the photo shoot, the NYSDOH’s Public Affairs Group developed advertisements to use in the media campaign that encouraged pregnant and parenting families to visit the NYSDOH home visiting web pages. The web pages contain a searchable chart that assists families to locate evidence-based home visiting programs in their community. The searchable chart on the NYSDOH website is at https://www.health.ny.gov/ParentingSupport. Title V staff presented on these findings at the third annual NYC Home Visiting Summit in October of 2018.
Recognizing the need to promote systems change on the local level to improve communitywide MCH outcomes, the Title V program has continued to fund 23 Maternal and Infant Community Heath Collaboratives (MICHC) projects in 32 NY counties, extending their service contracts through September 2020. The MICHC initiative seeks to improve maternal and infant health outcomes for high need, low income or Medicaid-eligible women and their families by supporting the development of multi-dimensional community systems of integrated and coordinated community health programs and services. MICHCs work to improve preconception, prenatal, postpartum, and interconception health of Medicaid-eligible women by working collaboratively with community partners to implement strategies to: find and engage Medicaid-eligible women and their families in health insurance, health care and other community services; assess a woman’s needs and risk factors and make referrals to appropriate services; coordinate services across community programs; and promote opportunities and supports for women to engage in healthy behaviors. MICHCs utilize Community Health Workers (CHWs) to assist Medicaid-eligible women of reproductive age to effectively access continuous and coordinated health care and other needed community services responsive to their needs and risk factors. On a systems level, MICHC providers work with community partners in the health and social services arena to assess resources, prioritize community needs and strengths, and implement community-level strategies to address the needs identified. In project year 2018-2019, the MICHC program served 3,582 prenatal and postpartum women and their families.
The following outcomes were achieved:
- 79.7% of postpartum clients engaged prenatal care during the 1st trimester.
- 39.9% of clients attended a postpartum visit, with an additional 44.7% having a scheduled appointment.
- 2,119 babies were born to MICHC clients in 2019, of which 10.3% were born preterm (new indicator).
- 81.6% of postpartum clients initiated breastfeeding.
- 67% of clients referred for smoking cessation programs completed the referral.
- 67% of clients referred to family planning were completed.
- 68% of referrals for child primary care were completed.
Expanding access to CHW services was a top recommendation made by Governor Cuomo’s Taskforce on Maternal Mortality and Disparate Racial Outcomes and was a common suggestion for addressing maternal mortality made by women participating in the NYSDOH Maternal Mortality Listening Sessions conducted in Summer, 2018. CHW expansion has been implemented through the MICHC program with funding from the Governor’s maternal mortality initiative to support approximately 50 new CHWs to provide services to an additional 2,000 high-need pregnant and postpartum women and families. In addition to outreach, referral and home visiting services, CHWs also provide childbirth education and support, promote collaborative childcare and social support networks, assist with the development of birth plans and support increased health literacy.
Improving birth outcomes requires greater coordination of referrals and services on the local level. Stakeholders, including pediatricians and home visiting grantees expressed some concerns and confusion about where to enroll women into home visiting, when different home visiting programs are operating in close proximity. In addition, the length of enrollment as well as the number of home visits otherwise known as “dosage” has an impact on outcomes. It is important to match families to home visiting programs that can best meet their needs to maximize the family’s ability to stay to dosage and so communities can use all the home visiting programs available. To facilitate better collaboration and efficiency, Title V and MIECHV staff have been providing training and technical assistance on developing a coordinated intake and referral system for home visiting. MICHC contractors are serving as the lead agency for the pilot, which began with the first cohort in January 2017 and second cohort in January 2018. Four community teams were in the first cohort and five started in the second cohort. More teams recently joined to bring the second cohort to 10.
Title V and MIECHV staff provided tools and guidance to the community teams including monthly coaching calls. The calls covered topics including stages of team development, systems mapping, team charters, creating a decision tree, coordinated outreach, common referral forms, developing an outreach plan, data collection, and team building. In addition to the group coaching calls, teams received individual calls for focused technical assistance and review of materials and tools they produced.
