Priority Need: Prevent Infant Mortality

 

Perinatal services are focused on the health of women and babies before, during and after birth. The Georgia Perinatal-Infant Health program aims to assure pregnant women in Georgia every opportunity to access comprehensive perinatal health care services appropriate to meet their individual needs. DPH is committed to providing access to high-quality perinatal care to Georgians and recognize that there is a direct relationship between perinatal birth outcomes and the quality of health care services.

 

The number one cause of infant mortality in Georgia are disorders related to preterm birth and low birth weight. In 2018, the Infant Mortality Rate for Georgia was 7.1, per 1,000 live births, with the infant mortality rate among Black, non-Hispanic infants two times higher than White, non-Hispanic or Hispanic infants. Research indicates that maternal and infant morbidity and mortality can be reduced if high-risk pregnant women and newborns receive risk-appropriate care, health equity is ensured, and social determinants of health are addressed.

 

NPM 3: Risk-appropriate Perinatal Care

 

Perinatal Regionalization

Perinatal Regionalization is a collaborative system of hospitals & providers striving to assure that deliveries happen in the hospital with the appropriate level of care for the mother and infant. The purpose of the RPC’s is to coordinate access to optimal and appropriate maternal and infant health care. Regionalized systems assign hospitals risk-appropriate levels and ensure high-risk infants are born in facilities with appropriate technology and specialized health providers. The impact of appropriate level of care on maternal/perinatal health outcomes is great as low birth weight or premature infants born in risk-appropriate facilities are more likely to survive.

 

Basic perinatal services include comprehensive obstetric care through neonatal newborn services. There are six RPC’s, specially qualified hospitals, which are designated to specific geographic regions that provide the most advanced care for high-risk mothers and infants.

 

Maternal and Neonatal Levels of Care

In the reporting year, the Maternal and Neonatal Center Designation program developed rules outlining the requirements for designated centers effective November 2019. A contract with the American Academy of Pediatrics (AAP) was initiated to use the AAP Verification Program for the application and site survey process for Level II and Level III Neonatal Center Designations. The planning process for Level II and Level III Maternal Center Designations continued.

 

SPM 4: Breastfeeding

 

Breastfeeding

Georgia's 5-STAR Hospital Initiative was developed to recognize hospitals that have taken steps to promote, protect and support breastfeeding in their hospital. A five-star system was developed to encourage maternity centers to promote and support breastfeeding one step at a time. Georgia 5-STAR will award one star for every two steps implemented of the Ten Steps to Successful Breastfeeding, as defined by the World Health Organization (WHO) and Baby-Friendly® USA. In the reporting year, the Georgia 5-STAR program worked to review the current Georgia 5-STAR program offerings and past support provided to hospitals. Women’s Health developed additional support materials to assist hospitals in evaluating their progress on the Ten Steps to Successful Breastfeeding-Georgia 5-STAR journey and revised the training programs as suggested by the review.

 

In the reporting year, Women’s Health provided technical assistance by phone, emails, and in person visits. Individualized Technical Support Workshops were provided to hospitals that submitted applications to the program. The workshops were used as a platform to provide a more individualized approach to aid hospitals in overcoming their specific barriers to implementing the Ten Steps to Successful Breastfeeding in their facility.

 

In collaboration with the AAP, DPH delivered the Educating Physicians In Their Communities (EPIC) breastfeeding program, a physician peer-to peer training program that provides breastfeeding education to physician’s offices, hospitals and residency programs, distributes information on how to access lactation support services in the community, and offers free resources for patient education. During this reporting period, fourteen EPIC breastfeeding programs were administered. MCH partnered with WIC to provide breastfeeding educational trainings to all DPH staff including nurses, peer counselors, breastfeeding coordinators, nutritionists, and administrative staff.

 

SPM 3: Rate of Congenital Syphilis

 

Congenital Syphilis

The Sexually Transmitted Diseases (STD) Office’s mission is to prevent STDs by providing quality intervention strategies, programmatic support and education to all throughout the state of Georgia. With a focus on Congenital Syphilis, the STD team works to promote first and third trimester testing for HIV and Syphilis, as well as improve the data quality of Congenital Syphilis. The STD Office works to improve the identification of pregnant females with syphilis to ensure timely and appropriate treatment. During the reporting year, Syphilis During Pregnancy was added to the Notifiable Disease List. The promotion of first and third trimester testing for HIV and syphilis continued. Efforts to provide education through trainings, community outreach, provider outreach, and district STD staff continue to be a priority.

 

In the reporting period, a total of 1,643 cases of primary and secondary Syphilis were reported in Georgia. This is a 130-case increase from the previous year. When compared to other states in the U.S. Georgia ranked fourth in reported primary and secondary syphilis and tenth in reported Congenital Syphilis cases. In the current year, there were 31 Congenital Syphilis cases out of 126,051 Georgia resident births. In 2017, there were 23 Congenital Syphilis cases out of 129,158 Georgia resident births. From 2017- 2018, there has been a 35% increase in Congenital Syphilis cases.

 

SPM 4: Neonatal Substance Abuse

 

Neonatal Abstinence Syndrome

Neonatal Abstinence Syndrome (NAS) is a Notifiable Condition in Georgia as of January 1, 2016. DPH requires notice and reporting of incidents of NAS by a health care provider, coroner, medical examiner, or any other person who has knowledge of diagnosis or health outcomes related, directly or indirectly, to NAS.

 

In the reporting year, Women’s Health provided oversight and management of the NAS surveillance process in close collaboration with MCH EPI and birthing hospital staff. Cases were verified by MCH EPI staff through review and confirmation of case indicators. Georgia’s case criteria for a confirmed case of NAS is: (1) presence of one or more clinical symptoms of NAS and/or (2) a positive infant substance test result.

 

In January 2018, the Neonatal Subcommittee of the GaPQC began working on a quality initiative to impact the growing incidence of NAS. The committee developed a baseline survey for birthing hospitals to determine current practices around NAS diagnosis and treatment. The survey was piloted in four hospitals during March 2018 and was provided to all birthing hospitals in April 2018.

