Annual Report Fiscal Year 2019:  This section provides a summary of Federal Fiscal Year 2019 (FFY19) activities, accomplishments, and challenges related to National Performance Measures (NPMs) and State Performance Measures (SPMs) (2016-2020) for the Perinatal/Infant Health Domain.

The American Academy of Pediatrics recommends exclusive breastfeeding for the infant’s first six months and encourages breastfeeding through at least the infant’s first birthday in order to maximize health benefits associated with breastfeeding. Breastfed infants are less likely to develop diabetes or obesity and mothers who breastfeed lower their risk of breast and ovarian cancer, diabetes, and heart disease.

Strategy 1: Assure each county has one nurse who is a trained Certified Lactation Counselor (CLC); Strategy 2:  Promote breastfeeding within the Healthy Baby Home Visitation Program

To assure that mothers and their infants served by public health nurses (PHNs) through home visitation, family planning clinics, or other MCH-related services have access to breastfeeding support, the Women and Infant Health Program Manager (WIHPM) provides financial support to train PHNs as CLCs. The goal is to have a CLC-trained nurse in all 23 Wyoming counties, and in FFY19, 100% of counties had a CLC-trained nurse. CLC-trained nurses are able to provide breastfeeding and lactation support, including assessing the latching and feeding process, providing corrective interventions, counseling mothers, and understanding and applying knowledge of milk production. This effort supports new mothers through the challenges and uncertainty around breastfeeding, and it helps to increase the number of new mothers who are able to breastfeed successfully. Where possible, the WIHPM partners with PHN and the Women, Infants, and Children (WIC) Unit to coordinate in-state CLC trainings so that both WIC and PHN staff may benefit.

Through the ongoing collaboration between PHN and the Maternal and Child Health Unit (WY MCH), breastfeeding practices and support are offered through the Healthy Baby Home Visitation (HBHV) program. The HBHV Program is delivered by PHNs in all 23 counties in Wyoming to pregnant and postpartum mothers and their families. Through a Memorandum of Understanding with WY MCH, each county is required to assure all PHNs delivering MCH services receive annual breastfeeding training. Each county is also responsible for providing breastfeeding education, support, and referrals as part of the home visiting curriculum and for collecting data on initiation and duration of breastfeeding. Data on the PHN breastfeeding support provided by PHNs and HBHV client breastfeeding outcomes are reviewed quarterly by the MCH Consultant for PHN to encourage ongoing quality improvement.

Strategy 3: Award mini-grants and provide ongoing technical assistance to hospitals participating in the Wyoming 5-Steps to Breastfeeding Success Project; Strategy 4:  Develop a hospital recognition program for Wyoming 5-Steps to Breastfeeding Success

Wyoming has historically had a very high rate of breastfeeding initiation and exceeded the Healthy People 2020 goal of 81.9% of infants who are ever breastfed as far back as 2007. The Wyoming 5-Steps to Breastfeeding Success was launched in 2017 and provided mini-grants to four hospitals to use evidence-based methods to increase breastfeeding initiation and duration. All funded hospitals participated in required technical assistance calls with WDH, and 100% of grantees reported an improvement from baseline on a hospital self-assessment. Due to ongoing success in breastfeeding rates statewide, limited capacity and resources, and staff turnover, the WIHP did not release a second Request for Applications and has not developed a Wyoming 5-Steps to Breastfeeding Success hospital recognition program. The WIHPM will remain available to hospitals to provide technical assistance as needed to support ongoing facility-specific breastfeeding improvement activities.  

In 2018, WIHP and the MCH Epidemiology Program participated in the Association of Maternal and Child Health Programs (AMCHP) Data Communications E-Learning Collaborative. The Wyoming team used data from the CDC’s Maternity Practices in Infant Nutrition and Care Survey, Pregnancy Risk Assessment Monitoring System (PRAMS), and Wyoming Vital Statistics to develop Wyoming 5-Steps to Breastfeeding Success posters including hospital-specific data on progress related to each of the steps in the grant program. The Wyoming team consulted AMCHP and Wyoming hospitals to inform poster content development. In early 2019, the Wyoming team distributed posters for all Wyoming hospitals in order to promote continued awareness of evidence-based steps to improving breastfeeding initiation and duration rates in the hospital setting. The image below shows the Wyoming statewide poster.