Addressing a public health issue such as infant mortality requires coordination of all available resources to address the complex factors leading to infant deaths. MICHC initiatives are located in areas of NYS also served by federal Healthy Start (HS) grantees, namely in Queens, Brooklyn, Staten Island, Harlem, Bronx, and Syracuse; four of the six NY HS grantees are also MICHC grantees. Title V staff meet quarterly with the HS grantees to discuss communication, collaboration, and coordination between the HS, MIECHV, and MICHC programs to maximize existing resources and improve community infrastructure. The calls increased involvement of the HS grantees in NYSDOH initiatives, for example Medicaid’s First 1000 Days and the Infant Mortality Collaborative Improvement and Innovation Network (CoIIN). They also help Title V staff connect local grantees to local HS efforts, such as the coordinated intake project that the Brooklyn HS program is developing.
The NYS Title V program continues to enhance local systems building efforts through training, technical assistance, data collection and analysis, and quality improvement for NYS Title V funded community-based perinatal and infant programs. Quarterly calls continued and included topics such as maternal depression, annual data reports, collaborative outreach, and improving referrals.
For the MIECHV continuous quality improvement (CQI) cycle from October 1, 2018 to September 30, 2019, efforts on breastfeeding duration and improving referrals into the home visiting program were continued. All MIECHV funded sites participated in these improvement activities through September 2019. These topics were chosen by the MIECHV funded sites through surveys. Additionally, these topic areas closely align with the MIECHV state and federal priorities. The focus on referrals into the program was to increase enrollment into programs. The focus on breastfeeding duration was to increase the proportion of infants being breastfeed at six months. To help reduce burden, the sites selected their own data collection tools, with assistance if desired, and the strategies. In 2018, NYSDOH developed a framework for CQI activities and reviewed CQI fundamentals with the goal of building competencies of hove visiting staff. Based on lessons learned in the previous cycle, MIECHV staff began working with sites to create process maps and team charters for their respective projects. In 2019, MIECHV staff supported local implementing agencies (LIAs) as they implemented plan-do-study-act (PDSA) cycles, which are iterative, small tests of changes and review of data to inform actions. Data were collected and reviewed quarterly on coaching calls. Sites created a final report of their project at the close of 2019.
The goals of the Pathways to Success initiative, funded by the federal Office of Population Affairs beginning July 1, 2017 through June 30, 2020, are to strengthen community systems serving pregnant and parenting teens and young adults; improve the health, development, and well-being of young parents and their children; improve young parents’ self-sufficiency through educational attainment; and increase awareness of resources available to expectant and parenting teens and young adults. The initiative is focused in New York City based on 2015 NYS Vital Statistics data showing Kings, Bronx and Queens counties with the highest birth rates among females who were between the ages of 15 and 24.
The Pathways to Success grant supports three community colleges (Hostos, LaGuardia and Borough of Manhattan) and a community-based organization (Public Health Solutions) to develop, expand and sustain supportive communities to help expectant and parenting teens/young adults maintain their health and meet educational or vocational goals. The funded projects collaborate with Title V programs such as MICHC and MIECHV for home visiting supports, and other programs to strengthen support networks and referral systems for pregnant and parenting teens and young adults in these communities.
Pathways to Success utilizes an Asset and Risk Assessment Tool that assesses the student’s financial, social, and educational support, as well as mental health, employment status, housing, food, clothing, health care, transportation, parenting skills, and touches upon developmental assets in all eight categories. All students and community members enrolled in the initiative receive healthcare referrals for prenatal, interconception, and postpartum care, social service referrals to the Special Supplemental Nutrition Program for Women, Infants and Children’s program (WIC); local Department of Social Services (DSS); and educational or vocational supports to better ensure academic/career success. The goals of this program align with the Title V priorities including support and enhance adolescent social-emotional development and relationships, increase use of primary and preventive health care services, early identification and support for children’s special health care needs, and promote supports and opportunities that foster healthy and safe home and community environment.
From July 1, 2018 to June 30, 2019, the program served 737 expectant and parenting students or community members, developed 190 new partnerships, and made 817 referrals. The most frequently cited needs of the program participants were help obtaining information, resources, or services for emotional or parenting support; peer-to-peer education; community support; academic advisement; scholarships for single parents; vocational opportunities or employment services; and help with other daily living needs such as housing, transportation, childcare, supplies for their children, and food.
Due to the changing landscape of the health care system as well as standards of perinatal care, the NYSDOH is fully supporting efforts to update perinatal hospital standards in NYS. The NYS Title V program has developed a process to update standards for perinatal regionalization in NYS, re-designate all obstetrical hospitals and birthing centers, and develop standard metrics to assess maternal and neonatal outcomes to identify opportunities for quality improvement. This work began in 2017 and is jointly led by the NYSDOH Office of Primary Care and Health Systems Management (OPCHSM), which is responsible for regulatory oversight of hospitals, and is being accomplished in close partnership with key partners including birthing hospitals, clinicians, hospital associations, professional organizations and other key stakeholders.