 

GaPQC continued to implement the NAS initiative with 48 birthing hospitals. GaPQC hosted monthly webinars on recovery language, breastfeeding infants with NAS, and substance use treatment during pregnancy. There were approximately 60 participants on each call. Additionally, two Quality Improvement (QI) Technical Assistance calls were hosted with participating hospitals to provide further training on developing and implementing key driver diagrams and creating run charts. Hospitals continued to receive their monthly Vermont Oxford Network (VON) Microlesson Completion Reports and received their first quarterly length of stay report containing data calculated from hospital discharge data. The reports outlined their average length of stay compared to other GaPQC hospitals. The program was also approved for Part Four Maintenance of Certification Credit from the American Board of Pediatrics for all pediatricians participating in the collaborative to further encourage physician participation.

 

Other Perinatal/Infant Health Programs

 

Newborn Screening

Georgia Newborn Screening (NBS) is a six-part preventative health care system designed to identify and provide early treatment for 35 inherited disorders that would otherwise cause significant morbidity or death, including 29 disorders detectible through blood, hearing loss, and critical Congenital Heart Disease (CCHD). The NBS systems is comprised of six major components to ensure every newborn receives adequate screening for these 35 conditions and infants that screen positive for a condition receive appropriate and timely follow up. The six components of the system are:

 

• Education: of parents and health care providers
• Screening: universal testing of all newborns
• Follow-up: rapid retrieval and referral of the screen-positive newborn
• Medical Diagnosis: confirmation of a normal or abnormal screening test result by a private physician or tertiary treatment center
• Management: rapid implementation and long-term planning of therapy
• Evaluation: validation of testing procedures, efficiency of follow-up and intervention, and benefit to the patient, family, and society. This includes consideration of adding other tests to the system as indicated by appropriate research and scientific evidence.

 

In the previous fiscal year, the Commissioner of Public Health added three new conditions, Pompe Disease, Mucopolysaccharidosis Type I (MPS I), X-linked Adrenoleukodystrophy (X-ALD) to the state newborn screening panel. In December 2018 of the reporting year, the DPH Commissioner included an additional condition, Spinal Muscular Atrophy, to the state universal screening panel based on the rigorous review of the condition by the Newborn Screening and Genetic Advisory Committee (NBSAC) and subsequent recommendation to include the condition on the state panel. During the legislative session, DPH requested and was allocated funds to support the implementation of universal screening for four new conditions early in the next fiscal year. To educate hospitals and pediatricians about the new conditions, the newborn screening program hosted a webinar through AAP on the new conditions included on the state panel. The program issued memos to hospitals, pediatric providers and public health staff.

 

In November 2018, The NBSAC held ad hoc meeting during which Congenital Cytomegalovirus (cCMV) Screening was nominated to the state newborn screening panel. The NBSAC established a workgroup to review the condition and the implications of adding cCMV to the state panel. The work group included the parent of a child with a condition identified through newborn screening, a pediatric infectious disease physician, a pediatric neurologist, a cCMV laboratory expert, the Georgia newborn screening laboratory director, clinical coordinator, and lead follow-up nurse.  The work group met monthly for a six-month period and reviewed cCMV based on standard criteria outlined in Rules and Regulations that guide the addition to new conditions to the state panel and criteria used by the Advisory Committee on Heritable Disorders in Newborns and Children within the Health Resources and Services Administration.

 

In February 2019, the NBSAC held a regularly scheduled semi-annual meeting in which the Guanidinoacetate Methyltransferase (GAMT Deficiency) work group presented the outcomes of an extensive review conducted regarding adding GAMT to the state newborn screening panel. The work group concluded that GAMT meets many of the criteria required for inclusion on the newborn screening panel including a clear benefit to detection and treatment in the newborn period. However, the work group noted that further inquiry into the best method to detect GAMT through blood spot screening and the implications for the newborn screening follow-up process is needed. The work group recommended a pilot study be conducted to further investigate the implications GAMT screening. The NBSAC voted in favor of this recommendation pending the availability of funding to support a pilot study. 

 

Quality Improvement 

NBS continued to develop and implement strategies to consistently engage birthing centers and hospitals around the importance of newborn screening and the impact of high-quality specimen collection. In the reporting year, NBS developed and disseminated a brief instructional video reviewing necessary techniques for quality newborn screening specimen collection. The video is posted on the newborn screening website and all newborn screening specimen collectors were made aware of the video. During the reporting year, newborn screening specimen quality for all birthing facilities was monitored by the newborn screening program. Each quarter, birthing facilities that submitted newborn screening samples with zero errors received a letter from the MCH Director, recognizing the facilities’ success. Facilities with consecutive quarters of zero errors in their newborn screening samples received a certificate of achievement. To further bring awareness to techniques that resulted in proper newborn screening specimen collection, the newborn screening program created posters with quick tips for collecting newborn screening samples. The program also developed pocket guides with images of quality newborn screening samples to be used as a quick reference. The video, posters and pocket guides were all on-demand resources birthing facilities used to improve the quality of their newborn screening samples. The Newborn Screening Clinic Coordinator continued to monitor the overall rate of quality newborn screening samples and provided in-person technical assistance when needed.

 

Sickle Cell Foundation Community Health Workers

In the reporting year, DPH partnered with the Sickle Cell Foundation of Georgia, Inc. (SCFGa) to provide Community Health Worker (CHW) services for individuals of all ages with Sickle Cell Disease (SCD) in Georgia. CHWs aim to improve overall health outcomes for SCD by providing local families with resources to increase self-care management, self-efficacy, and successful transition from pediatric to adult care. Patient education and strategic partnerships are incorporated into the program to address issues. The overall program provides several benefits to those living with sickle cell disease. CHWs serve clients by linking them to medical homes, community-based programs and resources, public health services and healthcare transition planning with adolescents. Many primary care physicians that do not have specialized training in caring for patients with SCD are uncomfortable treating adults with SCD. Individuals with SCD sometimes do not understand the need for a medical provider other than a hematologist to manage their care. As a result, fewer than half of adults with SCD have access to primary care. The partnership between DPH and SCFGa is an innovative approach to strengthen the system of care for people with SCD by better linking social support services, medical care and public health services. This partnership signifies a ‘whole person approach’ to supporting individuals with SCD. The SCFGa has ongoing collaboration with renowned hematologist in the state to promote the benefit of the whole person approach. They have held joint presentations in Bibb, Emanuel and Chatham Counties and have presented this approach during a webinar hosted by the AAP.

 

Outreach and Education

The Newborn screening program employs various education and outreach strategies to families and providers. The program engaged directly with physicians and nurses at the Georgia Academy of Family Physician’s meeting in October 2018 as well as the Georgia Chapter of American Academy of Pediatrics meeting in November 2018. These meetings provided the program opportunities to interface directly with physicians and discuss the importance of newborn screening and newborn screening results with families during the newborn visit.