Additional Strategies:

Develop a WDH Breastfeeding at Work Policy in Collaboration with Wyoming WIC

From 2017 to present, WIHP has worked closely with Wyoming WIC to create a breastfeeding at work policy to support working parents employed by WDH and promote increased breastfeeding duration. Approximately 35% of the WDH workforce is made up of women of childbearing age. This policy has the potential to positively impact a large portion of new mothers in the state by modeling positive breastfeeding support practices to the larger community and other organizations. WIHP and WIC modeled the draft policy after other state health departments that have demonstrated success in breastfeeding support among their staff. It also better outlines WDH accommodations that have been put in place to support lactating women in the workplace, including the provision of hospital-grade pumps and compatible pump kits by WY MCH, access to lactation rooms in State offices, and information on Fair Labor Standards Act policies that protect breastfeeding parents.

The draft policy was reviewed by Public Health Division leadership but due to changing Wyoming Department of Health leadership and other emerging priorities, the policy was not adopted. WY MCH and WIC continue to support and implement workplace improvements to encourage breastfeeding duration, such as assuring every floor in the new State office buildings have mothers rooms with new chairs for lactating women to use as well as a refrigerator to store expressed breastmilk. WY MCH and WIC also worked closely with Human Resources to make sure federal and state breastfeeding laws are discussed during new hire orientation.

Risk-appropriate perinatal care is a key strategy for improving maternal and neonatal health outcomes. Studies conducted by the American College of Obstetrics and Gynecology (ACOG) as far back as the 1970s have demonstrated that access to risk-appropriate neonatal and obstetric care has the potential to decrease perinatal mortality and improve birth outcomes for both mothers and their infants. Risk-appropriate care is defined as access to care that matches both the mother’s and infant’s level of risk, including a full range of specialists available to help care for complex medical conditions. 

Strategy 1: Distribute facility-specific reports on Levels of Care Assessment Tool (LOCATe) results

WY MCH provided interested hospitals with a draft LOCATe report and had them meet with the CDC-assigned MCH Epidemiologist to discuss their assessments. This epidemiologist linked LOCATe data with hospital discharge data to examine pregnancy complications and the existence of maternal emergency hospital protocols and drills. 

A success related to risk-appropriate perinatal care is evident in two of Wyoming’s largest hospitals signing alliance agreements with a neighboring state children’s hospital to assure a formal process for consultation and transport. According to these hospitals this alliance has enabled the hospitals to reduce the number of neonatal transports, as well as better coordinate back-transports for infants and children who meet the criteria for a step-down in the level of care. One hospital has a teleneonatology service as part of this alliance agreement that has been in place since October 1, 2019. While this particular service is not used often, the hospital stated it gives providers confidence that they have support if needed. Through the teleneonatology service this hospital now has a neonatologist on staff who is able to review cases and provide feedback to improve care. Both hospitals also receive constant training from this children’s hospital, which has benefited both provider and nursing staff. One hospital also benefits from residency referrals, which help with acuity at the hospital.

Based on LOCATe results, another hospital educated new providers on what type of patients the hospital is capable of caring for. Wyoming facilities are currently focused on providing the best care within their level and launching initiatives to improve the quality of care for mothers and infants.  

No plans are in place to repeat the LOCATe tool; however, this remains a possibility during the 2021-2025 grant cycle.  

