Wyoming’s public health system is mixed (centralized and decentralized), with four independently run county health departments and the remaining 19 counties utilizing both state and county staff. The MCH Unit works closely with both state and county staff in all 23 counties to assure access to home visiting and care coordination services for CSHCN, high risk pregnant women, and high risk infants. Assuring access to these services is especially important in rural and frontier communities with limited providers. Ten counties have no obstetricians/gynecologists and 12 counties have no pediatrician. Limited access to both primary care and specialty providers means that many families seek care across state lines. This makes the health care delivery system in Wyoming unique and challenging. 

Both MCH and PHN participate in the Wyoming Home Visiting Network (WYHVN). This network of committed stakeholders promotes a system of high quality home visiting from pregnancy through age three as a core early childhood service available to all Wyoming families. Key stakeholders include Early Head Start, Early Intervention Services (Part C and Part B), Parents as Teachers (i.e. Wyoming Maternal, Infant, Early  Childhood Home Visiting (MIECHV) grantee), and Family Spirit, a tribal home visiting program.

Using primarily matching funds, the MCH Unit’s Children’s Special Health (CSH) program provides gap-filling financial assistance and care coordination services for eligible high risk pregnant women, high risk infants, and children with special health care needs. MCH is the payer of last resort; in order to be eligible for assistance, families must first apply for Medicaid, Kid Care CHIP (Child Health Insurance Program) and the Federal Marketplace. The program provides reimbursement to eligible providers for covered services provided to eligible clients. Program eligibility is determined based on financial and medical criteria.

CSH care coordination services are provided by state-level MCH/CSH Benefits and Eligibility Specialists and local-level PHNs. Examples of care coordination services provided include:

• Working with the client/family to identify needs, concerns, and priorities;
• Supporting families in following the client’s plan of care and recommended preventive well-child visits (e.g. tracking and providing appointment reminders based on care plan and Bright Futures periodicity chart);
• Locating, accessing, and connecting families to needed community services and resources;
• Assuring services are coordinated among interdisciplinary team members and across programs and agencies;
• Assuring families have access to health care coverage (e.g. helping families sign up for Medicaid, Kid Care CHIP, Marketplace, etc.);
• Investigating billing problems;
• Providing support for transition to adult health care services;
• Providing support for interpretation and translation services; and
• Evaluating the effectiveness of service delivery in meeting client and family needs.

Through a partnership between the MCH Unit, Parents as Teachers National Center (PATNC), and other key early childhood system partners, efforts are underway to map the early childhood system. The MCH Unit participated in the development of a Request for Proposals (RFP) for MIECHV needs assessment activities to include a systems map. The RFP guidance includes instructions for the proposer to consider the needs and services for CYSHCN in completion of the needs assessment and map. The MCH Unit will be significantly involved in the completion of the MIECHV needs assessment, as will PATNC in the completion of the Title V needs assessment.

In 2016, the MCH Unit and MCH Epidemiology Program completed the Levels of Care Assessment Tool (LOCATe) in order to better understand the system of perinatal care in Wyoming. Results confirmed that Wyoming is the only state without a level III/IV maternal or neonatal care hospital. This means that many pregnant women, children, and families must seek care out of state. Over ten percent of births occur outside of Wyoming. There is limited data available to determine the reason for delivering outside of the state. There are plans to repeat LOCATe statewide using a revised tool once it is released. The act of completing the assessment has significantly increased engagement with the Wyoming Hospital Association as well as with individual facilities. The LOCATe results also led to quality improvement projects including Wyoming facilities’ participation in a Utah Project Extension for Community Healthcare Outcomes (ECHO) on the maternal hypertension safety bundle. In late 2017, a group of stakeholders committed to improving perinatal health voted to establish a Wyoming Perinatal Quality Collaborative (WYPQC) and in 2018, a WYPQC Coordinator contract was executed. This is an example of MCH Unit’s efforts to provide a systems-building approach to ensuring access to high-quality health care services for Wyoming pregnant women and infants. 