 

ZIKA

As of May 2018, 686 cases have been identified with suspected Zika-associated birth defects and have been dispositioned into one of three categories: confirmed Zika-associated birth defects (32%), confirmed general birth defects (31%), or non-case (36%).

 

Potential cases were identified from three sources, including the Zika Active Monitoring System (ZAMS) and the Zika Pregnancy Registry (ZPR). Electronic birth certificates (eBCs) constituted the largest (73%) reporting source. However, birth defects reported on eBCs require confirmation through medical record review, per guidelines from CDC Zika Birth Defects Surveillance (CDC-ZBDS) and the National Birth Defects Prevention Network (NBDPN). Through this effort, MCH EPI fostered relationships with medical facilities, as well as drew attention to the need for birth defects reporting and established a protocol for tracking records from initial requests through confirmation, referral to early intervention services, and CDC reporting.

 

An Infant EPI focused on the surveillance of birth defects and NAS and a Medical Record Liaison assisted in the requesting of medical records. The Infant EPI and Medical Record Liaison collaborated to initiate medical record requests, review records for confirmation of reported birth defects, and abstract confirmed records. Once received, reviewed, and confirmed, the abstracted records were linked with confirmed cases from the Metropolitan Atlanta Congenital Defects Project (CDC-MACDP) and reported to CDC-ZBDS on a monthly basis.

 

Zika birth defects surveillance gave DPH the opportunity to develop a Birth Defects Registry that integrated data from 13 reporting sources, including eBCs and ZAMS/ZPR; expedited referral of affected infants and their families to early intervention services; and facilitated standardized, timely, reporting and confirmation of birth defects statewide. Funding for Zika-specific projects was discontinued at the end of the reporting year and Zika surveillance has been integrated into the ongoing activities of acute arboviral disease surveillance.

 

Safe Sleep

The Safe Infant Sleep program plans and promotes the Georgia Safe to Sleep Campaign. The campaign provides tools and resources that strengthen policy, provide consistent education and change infant sleep environments to prevent infant sleep-related deaths, empower professionals to educate parents, empower families to make informed decisions about infant sleep, and increase access to resources that support behaviors that protect infants from sleep-related deaths.

 

The Georgia Safe to Sleep Hospital Initiative, as part of the Georgia Safe to Sleep Campaign, is a statewide initiative designed to raise awareness about sleep-related infant deaths and evidence-based sleep practices to prevent infant mortality. The hospital initiative was launched in May 2016 to prevent infant sleep-related deaths in Georgia, empower professionals in multiple disciplines to educate parents about safe sleep environments and ensure they see proper sleeping practices modeled in hospitals. MCH continued to work with participating birthing hospitals to meet the goals of the program.

 

In the reporting year, all 79 Georgia birthing hospitals participated in the Safe Sleep Hospital Initiative. To support hospitals in their efforts to educate families about safe sleep practices, education materials were distributed throughout the state, including safe infant sleep educational flipcharts for educators, one-page handouts on the safe sleep environments, safe sleep brochures, crib cards, Spanish language materials and safe sleep books. Children’s Healthcare of Atlanta quality improvement project expanded to all three campuses to improve modeling of safe infant sleep and “floor talkers” were designed, developed and implemented in areas with the highest sleep related death rate. The Safe Sleep Program designed, developed and implemented the “Safe Infant Sleep Education and Crib Distribution” program and study. Currently more than 30 sites are hosting safe infant sleep educational classes and distributing a play yard with bassinet to expectant mothers in or near their third trimester. A pre-and post-education survey was administered. A train the trainer education course was developed to increase the number of safe infant sleep trainings that occur with consistent and accurate education.

 

Published Article and Poster Presentation:

    As Easy as ABC: Evaluation of Safe Sleep Initiative on Safe Sleep Compliance in a Freestanding Pediatric Hospital, S. Lazarus; T. McFadden; T. Miller             

 

Family and Community Support Services

Evidence-Based Home Visiting (EBHV) programs are an effective early-intervention strategy to improve the health and well-being of children and parents. Home visiting is a strengths-based, family-centered support strategy that gives pregnant women and at-risk families with children from birth until kindergarten entry the resources and skills they need to raise children who are physically, socially, and emotionally healthy and ready to learn.

 

MCH continues its commitment to implement comprehensive, community-based maternal and early childhood programs to include evidence-based home visiting (EBHV) programs in nineteen counties (Bartow, Brooks, Catoosa, Chatham, Clarke, Clayton, Crisp, DeKalb, Dooly, Echols, Fulton, Flynn, Houston, Liberty, Lowndes, Muscogee, Richmond, Rockdale, and Whitfield). Since 2010, Georgia has instituted a comprehensive, high quality, community-based maternal and early childhood system, with EBHV as the major service strategy for improving child and family well-being. The framework seeks to assure the well-being of families with young children by identifying all expectant parents, children birth to five and their families, offering a comprehensive screening to determine strengths and needs, and linking families to community services and supports, including EBHV.

 

EBHV programs available in Georgia are as follows: Early Head Start - Home Based Option (EHS-HBO), Healthy Families Georgia (HFG), Nurse-Family Partnership (NFP) and Parents as Teachers (PAT). EBHV program models are proven to improve outcomes in several domains including (1) maternal and child health, (2) positive parenting practices, (3) child development and school readiness, (4) reductions in child maltreatment, (5) family economic self-sufficiency and (6) linkages and referrals to community resources and supports.

 

During the reporting period:

• 24,042 home visits were completed
• 2,016 families were served
• 984 new families were enrolled into Georgia Home Visiting
• 2,459 children completed the child development screening Ages and Stages Questionnaire (ASQ)
• 8,291 First Step screens were completed
• 5,946 community referrals were made for services
• 824 maternal depression screenings were completed-181 screened positive (22%) and of those,155 were receiving services or a referral was made

 

Maternal Infant Childhood Home Visiting (MIECHV):

The Georgia Home Visiting Institute, Accelerating Your Success with Families, was held September 10, 2019. The event featured a plenary session speaker, EJ Carrion, and provided nine breakout sessions and exhibitors. Mr. Carrion, a motivational speaker and founder and CEO of the Student Success Agency, shared his personal story with a focus on how home visitors can engage and build relationships with young parents to help unlock their true potential. There were 277people in attendance.

