Maryland Title V identifies the priority for women’s maternal health as ensuring that birthing people are in optimal health before, during, and after pregnancy.

 

 

To this end, in FY 2023, Title V will employ the following strategies to improve maternal health outcomes statewide. Please note that for FY2023, Maryland Title V shifted from Oral Health to a broader focus of well women’s health.

 

Focus Area 1:  Oral health: To increase the number of pregnant people receiving preventive dental visits from a baseline of 28% (2019) to over 36% by 2025 (Healthy People 2030 Target: 45%)

 

During Fiscal Year (FY23), 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 to Oral Health providers as part of their care coordination.

 

In the future, Maryland Title V will propose transitioning from the National Performance Measure of oral health to a broader national performance measure: Women’s health by the national performance measure (NPM 1) of percent of women who had a preventive dental visit during pregnancy. Feedback was obtained on this transition, and overall, the feedback thought that this national performance measure aligned with work that was already occurring, including work at the local health departments.

 

Potential Future Objective 1: To increase the number of well-women visits from a baseline of 73% (2020; BRFSS) to over 78% by 2025.

 

If the broader national performance measure is approved, the Title V team will continue to work on increasing the number of well-women visits through partnership. The Title V team and the Maryland Family Planning Program (MFPP) will expand telehealth services in family planning and preventive care services.  Maryland Family Planning Services will not only provide family planning services, but also navigate social needs identified through the visits, and link to other primary care providers.  For the telehealth expansion, the MFPP will work with 11 local health departments including Baltimore City, Calvert, Carroll, Dorchester, Garrett, Harford, Howard, Prince George’s, Somerset, St. Mary’s, and Worcester and three non-profit organizations. These efforts promote the goal to increase well women visits as these visits provide preventive care and provide further coordination and referrals to comprehensive primary care visits. During FY2023, the team will begin by assessing existing telehealth resources in local health department family planning sites, identifying needs, barriers and opportunities to enhance services. The collected data will be used to plan and implement a virtual telehealth training and technical assistance program for participating sites. After the training and technical assistance program, MDH will disseminate a comprehensive telehealth toolkit to the 62 MFPP sites, 24 local health departments and all family planning service sites in Maryland.

 

 

During the Maryland General Assembly 2021 Legislative Session, Senate Bill 923 was passed that required Medicaid to extend coverage for eligible pregnant individuals with family incomes up to 250% of the federal poverty level (FPL) for one year immediately following the end of the birthing individual’s pregnancy. This coverage would include dental care as well as comprehensive medical care.  The extended coverage became effective starting April 1, 2022. Title V staff will continue to work with Maryland families to inform them about the extension of the coverage during provision of services such as care coordination and home visiting.

 

 

In addition, for FY2023, Title V staff will focus on increasing linkages to care, specifically through expanding the Postpartum Infant Maternal Referral Form (PIMR). During FY21 and 22, Title V staff released a PIMR best practices form that reviewed the process of the PIMR. The best practices document explained the purpose of the form, including referring mothers and infants who need additional support and information on community-based services at the local health departments.  During the next year, Title V staff will focus on understanding workflows from the local health departments as well as expand the electronic PIMR through the Regional Information Health Exchange, CRISP.

 

Care Coordination

 

Title V staff will continue to improve the quality and expand care coordination at the Local Health Departments to link pregnant and postpartum people to navigate their social needs and to navigate primary care. In FY2022, Title V allowed funding for Local Health Departments, which is mandated by House Bill 314, Laws of 1995 that the Federal Title V Maternal Child Health Block grant must go towards the local health department. Local Health Departments will continue linking pregnant people who are referred through the Maryland Prenatal Risk Assessment and PIMR. Title V has aligned care coordination through the Babies Born Healthy Program, an initiative focused on perinatal care coordination. 

 

 

Focus Area 2: Substance use prevention and linkages to care through 1) NPM 14.1, percent of women who smoke during pregnancy and 2) the state performance measure (SPM 1) of Overdose Mortality Rate for women, ages 15-49.