Strategy 2: Support hospitals in implementation of Alliance for Innovation on Maternal Health (AIM) safety bundles (e.g. hypertension, opioids use during pregnancy, low-risk Cesarean delivery)

Through Wyoming’s risk-appropriate care work, WIHP formed a partnership with the Utah Department of Health, specifically around its AIM maternal safety bundles. In 2018, six of the 23 Wyoming birthing hospitals joined the AIM Maternal Hypertensive Emergencies Safety Bundle. This safety bundle was important due to the increased rate of maternal mortality seen in the U.S., and hypertensive emergencies can lead to neonatal mortality or morbidity, as well. This safety bundle closed with an in-person meeting in Salt Lake City in March 2020 with representatives from all six Wyoming hospitals participating.

Strategy 3: Develop a Wyoming Perinatal Quality Collaborative (WYPQC) 

The Centers for Disease Control and Prevention (CDC) defines a perinatal quality collaborative as a state network working to improve the quality of care for mothers and babies, with members identifying health care processes that need to be improved through evidence-based practices as quickly as possible. In 2018, the WYPQC held a retreat and created a vision statement, mission statement, and core principles to help guide the collaborative’s operations.

The WIHP released a Request for Applications for coordination of the WYPQC in late 2018, and in April 2019 it awarded a contract to Brenda Burnett, RN, MSN, PCMH CCE, of Brenda Burnett Clinical Consulting, LLC. Ms. Burnett brought with her a wealth of clinical expertise in perinatal issues, as well as project management and quality improvement experience. Brenda facilitated the WYPQC through meetings and project planning, coordinated communication and activities, developed toolkits and outreach materials for projects, and assured ongoing engagement and recruitment of project partners and stakeholders. Brenda maintained her contract through December 2019; the WIHP is currently in the process of rehiring for the position. In late 2019, the WIHP released a call for nominations for WYPQC leadership roles, including Co-Chair. In December 2019, the WYPQC elected Erin McKinney, RN, MSN to serve as Chair; she also serves as Clinical Director of Women & Children’s Services at Cheyenne Regional Medical Center in Cheyenne.

The WYPQC meets quarterly providing updates from WIHP and reports from hospitals that are engaged in substance use disorder work, educational discussion from other programs that affect the maternal and infant population, and discussions on next steps for the collaborative.

Strategy 4: Implement Fetal and Infant Mortality Review (FIMR) in pilot community

WIHP continued to support the FIMR pilot project in Fremont County, Wyoming through 2018, in collaboration with providers and community members on the Wind River Indian Reservation. The Fremont County Case Review Team (CRT) reviewed 100% of Fremont County fetal and infant deaths from 2016. The CRT utilized the results of those reviews to make recommendations for action.  Preconception health was a chosen focus and included promoting management of chronic conditions before and during pregnancy and client-centered contraceptive counseling.

Through stakeholder engagement, the expansion of a FIMR either at the state or county level will be explored through FFY21. The WYPQC will be imperative in the exploratory process and the WIHPM has been coordinating efforts with other mortality reviews within Wyoming to discover any duplicative efforts. Training materials from the previous FIMR work are still available to train potential FIMR members and The National Center for Fatality Review and Prevention has offered technical assistance for this project. Considerations for continuing this project include resources, staff capacity, local-level interest, data support capacity, legal authority and protections, and opportunities to coordinate efforts with other death reviews.  

Additional Strategies:

Award Childhood Injury Prevention Mini-Grants

WY MCH funded seven organizations to implement evidence-based strategies to prevent childhood injury. WIHP provided technical assistance to two counties (Uinta and Johnson) on activities related to improving safe sleep and infant fall prevention. These counties worked on improving knowledge of crib safety and provided safe sleep education to caregivers in their respective communities.  

Promote WY MCH’s Newborn Intensive Care (NBIC) Program

The NBIC Program assures high-risk infants and their families have access to care coordination services and limited gap-filling financial assistance to enhance perinatal and infant outcomes. Promotion of this program further supports efforts to improve risk-appropriate perinatal care, especially for families that require out-of-state care at a Level III and Level IV facilities. Referrals for this gap-filling program come from providers around the state, as well as from our out-of-state tertiary care facilities with NICUs. The NBIC program served 83 high-risk infants in FFY19. WIHP plans to increase program referrals through increased education and outreach to the Public Health Nursing Offices and to providers through the WYPQC.