 

The Georgia Home Visiting Institute provided high quality training for Georgia home visitors and supervisors, community outreach staff, and family support staff to develop and enhance core competencies critical to their work. Trainings addressed strategies to improve the quality and effectiveness of home visiting services, with an emphasis on supporting healthy infant/toddler development and parent-child relationships to develop the skills necessary for establishing, building and enhancing relationships with families.

 

With the oversight of Georgia MIECHV under DPH, partnerships with other MCH initiatives strengthen program infrastructure and enhance service delivery to families.

MCH Partnership Examples include:

 

• Oral Health – Georgia MIECHV partnered with the DPH Oral Health section to provide education to home visitors. In December 9, 2019, the State Oral Health Director conducted a webinar for home visitors and provided a flip chart that home visitors can utilize with families. Home Visiting and Oral Health also developed an oral health survey for the home visitors to gauge their knowledge and needs.
• Children 1st /BCW -Georgia MIECHV partnered with BCW and Children 1st to develop standard operating procedures for districts with both home visiting and the Part C programs to use when collaborating. A Memorandum of Agreement template was developed, Technical Assistance (TA) provided, and a pilot was planned to test procedures.

 

Georgia Innovation Award Activities

The Innovation Award allowed the Home Visiting Program to implement the first multi-tiered model for professional development. This model included a workforce needs assessment that was administered to home visitors and home visiting leadership, workforce development through partnerships, and workforce sustainability. Key collaborations were made with local colleges and technical schools, Georgia Department of Early Care and Learning (DECAL), the Council for Professional Recognition, the University of Georgia (UGA) J.W. Fanning Institute for Leadership and Development and the UGA School of Public Health.

 

Family and Community Supports worked directly with the Institute for the Advancement of Family Support Professionals (IAFSP) to complete a customized training platform for Georgia’s home visiting workforce. IAFSP offered all home visitors the opportunity to learn new skills and advance careers. Through engaging, online modules and a personalized learning map feature, professionals led professional growth and advancement with the National Family Support Competency Framework as a foundation. The Institute developed through a MIECHV Innovation Award built upon previous work of project partners to enhance professional development across the field. Iowa Department of Public Health and Virginia Department of Health were co-leads on this project.

 

Georgia Home Visiting sites participated in an Emergenetics training on September 9, 2019. Emergenetics is an assessment tool that allows individuals to assess his/her personality and use assessment results to provide guidance on optimal ways to interact with others in a professional or personal setting with minimal conflict. The session was attended by over 50 home visiting leaders with positive feedback. The session had 39 participants.

 

Lemonade for Life training was offered on August 28, 2019 to address the need for additional training in the area of toxic stress/Adverse Childhood Effects (ACEs). Lemonade for Life trained home visitors on how to use the ACEs Questionnaire and help families translate the results. The goal of this training was to provide home visitors with the tools to help promote resiliency within the families they serve and prevent future exposure to ACEs. Twenty-five home visitors participated in this training.

 

MCH developed a Home Visiting Career Toolkit that included Home Visiting Career brochures, postcards and other items to be distributed to students. The Home Visiting Career Toolkits were shipped to ninety-nine colleges and technical schools throughout Georgia and informed students about home visiting as a possible career. Each MIECHV site also received a career toolkit to share with students that may be interested in the field of home visiting as a viable career choice.

 

Collaborative efforts between the Home Visiting Program, colleges, and several home visiting sites resulted in the development of home visiting internships. The internship program was piloted with four students at two MIECHV sites. The MIECHV site in Columbus hosted three Health Promotion major students from Columbus State University. The MIECHV site in Watkinsville hosted one student from Athens Technical College that majored in Early Child Care Education. In 2019 the internship program expanded to12 students that completed internships at nine home visiting sites. Two students completed an internship with the Georgia Home Visiting Program at DPH. All participating sites were asked to have interns shadow at least three home visitors and assist in planning one group connection activity. Each student was asked to write weekly summaries during the internship and submit to the Innovation Coordinator at the end of the internship. One intern provided feedback of their experience stating, “The role of a home visitor can have an extremely positive impact on child development and the family unit. Home Visiting is something I could see myself doing in the future if I am to stick with general public health, but I can also apply the tactics if I continue on to become a pediatrician.” Many of the interns provided positive feedback and were appreciative for the opportunity.

 

The Home Visiting Program established scholarships that provided support for home visitors striving to earn the Home Visiting Child Development Associate (CDA) Credential. The CDA is one of the most widely recognized credentials in early childhood education and integral in the advancement of early childhood education professionals. The Home Visiting CDA Credential was developed using competency standards that focus on increasing family resiliency and increasing safer environments for children. The CDA scholarship included support to complete all prerequisite education needed to apply for the CDA, as well as the cost to complete the CDA application. The Georgia DPH Home Visiting Program awarded 30 CDA scholarships and four scholarship recipients successfully obtained the Home Visiting CDA Credential. The other home visitors continue to work towards completion with the support of the Home Visiting staff.

 

 

The Healthy Start Federal Grant, administered by HRSA's Maternal and Child Health Bureau, was awarded to MCH on April 1, 2019. Healthy Start aims to improve health outcomes before, during, and after pregnancy and, to reduce racial and ethnic disparities in rates of infant death as well as negative health outcomes in the first 18 months of life. Healthy Start funds supported the Georgia Strong Families Program (GSFP) implemented in the West Central Health District - Columbus and South Health District - Valdosta.

 

Current Year: Oct 2019 – Sept 2020

 

Priority Need: Prevent Infant Mortality

 

NPM 3: Risk Appropriate Perinatal Care

 

Maternal and Neonatal Levels of Care

A contract with the American Academy of Pediatrics (AAp) was established to use the AAP Verification Program for the application and site survey process for Level II and Level III Neonatal Center Designations. This contract was executed in January 2020. The online application for Level I Maternal and Neonatal Center Designations opened in February 2020.

 

Perinatal Regionalization

To strengthen the system of regionalization, there has been continued work on increasing communication with RPC stakeholders to include meetings with RPC medical directors and outreach educators as well as conference calls with finance staff and data coordinators.

