In this section, South Dakota MCH Title V reports on planned activities in the Women’s/Maternal Health Domain for the period October 1, 2022, through September 30, 2023.  Priority needs identified in the 2019-2020 Needs Assessment process were: mental health; substance misuse; access to healthcare services; and social needs such as lack of transportation, desirable employment, education, and adequate housing. After reviewing the data, the NPM #1 workgroup agrees that mental health and substance misuse continue to be top priorities for this population and that a caregiver’s health can affect the health of the entire family.  After discussions at our 2021 block grant review and a follow-up meeting with HRSA Epidemiologists in April 2022, the MCH team revised the NPM #1 objective to keep the focus on the yearly well women visit.

NPM 1: Percent of women, ages 18-44 with a preventive medical visit in the past year

Objective:

Former objective:  Decrease the percent of women on the SD WIC program who experience postpartum depressive symptoms following a recent live birth from 17.1% (2019) to 16.2% by 2025 (PRAMS)

New objective:  Increase the proportion of women receiving a Well Women visit annually from 77.3% (2020) to 81.3% by 2025. (BRFSS)

Priority Needs:  Mental Health/Substance Misuse

Evidence-based Strategy Measures:

Former ESMs:

• Percentage of WIC clients with a positive response to the Whooley questions that received a PHQ 9 screening. 
• Percentage of WIC clients whose PHQ 9 score met criteria for a referral and were referred.

New ESMs:

• Number of Facebook messages posted promoting well women care
• Percentage of women with positive depression screen who are referred to their PCP (within the OCFS Community Health Offices)

Significance 

After reviewing our ESMs with the national reviewers and HRSA Epidemiologists, the MCH team along with the Well Women workgroup decided to change the overall focus to the promotion of well women care (vs. the process of depression screening).  The new strategies identified below steer us in that direction with the overall goal: getting more women in for a yearly preventive visit with their PCP.

Proposed Strategies:

Former strategy 1.1:  Implement an evidence-based and equitable behavioral health screening tool and referral protocol within the OCFS to assess for perinatal depression.

This strategy has been met. The PHQ-9 screening tool and referral protocol were implemented on October 1, 2021, in all OCFS Community Health Offices (WIC) across the state.

New strategy 1.1:  Develop partnerships with diverse, multisector stakeholders to promote preventive care for women of childbearing age.

Significance

The MCH team decided if we were going to reach all women of childbearing age with the well women message, we needed to develop multisector partnerships. No single organization or sector has full control over the determinants of population health, effective solutions require interorganizational coordination and collaboration. Multisector partnerships across local, regional and state agencies improve delivery of health and social services to vulnerable populations. http://www.cdc.gov/pcd/issues/201 0/nov/10_0104.htm

New Efforts

• Recruitment of more members with expertise from national women’s support groups, family planning, frontline clinicians, and regional health care

Strategy 1.2:  Create toolkit of resources on Maternal Mental Health/Substance Misuse and Health Equity for OCFS field offices.

Significance

A toolkit helps field staff to promote well woman health by providing information to navigate care related to mental health and substance use.

Activities done to this point

Members of the Well Women workgroup shared mental health resources including accessible treatment options for women with Perinatal Depression/Anxiety.  These resources have been added to field staff’s toolkit to address client’s mental health concerns. DOH SBIRT SD BH Resources 2.23.2021.pdf 

 New Efforts

• Planning for the next fiscal year includes adding additional resources to screen for and address substance misuse through a quality framework.
  • Training on Motivational Interviewing is already underway to empower field staff to adequately screen and refer women. 
  • Continuing education on substances of misuse to better inform field staff to appropriately direct care

Former strategy 1.3:  Develop partnerships with diverse, multisector stakeholders to address maternal mental health through a health equity lens.

The former strategy was revised and incorporated into new strategy 1.1.

New strategy 1.3:  Increase depression screening and referrals to PCP among low-income women on the SD WIC program

Significance

The MCH team and Well Women workgroup will continue to address the mental health priority by referring all WIC clients with a positive response to the PHQ-9 to their PCP.  If the client does not have a PCP, field staff will assist the client to find a provider.  This will promote the use of a PCP as a medical home to direct all care including preventive care.