To ensure standards for the NYS system of regionalized care aligned with current standard of practice, Title V staff began this initiative by researching standards of care for perinatal levels of regionalized care as well as conducting an extensive review of research and literature for evidence-based and promising practice. An expert panel, co-chaired by the Executive Director of American College of Obstetricians and Gynecologists District II of New York (ACOG-NY) and the Associate Commissioner of NYSDOH at the Western Region Office, was then established that consisted of maternal fetal medicine specialists, obstetricians and nurses for RPCs, Level III and Level II perinatal hospitals across NYS. In addition, the panel consisted of representatives from the NYSDOH OHIP, NYS Association of Licensed Midwives, Healthcare Association of NYS, Greater NY Hospital Association, Community Healthcare Association of NYS, March of Dimes, NYS Academy of Family Physicians, NYS Nurses Association, and representatives from health plans and the NYS Department of Financial Services. To gain a national perspective, the panel also included a representative from the Association of Women’s Health, Obstetric and Neonatal Nurses and a representative from the ACOG Maternal Care Consensus Panel from the University of North Carolina.
Three meetings of the expert panel were held where the panel reviewed standards of care and made recommendations to the NYSDOH regarding standards of care for birthing centers, Level I, II, III perinatal hospitals and RPCs. The standards included recommendations for requirements and qualifications of clinical and ancillary staffing, facility requirements and equipment, and laboratory requirements among others. Subcommittees were formed to address several topics, including the role of the RPC, neonatal and maternal subspecialists requirements, behavioral health, patient transfers, volume and acuity standards, and finance. Recommendations have been finalized with subcommittee discussions to address final recommendations regarding subspecialists, volume and acuity standards and finance. In addition to receiving input from the expert panel, Title V staff held conference calls with lower level birthing hospitals from around the state to ensure their perspective is captured in the recommendations to the standards and in relation to the perinatal system.
The final meeting of the expert panel on May 10, 2018 was an opportunity to review and discuss the proposed recommendations made by the expert panel through the first two in-person meetings and the multiple subcommittees. In 2016, legislation was passed allowing midwifery-led birthing centers in NYS. Regulations related to midwifery-led birthing centers were adopted November 13, 2019. The new standards will include physician-led and midwifery-led birthing centers as the first level of care, followed by Level I through III hospitals, while RPCs represent the highest level of perinatal care. ESM PIH-2: Percentage of birthing hospitals re-designated with updated standards was established to evaluate this work. The goal of this important initiative is to strengthen the perinatal regionalized system in NYS to ensure all birthing centers and obstetrical hospitals in NY meet current standards of care, and are affiliated with a strong RPC, so that all pregnant and postpartum patients and newborns receive the best care possible at an appropriate level perinatal hospital.
To build on NYS’s rich system of perinatal care and aim to provide the best and safest care for pregnant and postpartum women and infants, Title V staff leads the New York State Perinatal Quality Collaborative (NYSPQC) initiative through collaboration with RPCs, RPC-affiliate birthing hospitals, perinatal care providers, community-based organizations, NYS hospital associations, the National Institute for Children’s Health Quality (NICHQ), and other key stakeholders. The initiative aims to prevent and minimize harm through the translation of evidence-based guidelines to clinical practice. During the reporting period, several initiatives under the scope of the NYSPQC have focused on reducing infant mortality and morbidity including the: New York State Infant Mortality CoIIN Community-based Safe Sleep Project, National Action Partnership to Promote Safe Sleep – Innovation and Improvement Network (NAPPSS-IIN), NYSPQC Enteral Nutrition Improvement Project, and NYS Opioid Use Disorder (OUD) in Pregnancy & Neonatal Abstinence Syndrome (NAS) Project.
NYS also administers a strong Newborn Bloodspot Screening program that collects, analyzes and reports on newborn specimens for 50 diseases and condition recommended by the American College of Medical Genetics and the March of Dimes. Follow-up is provided through condition specific Specialty Care Centers located throughout NYS with systems in place to better ensure early identification and proper treatment of these infants.