 

The RPC’s in the six birthing regions in Georgia are actively responding to the current COVID-19 pandemic in addition to continuing to provide transport and high-risk care to mothers and babies across the state. Two perinatal regions, Albany in the rural southwest, and Atlanta, have been significantly impacted by the pandemic. Maternal and Neonatal Outreach educators from these two RPCs are supporting clinical needs within their facility in addition to providing support for their regions’ birthing centers.

 

A joint quarterly RPC Outreach Educator and Women’s Health meeting was held during January 2020 to plan regional training for the state’s birthing hospitals. A survey completed by all birthing hospitals identified a need for training for hospital staff to implement clinical simulation drills in their individual facilities. Clinical simulation drill implementation is required to implement maternal quality improvements for hemorrhage and hypertension emergencies. The curriculum was developed, and meeting invitations were sent to obstetrical unit staff in all birthing facilities in the state to attend one of five regional trainings scheduled in March through May. Due to the COVID-19 pandemic, the trainings were canceled. The trainings will be rescheduled when operations return to normal.

 

NPM 4: Breastfeeding

Breastfeeding

In the current year, the Georgia 5-STAR Hospital Initiative continued to provide technical assistance by phone, emails, and in person visits. In collaboration with the American Academy of Pediatrics- Georgia Chapter, DPH continued to deliver the EPIC breastfeeding program. In collaboration with WIC, Women’s Health provided breastfeeding educational trainings to all DPH staff including nurses, peer counselors, breastfeeding coordinators, nutritionists, and administrative staff. The team hosted a breastfeeding training, “Breastfeeding: Why are We So Squeamish About It?”. EPIC breastfeeding programs were also administered to hospital staff. A Mock Site Visit was conducted and designed to mimic the Baby Friendly USA designation assessment, allowing hospitals the opportunity to strategically approach continued areas of improvement and plan for a successful BFUSA designation, if desired. Clinical Competency Skills Lab Trainings were conducted to aid hospital staff in completing the five-hours of knowledge and skills competency verification as required by Baby Friendly-USA. To support virtual training opportunities, the Lactation Education Resource online training module was purchased.

 

SPM 3: Rate of Congenital Syphilis

 

Congenital Syphilis

The STD Office worked to prevent STDs by providing quality intervention strategies, programmatic support and education to all throughout the state. With a focus on Congenital Syphilis, the STD team works to promote first and third trimester testing for HIV and Congenital Syphilis, as well as to improve the data quality of Congenital Syphilis. In the current year, district and provider education continued. The following site visits and trainings were provided:

 

District Education

• Rome/Dalton Site Visit (October 1, 2019)
• Gainesville Site Visit (October 9, 2019)
• Congenital Syphilis Review Board Meeting (October 29, 2019)
• District Online Meeting (December 10, 2019)
• District Online Meeting (March 10, 2020)
• District Online Meeting (June 9, 2020)
• District Online Meeting (September 8, 2020)
• Statewide STD Update Meeting (May 27, 2020)

 

Provider Outreach

• Georgia Academy of Family Physicians Fall Conference (Nov. 14-16, 2019)

 

Challenges/barriers:

COVID-19 has limited the ability to plan or implement community outreach events in 2020.

 

Priority Need: Prevent Maternal Substance Use

 

SPM 4: Neonatal Substance Abuse

 

Neonatal Abstinence Syndrome

In the current year, GaPQC has continued to implement the NAS initiative with 46 (63%) of birthing hospitals in the state participating in the initiative. GaPQC supports the neonatal teams by hosting the monthly webinar series to facilitate education and collaboration. The didactic presentations are designed to guide hospitals through implementing interventions listed in the key driver diagram. We have included a QI focus as part of each webinar which follows the stages of the Model for Improvement from the Institute for Healthcare Improvement.

 

In March 2020 the neonatal subcommittee developed a survey for all hospitals participating in the NAS initiative. The purpose was to assess interventions implemented and where additional support could be offered. Preliminary survey results show the area of need to be on IT tools and using the Plan, Do, Check, Act (PDCA) cycle for rapid quality improvement. Based on the recent survey, the focus will be placed on increasing the frequency of QI technical calls, led by the neonatal physician champion.

 

Hospitals continue to receive their monthly VON Microlesson Completion Reports and received their first quarterly length of stay report containing data calculated from hospital discharge data. The reports outlined the average length of stay compared to other GaPQC hospitals. Revisions were made to the SMART Aim to decrease length of stay among newborns diagnosed with NAS in participating GaPQC hospitals from 16.3 days to 14.7 days by September 9, 2020, to reflect national recommendations with a 10% decrease. GaPQC received approval for Part Four Maintenance of Certification Credit from the American Board of Pediatrics for all pediatricians participating in the collaborative to further encourage physician participation.

 

GaPQC, along with all hospital teams and partners, are actively responding to the current COVID-19 pandemic and preparing for how GaPQC can support hospital systems to continue to improve maternal and neonatal outcomes without further taxing the system. Women’s Health will continue to use resources to support communities and continue to offer technical assistance as requested during these unprecedented times.

 

The Microsoft Teams platform has been utilized to maximize data sharing and create a webinar platform that is user-friendly and robust enough for recording and posting webinars for on-demand viewing. GaPQC supports the maternal and neonatal teams by hosting a monthly webinar series to facilitate education, collaboration, and support the process and structure measures for both AIM bundles and interventions for the NAS initiative. Webinars feature subject matter experts and hospital teams from Georgia and other states to share experience implementing the interventions.

 

A one-hour webinar to support hospital teams who are on the front lines caring for pregnant and birthing women and their infants during the COVID-19 pandemic was presented and led by a panel of experts in obstetrics and neonatal care, including our physician champions for NAS and the AIM bundles. Participants were given the opportunity to ask questions, share resources, and learn from one another. In-person trainings were changed to virtual when possible. The implicit bias training for hospital teams included a four day in-person train-the-trainer style training and the clinical simulation and debrief trainings included hands-on simulation and demonstration.

 

Challenges/barriers: At this time, decisions are based on the consideration of safety for staff and partners on the front lines of the COVID-19 pandemic. GaPQC is being proactive to minimize engagement by actively strategizing to build relationships that do not involve travel or meeting in person for the foreseeable future. Options continue to be explored to provide hospitals with rapid access to data in order to inform their QI initiatives and plans.

 

Rural hospital challenges: Even with funding provided for some, several of the rural facilities struggle with dedicating resources to the AIM project.