Partnership with Medicaid

In Wyoming, Title V and Medicaid are housed within one agency which allows for frequent communication and partnership. Partnership is formalized by a 2013 interagency agreement and is strongly supported by WDH leadership. Specifically, senior administrators for PHD and Healthcare Financing (Medicaid) meet monthly to discuss ongoing and new collaboration opportunities. The MCH Unit routinely provides updates to the PHD Senior Administrator to discuss during these partnership meetings.  MCH and Medicaid actively partner to address the following state priority needs:

• Reduce infant mortality
• Improve access to and promote the use of effective family planning
• Promote preventive and quality care for children and adolescents
• New: Prevent maternal mortality

In 2017, the MCH Unit received technical assistance related to Early and Periodic Screening, Diagnostic and Treatment (EPSDT), a topic prioritized by both the MCH Unit and Wyoming Medicaid. Collaboration on this project is formalized in a required interagency agreement which states that both entities shall “coordinate and collaborate in planning and implementing services related to maternal and child health populations including well-child checkups” (e.g. EPSDT). Collaboration on EPSDT and implementation of Bright Futures is essential in order to improve Wyoming EPSDT rates which currently rank 44th in the Nation.  Dr. Wendy Davis from the University of Vermont, College of Medicine presented during Wyoming’s 2017 Block Grant Review and during an October 2017 Wyoming Medicaid Medical Advisory Group (MAG) meeting.  Following Dr. Davis’ presentation on Bright Futures, 4th Edition and the promotion efforts in Vermont, the MAG voted to adopt the Bright Futures Guidelines, 4th Edition in Wyoming. In order to maintain momentum on this important cross-division project, the MCH Unit submitted a successful application for the Title V MCH Internship Program. Two graduate-level interns worked with MCH, Medicaid and other key stakeholders to develop a plan to implement Bright Futures, 4th Edition during Summer 2018. This joint project supports Wyoming’s 2016-2020 Title V priority to improve preventive and quality care for children and adolescents, a priority which directly aligns with three (3) Title V National Performance Measures (NPM). They include NPM 6: Developmental Screening, NPM 10: Adolescent Well Visit, and NPM 12: Transition. The student-developed plan to implement Bright Futures can be viewed in Appendix C. In 2019, the MCH Unit will reconvene interested stakeholders to prioritize and implement the students’ recommendations. The first step is to form a Bright Futures Implementation Task Force. So far, the MCH Unit has commitment from Wyoming Medicaid, WYhealth, and the Immunizations Unit to participate. 

Health insurance coverage for children in Wyoming is an emerging concern. The MCH Unit promotes enrollment in Medicaid primarily through the Healthy Baby Home Visitation Program and CSH Program. Specifically, in order for families to be eligible for CSH financial assistance, they first must apply for Medicaid, as CSH is the payor of last resort. PHNs at the local level provide support to families in applying for Medicaid. State-level CSH care coordinators also provide support to families in applying for and navigating Medicaid benefits.

In 2018, the CSH program facilitated a discussion between Medicaid and PHNs on the availability of waivers for the MCH population, specifically those with special health care needs.  The waivers include:

• Developmental Disabilities Waiver, including Supports and Comprehensive  Waivers. These waivers are open to children, adults and those with acquired brain injuries.
• Children’s Mental Health Waiver. This waiver is open to children 4 - 20.

A number of collaborative MCH/Medicaid projects have or have the potential to include joint policy level decision-making. For example, the Medicaid MAG’s vote to adopt Bright Futures, 4th Edition, was informed by a MCH-facilitated presentation by national EPSDT/Bright Futures expert Dr. Wendy Davis. Another opportunity for joint policy level decision making relates to reducing barriers to the use of long-acting reversible contraception (LARC). MCH and Medicaid jointly participated in Association of State and Territorial Health Officials (ASTHO) Improving Access to Contraception learning community and learned that facilities and providers may be disincentivized from stocking and offering LARC due to bundled Medicaid payments. On April 8, 2016, the Department of Health and Human Services' Centers for Medicare & Medicaid Services released an informational bulletin detailing payment and policy approaches several state Medicaid agencies have used to optimize access and use of LARC methods. One such approach requires unbundling payment for LARC from other labor and delivery services in hospital settings and from encounter fees in rural health clinics, federally qualified health centers, and Indian Health Services clinics.  See Women/Maternal Health Domain Annual Report for more details on current efforts to change Medicaid policy related to LARC reimbursement. 

The TItle V-Title XIX interagency agreement was last updated in 2013. In Fiscal Year 19, the MCH Unit plans to facilitate discussions regarding current language and proposed updates. The programs will reference the National Academy of State Health Policy (NASHP) report “Strengthening the Title V-Medicaid Partnership: Strategies to Support the Development of Robust Interagency Agreements between Title V and Medicaid.”