Under the HRSA-led national Infant Mortality CoIIN, the Title V program launched a new phase of the NYS Safe Sleep Infant Mortality CoIIN in July 2018, with a focus on community-based organizations (CBOs), to continue to reduce disparities in infant mortality through the promotion of infant safe sleep. Since October 2018, seven pilot sites, specifically MICHC and MIECHV grantees, have been participating in the project. The pilot sites are administering surveys to caregivers during the postpartum period, 30-60 days after their organization has provided the caregiver with safe sleep education. During the reporting period, the project held nine Coaching Call webinars. The webinar topics included breastfeeding and safe sleep, screening and referrals to tobacco cessation services, hazards associated with sitting and carrying devices for infants, recent safe sleep literature, and team learning and sharing regarding improvement activities. To support the pilot sites’ efforts, the Title V program provided Sleeping Safely Starter Kits, Sleep Baby Safe and Snug board books from the Charlie’s Kids Foundation, and safe infant sleep clothing (sleep sacks) to each participating pilot site in September 2019. In October 2018, the Title V program also provided sleep sacks and board books to all MICHCs and MIECHV grantees in NYS.
Additionally, Title V continued to increase awareness and collaboration for stakeholders on one of the leading causes of infant mortality in NY, Sudden Unexpected Infant Death (SUID). The NY Infant Mortality CoIIN develops key projects in partnership with the child welfare system including the NYS OCFS; NYS Office of Addiction Services and Supports (OASAS); the NYSDOH Division of Nutrition’s (DON); and Special Supplemental Nutritional Program for Women, Infants and Children (WIC) clinics. In May 2019, Governor Cuomo designated May as Infant Safe Sleep Month. During the reporting period, the Title V program has been working to implement the Governor’s directive that the NYSDOH and the NY OCFS continue their work on an infant safe sleep public awareness media campaign, expand outreach to medical providers, engage community-based organizations (CBOs) by promoting staff education tools, and distributing Safe Sleep Kits to 10,000 caregivers. The kits include sleep sacks, safe sleep literature, and NYSDOH educational materials. In August 2019, NY passed legislation expanding infant safety measures, including a ban on the sale of crib bumper pads.
In 2019, the NYSDOH updated and expanded translations of the patient education materials highlighting the ABCs (Alone, Back, Crib) of safe sleep available at no cost to the public. These safe sleep materials include a brochure available in the thirteen most commonly spoken languages in NYS (six translations were added in 2019), mirror clings, magnets, posters in English and Spanish, crib cards, and a one-minute video in English and Spanish made available on the NYSDOH YouTube channel. The NYSDOH also adapted an anatomical diagram originally created by National Institutes of Health (NIH) to provide patient education on the importance of putting a baby to sleep on his/her back while addressing the concern parents have regarding the potential for babies choking while they are on their backs. The anatomical diagram was translated into six additional languages in 2019 for a total of thirteen languages available; these were laminated and made available to all NYS birthing hospitals and stakeholder organizations.
During the reporting period, the NYSDOH, in collaboration with Title V staff, developed a safe sleep campaign to promote the ABCs of safe sleep and a new message: Baby should sleep in a smoke-free home. NYSDOH created three 10-15 second videos for the campaign and a new safe sleep poster in English and Spanish, all of which featured the new message. The videos were created to run on Facebook and Instagram, reaching women ages 16+, grandparents and caregivers. The out-of-home and social media campaigns were scheduled to launch on November 4, 2019 and run through January 2020. For the out-of-home print campaign, NYSDOH is targeting NYS counties with the highest infant mortality burden with bus shelter ads and posters in convenience stores and bodegas. Additionally, Title V staff updated the Department’s safe sleep website (www.health.ny.gov/safesleep) to include information about tobacco cessation and the updated patient education materials.
The Title V team, in collaboration with NICHQ, continues to develop the electronic NYSDOH Safe Sleep Toolkit, which will feature change ideas, presentations, materials, tools, references and key insights from hospitals and community-based organizations that are working to improve infant safe sleep practices. The target audience is public health and health care professionals. The toolkit is expected to be released during the next reporting period.