 

Related legislation: O.C.G.A. §31-12-2 (2017) statutory reporting requirement for NAS

 

Other Perinatal/Infant Health Programs

 

Newborn Screening

NBS is a life-saving public health service offered universally to infants born in Georgia. At the federal level, the Advisory Committee on Heritable Disorders in Newborns and Children (ACHDNC) conducts thorough evidence reviews to determine if a condition should be added to the Federally Recommended Uniform Screening Panel (RUSP). Georgia’s condition review process is similar to that at the federal level and Georgia typically adheres to RUSP. Recently, Georgia added and successfully implemented four new conditions to the NBS panel (Pompe Disease, Mucopolysaccharidosis Type I, X-linked Adrenoleukodystrophy and Spinal Muscular Atrophy). The implementation process included targeted communication to families via the NBS brochure and targeted information sent directly to hospitals and physicians who routinely submit NBS specimen, and general updates on the process shared during stakeholder meetings and Board of Health meetings. Staffing for short-term follow-up services was also expanded to meet the anticipated increase in infants that screen positive for a condition on the NBS panel. The Georgia Public Health Laboratory successfully purchased and calibrated new equipment, validated new testing methods, and completed updates to the IT systems that support efficient screening and follow-up.

 

DPH completed a NBSAC recruitment cycle and engaged more family representatives and more representatives from areas outside the metro-Atlanta area. In February 2020, the NBSAC held a regularly scheduled semi-annual meeting during which a nomination to add Krabbe disease to the state NBS panel was presented. The NBSAC established a workgroup to review the condition and implications of adding Krabbe to the state panel. The work group members include the co-chair of the NBSAC, a physician skilled in pediatric transplantation and gene therapy, a family member of a child with Krabbe, a genetic counselor and board member of KrabbeConnect, a clinical, biochemical, and molecular geneticist, the Director of the NBS short-term follow-up program, a pediatric neurologist and the parent of a child with a condition identified through newborn screening. The work group met monthly for a six-month period, conducting independent research and discussing the evidence based on standard criteria. The workgroup will have an opportunity to present a summary of findings and recommendations to the NBSAC during the next semi-annual meeting.

 

The NBS program designed and implemented a quality improvement project to improve the quality of specimen collection and decrease the number of days the specimens are in transit to the DPH Laboratory. The project was designed for small cohorts of hospitals to be engaged over a six-month period. In December 2019, the NBS Team successfully conducted an initial training for the project, which welcomed 23 nursing staff from ten birthing facilities in metro-Atlanta. All ten hospitals identified two NBS Champions per facility and agreed to participate in the six-month QI project. During the training, participants learned about NBS specimen collection, data collection and the principles of quality improvement and small acts of change. At the close of the kickoff training, the ten QI hospitals staff received posters and “badge buddies” that display instructions for specimen collection, and illustrations on acceptable versus unacceptable specimens to share amongst fellow staff who routinely collect NBS specimen. Following the initial in-person meeting, the NBS team held monthly cohort calls with NBS champions to discuss strategies they implemented during the month and the impact of the strategies on specimen quality or transit time.

 

To truly realize the benefits of NBS, the NBS program supports comprehensive strategies to enable the development of infants identified with a condition via NBS. For example, In the previous funding year, the sickle cell short-term follow-up and hematology program through Augusta University added a social worker to the team to help better coordinate care for infants and children with sickle cell, or other significant hemoglobinopathy. This program services children in Augusta and conducts outreach clinics in South Georgia. Children and families who attend these clinics have access to medical care and to case management services coordinated by the social worker. The social worker most often helps families address needs for transportation, social security appeals, school 504 plans, family leave request, and community resources. The social worker also conducts developmental screens on children who have not had one conducted by their primary care physician or for who the hematologist has concerns. Any child that that showed signs of developmental delay is referred to their primary care provider for further follow up.

 

In the current year, the Medical Nutrition Therapy for Prevention (MNT4P) Program provides ongoing services to individuals with conditions identified through NBS. Medical nutrition therapy is the primary and lifelong treatment for most of the inherited metabolic disorders (IMD) diagnosed through NBS. The MNT4P is working to improve health outcomes and the quality of life for individuals with IMDs by increasing access to medical nutrition therapies necessary for treatment and maintenance of these metabolic disorders.

 

NBS and NBS follow-up has been sustained during the COVID-19 pandemic. Adjustments have been made to protocols to maintain the urgency of follow-up while minimizing risk of exposer to the virus. NBS follow-up teams conduct conference calls with subspecialists to whom they typically refer infants that require further testing or are diagnosed with an NBS condition. During the calls, the teams discuss processes specialty clinics have put in place to keep children safe during appointments and under what circumstances a child’s follow-up appointment may be postponed avoiding unnecessary exposure to the coronavirus. The follow up teams included this new information in letters faxed to primary care providers when an infant screen positive for an NBS condition. Specialists maintain 24/7 call lines to support pediatricians providing services to infants and children with an NBS condition. The sickle cell follow-up teams provided supplementary guidance to pediatricians around initiating penicillin prophylaxis in cases where families are delayed in accessing follow-up or choose not to schedule an appointment with a hematologist during the pandemic. To maintain continuity of care, telephone visits are conducted for non-urgent patients.

 

Emerging Threat Response-Epidemiology

During the current year, several activities have been performed to maintain and enhance the surveillance of Zika-related health impacts through the development of the Congenital Infections Registry (CIR) and expansion of the Epidemic Response Team. Other congenital exposures have been included in the initial proposal of the CIR, including syphilis and hepatitis C. Most recently, with the ongoing COVID-19 pandemic, exposure to SARS-COV-2 began integration into the CIR as well.

 

MCH EPI was awarded Component W of the Epidemiology and Laboratory Capacity grant in August 2019. To accomplish longitudinal surveillance of emerging congenital infections, a SendSS module, the Congenital Infections Registry (CIR), began construction. Several staff have been hired to carry out the effort, including an Epidemiologist to serve as the Congenital Infections Registry Coordinator (CIRC2), a Medical Records Epidemiologist Liaison (MREL), and a CDC Contractual Field Staff (CFS). The CIRC2, MREL, and CFS joined the Newborn Surveillance Team to work closely with the Infant Outcomes Surveillance Manager (IOSM) on the CIR. Syphilis was the first congenital exposure selected for the CIR. The Newborn Surveillance Team have worked closely with the Technical Developer, STD EPI, and STD Program staff to (1) select with CDC key variables for surveillance; (2) map variables common among the STD Case Management module in SendSS, Vital Records (VRs), and variables requested by CDC for SET-NET; (3) create a workflow that triggers a case to be shared between the STD Case Management and CIR modules in SendSS; (4) develop a data export mechanism for validation and reporting to CDC on a quarterly basis; and (5) with the help of district Disease Investigation Specialists (DIS), collect, review, and abstract medical records for submission to CDC. To date, the CIRC2 and CFS have begun working on the 2018 syphilis cohort (N=207) by abstracting the birthing hospital records and initiating follow-up of 52 dyads composed of pregnant women with confirmed syphilis disease and infants with congenital syphilis exposure. The CIRC2 has successfully reported the initial forms (i.e., maternal health history and pregnancy outcome and birth forms) of these 52 dyads to CDC.

