Maryland Title V identifies the priority needs for women’s/maternal health as “ensuring that all birthing people are in optimal health before, during, and after pregnancy,” and “addressing the racial disparities in Severe Maternal Morbidity rates among Black NH and White NH.”
To this end, in SFY 2022, Title V will employ the following strategies to improve maternal health outcomes statewide:
Preventive Dental Visit-Pregnancy
During State Fiscal Year (SFY 2022), the Office of Oral Health (OOH) will leverage its established partnership with the Maryland section of the American Congress of Obstetricians and Gynecologists (ACOG) to disseminate Oral Health During Pregnancy: Practice Guidance for Maryland’s Prenatal and Dental Providers through local health departments and other providers. The practice guidance contains essential information on oral health during pregnancy, including background on oral conditions during pregnancy, myths, and facts about the safety of oral health care for pregnant women, pharmacological considerations for dental care for pregnant women, and detailed practice guidance for prenatal providers. The document also includes a variety of associated resources for use in practices and for patients. In addition, the OOH will also provide detailed information on how to apply the document’s guidance in their practices. The Office of Oral Health team will conduct outreach to providers to assist them in establishing local referral networks for their pregnant patients, with the goal of increasing access to oral health care for this population.
Maternal and child health care coordination at the local health department will continue linking pregnant people who are referred through the Maryland Prenatal Risk Assessment (PRA) to oral health providers as part of their care coordination.
Smoking During Pregnancy
For SFY 2022, Title V will continue and strengthen the partnership with MDH’s Center for Tobacco Control and Prevention. Specifically, Title V will work with local health departments for care coordination and connect individuals who smoke tobacco to the QuitLine or local health department tobacco cessation programs. QuitLine Coaches use cognitive behavioral coaching and practical skill-building to reinforce effective coping strategies, help the participant manage stress, and build self-efficacy. The QuitLine is a free service to all Maryland residents age 13 and older. Title V will also collaborate with the Center for Tobacco Control and Prevention to update a tobacco cessation toolkit for OB/GYN providers.
Overdose Mortality for Women ages 15-49
In SFY 2022, the Maryland Family Planning Program will focus on expanding SBIRT (Screening, Brief Interventions, and Referrals to Treatment) throughout their 62 service sites across Maryland. In addition, the program will focus on improving partnerships between substance use disorder clinics and family planning clinics particularly in Western and Northern Maryland.
Title V will continue to partner with Medicaid and the Overdose Data to Action (OD2A) funded under Centers for Disease Control and Prevention to improve linkages to care, specifically implementing an electronic version of the Prenatal Risk Assessment (e-PRA). During SFY 2022, Title V will work with Baltimore City, Baltimore County, and Anne Arundel County to increase the number of prenatal clinics referring clients to local health departments for care coordination. The Baltimore Metro region was chosen as an initial site to leverage existing efforts of clinics using the e-PRA. In addition, Title V will partner with OD2A to update the postpartum infant maternal referral form (PIMR), that is used to link birthing people and infants to care coordination at local health departments as well as partner with the State’s Health Information Exchange (HIE), called CRISP.
In addition, Title V and OD2A will partner together to develop a toolkit for substance use prevention and linkage to treatment targeted towards public health professionals. The toolkit, developed in partnership with The Association of State and Territorial State Officials (ASTHO), will include information such as sample linkage to care workflows, Maryland program highlights, and links to existing resources, such as previously developed toolkits and existing provider services. The toolkit is currently in a draft phase and is slated for dissemination by the Fall of 2021. Additional appendices that target the care needs of specific populations (such as the maternal and child health population) will also be developed during SFY 2022.
Finally, Title V will understand opioid use through PRAMS by analyzing the supplemental questions on opioid use that will be used for further public health action.
Maryland has a unique health care finance structure by agreement with the Centers for Medicare and Medicaid Innovation (CMMI), called the Total Cost of Care. By agreement with CMMI, the State has adopted a Statewide Integrated Health Improvement Strategy (SIHIS) to advance hospital quality, care transformation across the health care system, and population health. The last goal, total population health, has three domains: diabetes, opioids, and maternal and child health. The maternal and child health goal has two specific outcomes of interest: severe maternal morbidity and childhood asthma. CMMI approved the State’s strategy proposal on March 17, 2021.
As maternal and child health was identified as the third domain within population health, the Health Service Cost Review Commission approved an additional $40 million dollars over four years to meet the SIHIS Maternal and Child Health goals. The majority (80%) of the funds will go towards Medicaid to increase linkages to care for birthing people with opioid use disorder, reimburse for doula/birth worker support services, and expand group based prenatal care and maternal and infant home visiting. The remaining funds will go towards public health services to expand asthma home visiting, promising practice and evidence based home visiting, as well as expanding group prenatal care for birthing people, regardless of payor. During SFY 2022, the Title V program and Maternal and Child Health staff will be working to expand the programs identified through SIHIS.