Title V staff are collaborating with the National Action Partnership to Promote Safe Sleep – Innovation and Improvement Network (NAPPSS-IIN). NAPPSS is an initiative to make infant safe sleep and breastfeeding the national norm by aligning stakeholders to test safety bundles in multiple care settings to improve the likelihood that infant caregivers and families receive consistent, evidence-based instruction about safe sleep and breastfeeding. In 2019, the project, which is funded by HRSA’s Maternal and Child Health Bureau (MCHB), expanded from five pilot site hospitals in five states, including NYS, to twenty hospitals in ten states. NYS’s representative hospitals during the reporting year included New York Presbyterian (NYP) Lawrence (Westchester), Montefiore Medical Center – Wakefield Division (Bronx) and Crouse Hospital (Onondaga). Montefiore Medical Center – Wakefield Division and Crouse Hospital joined the project in May 2019. During the reporting period, six conference calls were held with the NAPPSS-IIN partners. The Title V team will continue to hold quarterly conference calls with statewide and national safe sleep and breastfeeding stakeholders to disseminate, spread and scale best practices to improve safe sleep practices, breastfeeding rates, and reduce disparities in both areas.
NYS’s efforts related to safe sleep are measured by NOM #9.5 Sleep-related Sudden Unexpected Infant Death (SUID) rate per 100,000 live births. NY is far below the national average at 58.3 vs. 91.2 nationally as reported in 2017, which demonstrates the efforts NY has made to reduce the incidence of SUID.
The NYSPQC initiative also focused on an Enteral Nutrition Improvement Project that aimed to reduce the percentage of newborns born prior to 31 weeks’ gestational age discharged from a Neonatal Intensive Care Unit (NICU) below the 10th percentile on the Fenton Growth Scales. Outcome, process, and balancing measures were calculated for infants born prior to 31 weeks’ gestation, admitted within 48 hours of birth to a NICU, and discharged alive. Key measures were the percentage below the 10th percentile for discharge weight, difference in Z-scores for birth and discharge weights, incidences of comorbidities nosocomial sepsis and necrotizing enterocolitis, post-menstrual age at discharge (days), and median initial length of stay (days). With efforts and results shared through monthly Coaching Calls, quarterly performance measure data reports, and yearly Learning Sessions, all NYS RPCs began participation in 2010 and an additional 20 Level III facilities joined the project in 2016. Throughout the project, RPCs exhibited longer lengths of stay, higher percentages of breastmilk feeding, and higher rates of growth restriction at discharge, which may reflect greater clinical severity of their patients as well as the breastmilk paradox, where breastmilk fed babies grow more slowly. The initiative appears to have significantly improved growth, as measured by a sustained decrease in the percentage of infants weighing below the 10th percentile at discharge, with the rate among RPCs dipping significantly below the baseline and nearing the lower rate reached by the Level IIIs. There were no significant changes in the incidences of comorbidities or in discharges above the 75th percentile for weight, further substantiating that the interventions were safe. The goal of reducing baseline percentages by 10% was exceeded; for RPCs change was from 32.6% to 29.3%, and for Level IIIs change was from 30.8% to 27.7%. This project has ended. We estimate that over 370 additional babies were discharged above the 10th percentile for weight, and more than 750 babies received exclusive breast milk at their first full feedings because of the initiative’s efforts, and therefore conclude that our project was highly successful overall.
The NYSPQC Project Team has been conferring with the Vermont Oxford Network (VON) and California Perinatal Quality Care Collaborative (CPQCC) and hosted an onsite meeting with the NYSPQC’s Neonatal Clinical Expert Work Group, NICHQ, and Joseph Shulman, MD, from California’s DOH for an in-depth review of an additional QI project relevant to high-risk neonatal populations. This meeting took place in January 2020. Topics under consideration include the “Golden Hour,” i.e., appropriate fetal and newborn interventions at the time of and immediately after delivery; antibiotic stewardship in the NICU; transition from NICU to home; and health equity/family-centered care.
Further, the NYSPQC, in partnership with ACOG-NY, Healthcare Association of NYS (HANYS) and the Greater New York Healthcare Association (GNYHA), and with support from NICHQ, is leading the NYS OUD in Pregnancy & NAS Project. This learning collaborative, which kicked-off in September 2018, is currently being piloted in 17 pilot site birthing hospitals and seeks to identify and manage women with OUD during pregnancy, and improve the identification, standardization of therapy, and coordination of aftercare of infants with NAS. To date, topic areas of focus have included verbal screening related to substance use for all pregnant women during the prenatal period and on admission to the birth hospitalization, trauma informed care, improved communication between obstetrics and pediatrics, reducing stigma, training clinical staff on the signs and severity of NAS, improving both pharmacologic and non-pharmacologic care for infants with NAS, Eat Sleep Console as a method of treatment for infants with NAS, considerations for breastfeeding for women who use substances, and linkages to care. A statewide project expansion is planned for Spring 2020. The NYSPQC is participating in the National Alliance for Innovation in Maternal Health (AIM) through this initiative.