 

Safe Sleep

In the current year, all 77 Georgia birthing hospitals have participated in the hospital-based initiative. The following activities supported hospitals in their efforts to educate families about safe sleep practices:

 

• Distributed “this side up” infant gowns to birthing hospitals. This portion of the hospital-based program, as well as the travel bassinet distribution, ended in the current year.
• Distributed the “Sleep Baby Safe & Snug” board books to 75 of the 77 facilities.
• Developed a guide to assist Children’s Hospitals with implementing a safe infant sleep program.
• Expanded the Children’s Healthcare of Atlanta quality improvement project to all three campuses to improve modeling of safe infant sleep. Policy has been approved and put into place for safe sleep. A second article on the effort was accepted for publication in the Journal of Injury Epidemiology.
• Finalized an outcome evaluation of the hospital-based safe infant sleep program with the birthing hospitals. Kennesaw State University was the principal investigator. Results were positive.
• Participated in the Emory Healthcare baby shower program for expecting employees.
• Provided hospital representatives with an online safe sleep training that families and caregivers can take instead of traveling to an in-person class, to help with education during social distancing due to COVID19.

 

The safe infant sleep program distributed educational materials throughout the state, including safe infant sleep educational flipcharts for educators, one-page handouts on the safe sleep environments, safe sleep brochures, crib cards, Spanish language materials and safe sleep books. The program conducted focus group testing of newly created room sharing educational materials at six sites around the state. The materials were revised based on feedback. The materials were developed to specifically address the high number of sleep-related infant deaths that occur within the adult bed each year (>50 percent of all deaths). Materials will be distributed through PCM sites, OBGYN offices and other locations.

 

The program also launched the “Safe Infant Sleep Collaborative Network”. The network is a tool meant to provide updated resources, peer support and education on safe infant sleep to anyone working with families. The program also continues to promote and teach the “train the trainer” sessions to help build local capacity to provide safe infant sleep education within their communities.

 

The program expanded the previously designed, developed and implemented, “floor talker” educational opportunity in collaboration with the Child Fatality Review Panel to 244 additional sites throughout Georgia, including MCH home visiting sites, with specific focus to the areas with the highest rates of sleep-related infant mortality.

 

The program designed, developed and began implementation of a “Safe Infant Sleep Education and Crib Distribution” program specifically designed for areas where the birthing hospital has a Medicaid-enrolled birth census at 75 percent or greater. The program is designed to address health inequity for families enrolled in Medicaid due to Medicaid-enrolled families having a four times greater risk of sleep-related death than families with any other insurance payer.

 

Additionally, the Safe Sleep program worked with the national representative assigned to Georgia, from the National Center on Shaken Baby Syndrome to help address areas with the highest reported numbers of abusive head trauma.

 

The program had two poster presentations and one oral presentation:

• Wisconsin Association for Perinatal Care Annual Conference: Salm Ward, T. C., Miller, T. J., & Naim, I. A. (2020). Evaluation of a multi-site safe infant sleep education and crib distribution program in Georgia. Poster.
• University of Georgia State of Public Health Conference: Salm Ward, T. C., Miller, T. J., & Naim, I. A. (2020). Evaluation of a multi-site safe infant sleep education and crib distribution program in Georgia. Poster
• American Academy of Pediatrics Annual Conference (2019) Lazarus, SG., Miller, T.J. Expansion of a multi-pronged safe sleep quality improvement initiative to three children’s hospital campuses. Oral Presentation

 

Family and Community Support Services

In the current year, the Family and Community Supports program continues its commitment to implement evidence-based, comprehensive and community-based maternal and early childhood programs. Home Visiting programs currently include the Early Head Start Home Based Option (EHS-HBO), Healthy Families Georgia (HFG), Nurse Family Partnership (NFP), and Parents as Teachers (PAT). Family and Community Supports partners with the MMRC and participates in their action-oriented processes providing education and resources for women and infants through outreach activities in the community.

 

To strengthen collaboration with the Healthy Start grantee sites and Title V, Family and Community Supports coordinates and conducts a quarterly call with the six Healthy Start sites in Georgia and the Healthy Start National Project Officer to foster collaboration and team building and identify opportunities to leverage resources for successful partnerships. The most recent quarterly call focused on home visiting protocols amid the COVID-19 pandemic which included Home Visiting sites developed strategies to provide services to clients via phone, virtual visits, and group activities. Several sites have implemented innovative strategies such as mailing educational materials and information to families as well as developing educational videos to send to families for review and participation with families at home. Home visitors have implemented strategies to deliver these items to the families and observe the social distancing recommendation.

 

Continuous Quality Improvement Cohort

In the current year, FACS has participated in the Continuous Quality Improvement Cohort (CQI) The CQI approach assist home visiting programs to measure processes and outcomes, incorporate new knowledge and practices in a data-driven manner, highlight training and technical assistance needs, help monitor fidelity of program implementation and provide rapid information on a small scale about how change occurs. CQI also helps to identify key components of effective interventions and empower home visitors and program administrators to seek information about their own practices. CQI has the potential to be transformative for programs and is an opportunity to improve upon everyday practices in small ways that result in large gains in program efficiency and services delivery.

 

Specific Community of Practice

• January 14, Maternal Depression cohort- one Title V attendee, Bibb.

Outcomes- Melissa Keane, a Perinatal Mental Health Counselor, Postpartum Support International’s Georgia Chapter, provided a Perinatal Mental Wellness Presentation. Attendees were encouraged to take a CQI action step after the presentation and explored potential process steps for incorporating Postpartum Support International Georgia as a new resource for supporting participants with maternal depression.

• January 27, Parent Child Interaction cohort- two Title V attendees, Bibb and Gordon.