Maryland Perinatal-Neonatal Quality Collaborative
The Maryland Perinatal-Neonatal Quality Collaborative (MDPQC) is focused on addressing maternal hypertension. For SFY 2022, the MDPQC will focus on sustained implementation of quality improvement initiatives, which will include identifying barriers, assisting low performers, and continuing regular check-in calls, learning events, and data reporting. An in-person learning event will be organized to provide updates and invite high performers to share best practices and lessons learned. The effectiveness of the collaborative will also be assessed at the midpoint of each initiative, with the Steering Committee and participating hospitals providing feedback, and a root-cause analysis will be conducted for any under-performing measures, as needed. The MDPQC will continue to heavily focus on health disparities and will push out data-driven improvement activities and resources to promote health equity.
Maternal Health Innovation Program
In SFY 2022, the Title V Program will continue to work with the Maternal Health Innovation Program, also called “MDMOM,” by Johns Hopkins University, and specifically finalizing the statewide maternal health improvement strategic plan. The maternal health improvement strategic plan will focus on five goals: 1) promote equity and mobilize against racism in maternal health, 2) achieve maternal health (preconception, prenatal and birth, postpartum and inter-partum periods) using the life course models to support Maryland mothers through advocacy and implementation of policies, 3) improve resiliency for birthing people, families and communities that acknowledge the importance of relationships social determinants of health for an optimal quality of life, 4) improve access to and utilization of data to make informed decisions, and 5) develop a maternal health workforce that will be available, accessible, and culturally relevant and based on principles of racial equity and justice.
In SFY 2021,Title V through MDMOMs held a competitive bid for an Equity Advisor. For SFY 2022,Title V will continue to work with the Equity Advisor to ensure the strategic plan incorporates equity principles and provide recommendations on analysis and contextualization of data to demonstrate the impact of racism, determinants of equity, and determinants of health. This data and information will be used to develop Title V local health department grant applications with an equity focus. Additionally, the Equity Advisor will work with the Title V Manager to outreach and develop partnerships with community-based organizations.
Finally, Title V will partner with the Maternal Health Innovation Program (MDMOM) core leadership team to scale up the severe maternal morbidity review process, continue implicit bias training for perinatal providers, and implement the maternal health warning signs for home visitors.
Maternal Mortality Review Committee
During SFY 2022, the Maternal Mortality Review Committee will continue to conduct de-identified, confidential case reviews for all pregnancy-associated deaths to identify clinical and non-clinical factors and systems issues contributing to these deaths. There will be additional focus on streamlining medical records requests as there were challenges in obtaining records during COVID-19 pandemic. More attention will be focused on understanding the broader context of the cases and environments by reviewing the social determinants of health (e.g., poverty level of the area, high food priority area), maternal and child health services (e.g., home visiting, WIC, administration care coordination unit) in addition to the medical records. A competitive bid process will be conducted for the administration of the Maternal Mortality Review Program during SFY 2022 to expand the scope of work of the coordination activities.
The Maternal Mortality Stakeholder Group will continue to review the findings and recommendations in the annual Maternal Mortality Review Report, examining issues resulting in disparities, and identifying new recommendations with a focus on disparities in maternal deaths. These findings will inform the Maternal Health Improvement Program Task Force as the implementers of the Maryland Strategic Plan.
Maryland Family Planning Program
The Maryland Family Planning Program will continue to promote optimal health outcomes for men, women, and families through ensuring access to breast and cervical cancer screening, prevention and treatment of sexually transmitted infections, HIV testing and prevention education, infertility and preconception services, health education and counseling and referrals to community resources. This program provides access to affordable, broad range of family planning methods, including Fertility Awareness-Based to assist individuals with their reproductive life plan, which includes postponing, preventing, achieving and the spacing of their pregnancies. In SFY 22, the Maryland Family Planning Program will focus on expanding SBIRT (Screening, Brief Interventions, and Referrals to Treatment) throughout their 62 service sites across Maryland. In addition, the program will focus on improving partnerships between substance use disorder clinics and family planning clinics particularly in Western and Northern Maryland. In SFY 2022, the Maryland Family Planning Program remains committed to providing support to subrecipients as they continue their innovative telehealth practices, as well as assist with strategic efforts to return to safe practices while clinics reopen post-Covid.
Merck For Mothers Safer Childbirth Cities
Through funding to the Baltimore City Health Department and B’more for Healthy Babies (BHB), a city wide initiative to improve maternal and infant health, Title V funds Baltimore Healthy Start through the Baltimore City Health Department. Baltimore Healthy Start, and therefore, Baltimore City is a recipient of the Merck for Mothers Safer Childbirth Cities Initiative, which aims to support community-based organizations in US cities with a high burden of maternal mortality and morbidity to implement evidence-based interventions and innovative approaches to reverse the country’s maternal health trends and directly confront racial inequities in maternal health outcomes.
For SFY 2022, Baltimore Healthy Start and its partners are working with the Baltimore City Health Department and B’more for Healthy Babies to implement the local Maternal Mortality Review process. In addition, Baltimore Healthy Start will partner with additional Baltimore Hospitals for Patients as Partners series, an initiative that bring the knowledge and experience of maternity patients to bear on hospital and health system quality improvement process, implement a maternal health monitoring intervention of prenatal and postpartum home-based assessments for Baltimore Healthy Start clients, with immediate medical referral if needed, provide postpartum care services, delivered by certified registered nurse practitioners, co-located and co-scheduled in Federally Qualified Health Center (FQHC) pediatric clinics at 2-week, 4-week, 2-month, 4- month, 6-month, and 12-month infant well-child visits.
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