 

Objective 1 for Focus Area 2: To increase the number of women who abstain from smoking tobacco during pregnancy from a baseline of 95.3% (2019) to 96.3% or more (Healthy People 2030). 

 

Smoking During Pregnancy

 

Referrals to Maryland QuitLine

For Fiscal Year 2023, 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.

 

In FY2023, the Maryland Family Planning Program will continue to 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.

 

 

Objective 2 for Focus Area 2: To decrease the overdose mortality rate for women, ages 15-49 from 24.1 per 100,000 to 22.9 per 100,000 by 2025.

 

Improve Linkages to Care through Overdose Data to Action

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 (ePRA). During FY2023, Title V will explore the feasibility of implementing an ePRA statewide to increase the number of prenatal clinics referring clients to local health departments for care coordination. This work will be informed by the lessons learned during the pilot projects in FY22. In addition, Title V will partner with OD2A to implement an electronic version of the postpartum infant maternal referral form (PIMR), that is used to link birthing people and infants to care coordination at local health departments, statewide. Title V will partner with the State’s Health Information Exchange (HIE), called CRISP, to achieve this.

 

In addition, Title V and OD2A will conduct a Gap Analysis of resources available to pregnant people experiencing Opioid Use Disorder (OUD), to better understand the landscape of OUD in the state, and areas in need of support. This gap analysis will understand opioid use through PRAMS by analyzing the supplemental questions on opioid use that will be used for further public health action as well as discussions with stakeholders. This gap analysis will serve as a basis for future planning and collaborations with partners such as Maryland Behavioral Health Administration, the Opioid Operational Command Center, Maryland Medicaid, Clinical Providers, Community-based organizations, local health departments and more.

 

Title V will continue to partner with Maryland Medicaid on the Maternal Opioid Misuse Model. Title V staff will continue to serve on the MOM model advisory council. The MOM model advisory council provides input into the model and how to further expand the model in the State. In addition, the Advisory Council will provide input in the partnership with the Maryland Addiction Consult Services.

 

 

Focus Area 3: Reduce rates and eliminate disparities in Maternal mortality and morbidity with the state performance measure of reducing severe maternal morbidity rates that aligns with the Statewide Integrated Health Improvement Strategy.

 

Objective 1 for Focus Area 3: By 2026, reduce the Severe Maternal Morbidity Rate from a baseline of 242.5 per 10,000 delivery hospitalizations to 197.1 per 10,000 delivery hospitalizations and decrease disparities between Black to White SMM rates by at least 20% .

 

Statewide Integrated Health Improvement Strategy (Severe Maternal Morbidity)

Overall, Focus Area 3 is based on the Statewide Integrated Health Improvement Strategy goals. Through an agreement with the Centers for Medicare and Medicaid Innovation (CMMI), the aim of SIHIS is 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.

 

Overall, as Title V staff will focus on 1) incorporating equity principles into practice either by partnering and working with more community-based organizations 2) shifting committee structures to include people with lived experiences 3) looking for sustainable funding for essential supportive services by partnering with Medicaid.

 

 

Maternal Health Innovation Program

In Fiscal Year 2023, the Title V Program will continue to work with the Maternal Health Innovation Program, also called “MDMOMs,” by Johns Hopkins University, by monitoring the maternal health improvement Strategic Plan. During FY2022, Title V worked with the Task Force to elect co-chairs for the Task Force. Previously, the Title V manager with support from the Bureau Director chaired the Task Force. Two co-chairs were elected, and Title V staff worked with the Equity Advisor from the Bizell Group on a mechanism to compensate the co-chairs. Approval for compensation required internal approval and as the Task Force is not in statute or in regulations, compensation for the co-chairs was allowed. Often, compensation in committees or boards that are in statutes or regulation disallow compensation.

For FY2023, the Title V program will continue to home in on recommendations and coordination’s of the Task Force, based on the Maryland Maternal Health Improvement Strategic Plan.  The Task Force focuses 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 and 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.  With the Equity Advisor, Title V will incorporate equity principles and provide recommendations on analysis and contextualization of data to demonstrate the impact of racism, determinants of equity, and determinants of health.