Activities done to this point 

An evidence-based depression screening policy and procedure was developed by MCH Leads and forwarded to OCFS Nurse Team Leads for final evaluation and implementation.  Nurse team leads train and evaluate field staff within the OCFS.

New Efforts

• Develop CQI tool to measure compliance with depression screening protocol and referral process.

Added Strategy 1.4:  Develop a policy recommendation with DSS to create Maternal Medical Homes 

Significance

Rates of maternal mortality and morbidity from pregnancy related complications in the United States have increased with an average of over 750 deaths per year. Complex medical, social, and behavioral risks increase the likelihood of major morbidities and death. Low birthweight, short interpregnancy spacing, gestational diabetes, and social determinants of health and disparities increase the likelihood of adverse outcomes. Some of these risk factors could be minimized through pregnancy care management in a medical home model.

South Dakota is designated as a frontier state by the Affordable Care Act. The frontier nature of South Dakota presents barriers when it comes to accessing a variety of health care services, including primary, prenatal, obstetrical, and postpartum care. According to the Health Resources and Services Administration (HRSA), 58 of South Dakota's 66 counties are designated as Medically Underserved Areas; residents lack access to primary care services.

Problem

Due to the way the health home program is set up in South Dakota, attributing pregnant women based on claims to a pregnancy health home would be difficult.  It may also be difficult to get OBGYNs to enroll as health home providers.  Historically they have not had the staff or the time to do case management. The maternity medical home offers a way to organize interventions, and ensure coordination of social, behavioral, and health services.

Activities done to this point

• National Academy for State Health Policy Maternal and Child Health Policy Innovations Program Policy Academy (NASHP) is a two-year policy academy comprised of representatives from state Medicaid agencies, public health agencies, and other state stakeholders.
  • Identify, develop, and implement policy changes or develop specific plans for policy changes and/or strategies necessary to build state capacity to address maternal mortality for Medicaid-eligible pregnant and parenting women, with the goal of improving access to quality care.
  •  technical assistance to improve health care delivery systems and related supports for Medicaid-eligible pregnant and parenting women, with a particular focus on implementing policies or health system transformation that address racial disparities in maternal mortality
• Bright Start current state-South Dakota DOH has a 20-year history of providing Bright Start nursing services to families in specific communities across the state, but the program has never been available statewide due to funding limitations. The Bright Start program implements the evidence-based Nurse Family Partnership (NFP) model as well as an adapted curriculum with clients who do not fit the NFP model requirements but are still in need                                          
  • In FY21 Bright Start served 604 families
  • In FY20, 596 families were served
  • SD has an average of 850 first-time pregnant moms covered by Medicaid each year
• Data from PRAMS and March of Dimes (MOD) to inform risk factors.
• The Association of State and Territorial Health Officials (ASTHO) links PRAMS data to Medicaid claims to understand the cost for risk factors identified in the payment model

New Efforts

• North Dakota-South Dakota (NDSD) PQC-quality improvement work across the state to address maternal morbidities. Education and implementation of a hypertension bundle was initiated, and work continues in this area.
• The maternal mortality review committee (MMRC) has provided information and trends on pregnancy related deaths. They have also identified barriers to health care access and the impact of social determinants of health.

• Bright Start expansion- Approval from state legislature for funding to expand the Bright Start program to include more counties across the state.
• Expansion of Pregnancy Care within the office of child and family services (OCFS) -modified case management available for all women regardless of status as non-contract county.
• Work toward Maternal Medical Homes continues with the plan for a pilot maternal medical home in one location with a Pregnancy Care nurse and obstetric provider in the next several months.

Ongoing Efforts Supported by MCH for the Women/Maternal Domain:

• Continue to educate all women on the importance of yearly preventive visits which address mental health as well as physical health in Community Health Offices across the state.

• Continue to support the OCFS Pregnancy Care program to provide prenatal and postpartum education, assist low-income pregnant women to obtain early and on-going prenatal care, provide smoking cessation counseling and referrals and link women to resources that can help support healthy pregnancies and healthy newborns.

• Continue to partner with Title X, Bright Start Home Visiting, the SD WIC program, and other community partners to promote yearly check-ups for women of childbearing years and their families.

• Continue to support the CDC’s PRAMS and utilize the findings for planning, assessing, and evaluating our programs with the goal of improving health outcomes for women and infants.