Improve Newborn Screening Timeliness and Quality

Timely newborn screening allows for early diagnosis and treatment of disorders that can negatively affect a child’s mental and physical health for a lifetime. In some cases, these disorders can cause death if not diagnosed and treated early.

In August 2019, the Wyoming Newborn Screening Advisory Committee met to vote on changes to the current Rules and Regulations to improve program operations. The committee voted to increase the fee from $84.00 to $97.32 and add Spinal Muscular Atrophy to the Wyoming Newborn Screening Panel. The Newborn Screening Program (NBS) then drafted Rules to include adding a public URL to view the types of conditions included in the Wyoming Newborn Screening Panel, add a section requiring qualified healthcare professionals to collect a second newborn screen between seven and fourteen days after birth, add clarifying language to the informed consent section that covers initial and second blood spot specimens, and give the program the authority to increase the fee by 25%, should the program necessitate it. WIHP also decided to pay for courier services via FedEx for midwives who collect the blood spot specimens in Wyoming to assure that the specimens reach the testing laboratory in a timely manner. At present, the Governor of Wyoming has the proposed Rules to sign, and they will be effective once he does so.

In December 2019, the courier that transported newborn screening specimens from every birthing facility in Wyoming to the contracted testing laboratory in Colorado ceased operations suddenly. NBS implemented a stop-gap solution for the birthing facilities to use FedEx to courier the specimens until another courier option could be put into place. A new courier was selected through a Request for Proposals process and began operations July 20, 2020.

The NBS program worked with MCH Epidemiology to create a newborn screening dashboard using Tableau data visualization software. The dashboard can pull data on key quality indicators (e.g. collection time, courier time) directly from the feed from the Colorado Department of Public Health and Environment (CDPHE) and present it in an easy-to-use format that allows hospitals to see their standings and compare their data to that of other hospitals in the state. CDPHE identified a data quality issue, which has since been resolved. NBS will work closely with MCH Epidemiology, the Wyoming Hospital Association, hospitals, and other stakeholders to finalize and launch the dashboard. In the meanwhile, the dashboard will be used internally to identify quality improvement needs.

Other WIHP Activities:

Healthy Baby Home Visitation Program (HBHV)

WY MCH partially funds the HBHV Program offered by trained PHNs in all 23 Wyoming counties using Title V State matching funds. Through a Memorandum of Understanding with WY MCH, each county provides home visitation services and care coordination services for high-risk pregnant women, high-risk infants, and children and youth with special health care needs. Through June 30, 2020, 23 counties delivered the Best Beginnings model based on the Florida State University Partners for a Healthy Baby curriculum and four counties delivered the evidence-based Nurse Family Partnership model. In FFY19, WY MCH partnered with PHN and MCH Epidemiology to research other available evidence-based models that were nurse-delivered and well-suited for a rural/frontier environment. Presentations on models under consideration were held in late 2019 with local PHN staff and Wyoming Department of Health leadership. With leadership approval, PHN is pursuing a contract to deliver the Maternal Early Childhood Sustained Home-Visiting (MECSH) model. As of July 1, 2020, all clients served through Nurse Family Partnership have transitioned to Best Beginnings. Over the next year, all clients served through Best Beginnings will be transitioned to MECSH. WY MCH will continue to provide ongoing support to PHN during this transition. 

The Wyoming Home Visiting Network (WYHVN) was formed under the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) grant program, which is administered by Parents as Teachers (PAT), as a way to assure cross-model collaboration and systems-building work for home visiting in Wyoming. The group has grown and evolved, and it continues to meet quarterly to assure ongoing coordination of home visiting services. WYHVN is committed to improving cross-model referrals statewide, and to promoting the available home visiting models in each county through marketing and outreach. In early 2019, the WYHVN also worked to coordinate with Parents as Teachers to support the MIECHV needs assessment process, and to assure that the product of the needs assessment reflects the needs of the entire home visiting system in Wyoming.