Outcomes- The session focused on peer sharing of current tests, strategies for introducing PCI to newly enrolled families, strategies to increase PCI with existing families, and holding the gains from the previous year.

 

Power of Your Data Model Specific Webinar Series

• February 18, Parents as Teachers session- one Title V attendee, Gordon.

Outcomes- The session focused on custom reports, trends observed in data cleaning efforts and using data for improvement. Participants gained new insights into how to use the Home Visiting Deliverable, Intake and newly added Home Visiting Referrals made to Service Providers reports in their ongoing supervision efforts; including the use of data for improvement. Highlighted current trends observed in data cleaning efforts, exploring potential challenges with collecting and documenting the Well Child Visit Record. Program Supervisors provided feedback on the type of data that would best support their work.

 

The tenth annual Georgia Home Visiting Institute (HVI) was held virtually on August 18, 2020, with 274 attendees present. Originally scheduled as in in-person meeting at the Peachtree City Hotel and Conference Center in Peachtree City, Georgia, the event was held virtually using the Zoom video conferencing platform due to the COVID-19 pandamic. The HVI was sponsored by DPH in partnership with United Way of Greater Atlanta. The Georgia Home Visiting Professional Development Work Group served as the HVI planning committee comprised of state leaders of Georgia’s early childhood home visiting programs and state partners committed to strengthening and professionalizing the field of home visiting. 

 

The primary objective of the HVI was to provide high-quality training for Georgia home visitors, supervisors, and community outreach staff to develop and enhance core competencies critical to their work. The HVI addressed strategies to improve the quality and effectiveness of home visiting services. The goal of the 2020 HVI was to provide quality learning and skill-building opportunities for home visiting and early childhood professionals in Georgia. Strategies for strengthening individual programs and services, networking with partners and peers in the field, and opportunities for collaboration to strengthen the system of family-serving programs throughout the state were also provided.

 

The keynote plenary was led by Dr. Junlei Li, the Saul Zaentz Senior Lecturer in Early Childhood Education at Harvard Graduate School of Education and Dr. Dana Winters, faculty director of the Fred Rogers Center for Early Learning and Children’s Media, Saint Vincent College. The Fred Rogers’ Center promotes the legacy of Fred Rogers’ and his deep commitment to showing children the utmost respect and caring in every interaction. In the virtual plenary, Drs. Li and Winters co-led an overview of the Simple Interactions approach, designed to help affirm the power of human relationships in both ordinary and unusual times. Dr. Heather Forkey, Associate Professor of Pediatrics at the University of Massachusetts Medical School, and Division Director for the Child Protection Program and Foster Children Evaluation Service (FaCES) of the University of Massachusetts Memorial Children’s Medical Center, also presented. Dr. Forkey presented on the concept of “self-regulation” and provided practical strategies for guiding caregivers to self-regulate, support attachment, address challenging behaviors, and promote co-regulation of kids.  

 

Oral Health

The Oral Health Program provided Home Visitors a flipbook guide on oral health to help educate families on improving oral health behaviors. It was originally created by the Rhode Island state Oral Health Program and Oral Health Coalition with feedback from Home Visitors. The flipbook was adopted with permission and rebranded by Georgia DPH. Flipbooks were provided to all the Home Visitors in the state and are provided to families through home visits.

 

Challenges/barriers: The COVID-19 pandemic created a need for flexible and sustainable service delivery solutions to ensure that families continue to receive the benefits provided through home visiting programs. Although traditional, face-to-face home visits are currently discontinued, virtual visits are being conducted and the responses from home visit providers and clients are positive. MCH is committed to ensuring that families continue to be provided with evidence-based programs and support throughout the pandemic.

 

Improving Birth Outcomes

In the current year, MCH created the Improving Birth Outcomes Initiative to amplify efforts, identify gaps, and create a collective, streamlined set of priorities to reduce infant mortality rates. The Improving Birth Outcomes Initiative has developed strategies to support improving birth outcomes and reduce premature births and infant mortality among all infants, specifically black infants, by creating partnerships and collaborations aimed at focusing on the Social Determinants of Health (SDOH) and addressing the correlations between race, equity, infant mortality and pre-term birth. MCH has introduced a community approach that includes community-based outreach and education as an essential component that has the potential to substantially improve infant health outcomes.

 

During the current year the Improving Birth Outcomes Initiative, MCH in partnership with HMHB and the Georgia Bureau of Investigations, convened the Infant Mortality Working Group including representatives of area health and human service agencies  to participate in a strategic planning process for the Georgia Improving Birth Outcomes Initiative. Strategies to improve infant mortality, specifically infant mortality in the Black population will be developed.  

 

MCH is partnering with the Office of Vital Records to improve Fetal Death Certificate reporting. When reported accurately, Fetal Death Certificate data will positively impact the ability to interpret and draw conclusions on the Perinatal Periods of Risk analyses and/or other analyses involving fetal deaths, improving the ability to inform programmatic decision making and impacting conclusions on infant mortality.

 

MCH is collaborating with the Mercer University School of Medicine’s Center for Rural Health and Health Disparities to conduct a qualitative mixed-methods analysis in rural areas of the state with high infant mortality rates to understand the landscape of the community to better assess needs. Exploring rural and urban mortality differences examines the impact of rurality on infant mortality and explores regional differences in primary and underlying causes of infant mortality. The environmental scan will explore socio-economic determinants of health including poverty, education, rural attitudes and culture, psychosocial risk factors, access to healthcare, employment, transportation, insurance status and other risk factors such as smoking rates, obesity, and safe sleep practices. The environmental scan will guide strategic planning and decision making to lead to evidence-based responses that improve birth outcomes in rural communities.  

 

MCH will continue to support evidence-based home visiting programs in communities where infant mortality rates are disproportionately impacted by the leading causes of infant mortality and encourage participation in the Healthy Start CANs to enact community-level change in reducing disparities.

 

Strategies are being developed to expand the MCH 1st Care Program to additional counties in the state in order to provide public health nursing in-home assessments and education to families after premature and low birth weight babies are discharged from the hospital.

 

Plans to develop a Community Engagement Toolkit to promote collective impact and health equity is being developed to provide community organizations with structured guidance on the issues to consider when planning and designing community engagement to improve birth outcomes in a community. The toolkit will focus on quality and effectiveness, process planning, and designing engagement tailored to the community and stakeholders affected.