During the reporting period, the NYSPQC began participating in the Association of State and Territorial Health Officials (ASTHO) Opioid Use Disorder, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative (OMNI) Learning Community. The purpose of the learning community is to provide technical assistance, build capacity, and disseminate strategies and best practices to support program and policy implementation on substance use disorder (SUD) among pregnant and postpartum women and infants prenatally exposed to opioids, including NAS. Agencies and organizations convened as part of this effort include: ACOG-NY; HANYS; GNYHA; Northwell Health; NYSDOH OHIP, Office of Drug User Health, and AIDS Institute; NYS OASAS; NICHQ; and Community Health Care Association of New York State (CHCANYS). The overarching goal of the NYS OMNI team, in alignment with the NYS OUD in Pregnancy & NAS Project’s goal of increasing the percent of pregnant women screened for SUD with a verbal screening tool, is to train prenatal care hospital staff on standardized screening, develop provider resources for screening and referral, and connect diverse work happening across the state.
One DSRIP project involved a state funded MICHC program Mothers and Babies Perinatal Network in Binghamton, NY, who implemented the Care Transitions Model for newly delivered Moms and Babies by aiming to improve pregnancy and birth outcomes for every woman, infant, and family. Mothers and Babies Perinatal Network and UHS Hospitals collaborated to improve post-discharge results for mothers and newborns with Medicaid coverage. Participating in the Care Transitions project, Mothers and Babies Perinatal Network partnered with two local hospitals to deploy Health Coach services to over 500 new mothers, providing face-to-face visits and follow-up phone calls during the 30-day post maternity discharge. Mothers and Babies and UHS presented the results from their collaborative approach at a Care Compass Network Stakeholders Meeting. The presentation can be seen on YouTube by following this link: https://www.youtube.com/watch?v=c4fTXeblp6I. The outcome goals were parental/family practice of safe sleep strategies for infants, identify and refer post-partum women for perinatal mood disorders/post-partum depression. The project found:
Safe Sleep for Babies Education: 100% all moms receiving a home visiting and 30-day follow-up (including safe sleep)
- Identification of families with no crib – provision of pack n play
Depression/mental health screen: provision of PHQ-9 survey. 559 completed (10/1/18 – 9/12/19)
- 24 (4%) scored 10 or more/100% referred
90-day phone follow up
1/1/19 – 6/30/19: 134 calls made; 58 completed (43%)
100% following the safe sleep guidelines
0 re-hospitalizations of moms
3 re-hospitalizations for babies (all medically necessary)
Another DSRIP project involves two NFPs – one in Chautauqua county and the other in Erie county. The Erie county NFP receives MIECHV funding. Catholic Medical Partners in western NY selected establishing or expanding home visiting as one of their strategies. Catholic Medical Partners began implementing an NFP in Chautauqua County in 2016 and began implementing an NFP program in Erie County in October 2018.
Through Medicaid Redesign, Health Information Technology (HIT) projects were established in four high need areas (Monroe, Onondaga, Westchester, and Kings counties) to demonstrate the effectiveness of HIT to coordinate perinatal services, reduce costs by streamlining fragmented and redundant systems, increase on-time patient access to medical records, and improve quality of care. In 2017, one of the HIT projects (Westchester County) stepped down, as they were not able to meet the planned objectives. The HIT systems are designed to identify the medical, pregnancy, and psycho-social risks of pregnant women and make and track referrals to needed services. During development of the HIT systems, national guidance and state legal counsel addressed system issues related to confidentiality. In 2018, HIT systems went live for all three projects with full data collection in September 2018. Data extract templates were developed for the pilot projects to submit de-identified aggregate data on a quarterly basis to the Department. Based on gathered data extracts, analysis will be conducted and reported to the state and Medicaid Redesign Team, presenting the efficacy of the HIT projects in the targeted communities. During 2019, HIT projects were continuing to expand their provider enrollment within their network implementing sustainability plans.
The NYS Title V program remains ready to address any public health issue impacting the maternal and child health population including new and emerging public health priorities such as the opioid epidemic and maternal depression. The Maternal and Women's Health annual report and application sections include information related to The NYS Title V program’s role in the opioid epidemic and maternal depression.
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