Statewide Integrated Health Improvement Strategy Funds

 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 goes 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. These are services that provide additional support for the most impacted populations and communities. Through partnership with Medicaid, these services can be more sustainable beyond the SIHIS grant fund periods. 

 

A portion of the MCH SIHIS funds went toward grant funds to allow expansion of promising practice programs. For example, while Nurse Family Partnerships and Healthy Families America are the two evidence-based models supported by Medicaid reimbursement, these models are prohibitive in jurisdictions where they have not already implemented the model. The reason is due to start-up costs. For example, starting a Nurse Family Partnership Home visiting program may cost more than $1 million dollars and maintaining fidelity to this model incurs high ongoing costs.  During FY2022, four home visiting sites in priority jurisdictions with elevated SMM events were selected after an open bid procurement. During FY23, Title V will continue to implement the grant funds and continue the expansion of their home visiting services. These organizations are: Montgomery County Health Department, the Family Tree, Washington County Health Department, and Baltimore Healthy Start. In addition, in order to expand CenteringPregnancy, a group-based prenatal care, Mercy Medical Center was selected as a site to implement the CenteringPregnancy Model. During FY23, Title V will also put forward a competitive procurement to further expand CenteringPregnancy in Maryland.

 

The remaining SIHIS 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 FY2022, 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 and neonatal antibiotic stewardship. For FY2023, 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 is scheduled for Summer 2022 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 Mortality Review Program

During Fiscal Year 2023, the Maternal Mortality Review Program 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.  During Fiscal Year 2023, the administration of the MMR Program will be overseen by the Maryland Patient Safety Center after a competitive bid process, allowing for the expansion of the scope of work of the coordination activities.

 

Through the support from the Centers for Disease Control and Prevention Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) program, Maryland plans to move towards a multi-disciplinary review team in FY23 instead of a predominantly physician-led, medical review team to conduct comprehensive case reviews in line with the national best practices. The Multi-disciplinary review team, called the Statewide Maternal Mortality Review Team (MMRT) will identify and review pregnancy-associated deaths, identify factors that contribute to these deaths, and propose recommendations that aim to prevent future deaths.  The overall mission of the Program is to review the issues surrounding the pregnancy-associated deaths, to identify interventions, and to promote change among individuals, health care systems, and communities in order to prevent maternal deaths, reduce maternal morbidities and improve population health.  Members of the MMRT will represent the diversity of Maryland’s population and will consist of individuals with both clinical and non-clinical expertise as recommended by national best practices. There will be approximately 20 members on the Review Team.

 

The member positions that will be included on the team include:  individuals who work with pregnant or postpartum individuals and have expertise in Clinical Social Work, Community Doula Work, Community Birth Work, provision of behavioral health services, or social services such as housing or food insecurity; individuals with expertise in Community Health Nursing/Maternal, Infant, and Early Childhood Health Home Visiting or Nursing Care for Pregnant Individuals, Postpartum Individuals, or Families of Pregnant or Postpartum Individuals; Individuals with expertise in quality improvement for pregnant or postpartum patients or pregnant or postpartum patient safety; Physicians with expertise or specialization in Obstetrics and Gynecology; individual with expertise in Public Health Epidemiology; physicians with expertise or specialization in Maternal Fetal Medicine; physicians with expertise or specialization in Addiction Medicine, Family Medicine, Internal Medicine, Anesthesiology, Critical Care,  Emergency Medicine, Pediatrics, Adolescent Medicine, Preventive Medicine, or Cardiology, specifically Cardio-Obstetrics; advanced Practice Clinician in Women’s Health (Certified Nurse Midwife or Women’s Health Nurse Practitioner), representative from the Maternal Mortality Stakeholder Group, public health officials, State Medicaid, a representative from the Office of the Chief Medical Examiner.

 

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 to assist individuals with their reproductive life plan, which includes postponing, preventing, achieving and the spacing of their pregnancies.   In FY23, 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 FY23, 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.