PRIORITY: Women have access to and receive coordinated, comprehensive services before, during and after pregnancy

NPM 1: Well-woman visit (Percent of women, ages 18-44, with a past year preventive visit)
SPM 1: Preterm births (<37 weeks of gestation)

NPM 14: Smoking (during pregnancy and household smoking)

 

Local MCH Reach: Based on SFY2020 MCH Aid-to-Local applications received, 64 of 70 grantees (91%) plan to provide services to the Woman & Maternal population.

 

 

NPM 1: Well-woman visit (Percent of women with a past year preventive medical visit)

 

Objective: Increase the proportion of women receiving a preventive medical visit annually.

 

State Title V staff will continue to promote the importance of women receiving a preventive medical/well-woman visit annually. Primary strategies to achieve the goal of increasing the number of women receiving education about the importance of a well visit as well as those receiving an annual well visit include:

• providing education and resources to local Title V MCH local agencies, partnering with other community agencies to provide on-site assistance for accessing health care coverage in the pre/interconception period;
• developing a toolkit for use by providers across settings, not only public health; and
• promoting the development of personal health plans, including a reproductive life plan, for individuals receiving services across settings.

 

All of this work will be done in alignment and collaboration with Title X Family Planning. The importance of women’s health and the annual visit will be highlighted at trainings and other events, and associated resources will be distributed (annual Governor’s Public Health Conference, MCH Home Visiting Regional training, and other appropriate venues). Recent activities have been focused on the development of a Well-Woman Visit Integrated Toolkit (see more below) and a Reproductive Life Plan Workbook that will be inclusive of the One Key Question® approach (currently being implemented in Kansas) and existing LARC resources. This will continue to be the primary work for women of reproductive age throughout FY20. Both of these toolkits will be modeled after the same format used in development of the other MCH Integration Toolkits shared mentioned Report. Patient and provider resources will be accessed from ACOG and the Office of Women’s Health and include key messages and guidance such as the Women’s Preventive Services Initiative Chart. Toolkit components will include the following:

• Technical Assistance (TA) Webinar
• Integration Plan with Implementation Guide
• Screening Tools
• Flowchart with Algorithm
• Resource/Reference Guide (provider version and client version)
• Templates (including sample policies and procedures)
• Resources (includes links from webpage to documents and other websites)
  • Programs and Targeted Interventions (Promising Practices, Evidence-Based Interventions)
  • Patient Education Resources (patient handouts, online resources, etc.)
  • Provider Resources (latest research, best practice guidelines and recommendations, opinion statements; provider training opportunities)
  • Medicaid Coverage (guidelines, billing codes, inclusions in coverage)

 

Well-Woman Visit Integration Toolkit: Title V and Title X are collaborating to create an Integration Well-Woman Toolkit. The release is planned for May 2020 during National Women’s Health Week as part of a statewide media campaign “Past the Pap…Why an annual preventative visit is more than a pap smear!” Plans are being made for a Governor’s proclamation with signing ceremony to officially recognize Women’s Health Week in Kansas as well as a media release announcing the toolkit and social media blasts centered on the importance of women receiving an annual well-woman visit. Ideas for celebrating National Women’s Health Week in partnership with the HHS Office of Women’s Health will be shared with all MCH and Family Planning public health network partners as well as other partners representing the medical setting.

 

Women’s Preventive Services Initiative (WPSI) Materials

One Key Question®: To support broader MCH women’s reproductive health goals, full implementation is underway of the One Key Question® (OKQ) Initiative, property of the Power to Decide, in partnership with Title V and Title X clinics. Following introduction to the initiative at the 2018 Governor’s Public Health Conference, KDHE continued to promote and prepare local grantees for full implementation. The Power to Decide returned to Kansas in February and March 2019 to provide full-day training events in three locations across the state. Over 100 individuals were trained representing County Health Departments, FQHCs, Home Visitors, WIC Clinics and Community Health Organizations. Power to Decide will provide this first Kansas OKQ training cohort with additional implementation guidance and technical assistance (TA) in the form of consultation calls and webinars. We plan to build on this training by assisting cohort one with full integration of OKQ into their practices/clinics with TA from Power to Decide. Plans are underway to bring Power to Decide back to Kansas in 2020 for training cohort one. We plan to target FQHCs and Safety Net clinics around the state for the second training.

 

Kansas Training Flyer & OKQ Algorithm

Local MCH Agencies: Title V staff will continue to support the promotion of women receiving a well-woman visit annually, by messaging the importance of local Title V grantees partnering with other community agencies to provide on-site assistance for accessing health care coverage in the pre/inter-conception period. We will continue to target OKQ and promote the development of personal health plans, including a reproductive life plan, for individuals receiving MCH services. Local grantees either provide direct well woman preventive care or enabling services by providing resources and referrals for women to receive annual well visits. Women will be assessed for a visit in the past year and will be educated on the importance of preventive care. Referrals will be made to the local agency’s family planning clinic or another provider in the community for clients that have not had a visit in the last year.

 

Objective: Increase the proportion of women developing a reproductive life plan annually.

 

Reproductive Life Plan Booklet: As noted above, the development of a Reproductive Life Plan Booklet is underway related to the Women’s Health Toolkit. Several collaborative work group meetings have occurred between KDHE and local agencies in the metro Kansas City area, including the Wyandotte Health Council, Unified Government of Wyandotte County (Local Public Health Department), and Vibrant Health Care (FQHC) to develop a comprehensive Reproductive Life Plan workbook for use across agencies and sectors of the health care system in our state. The workbook will consist of several sections including:

• Your Future
• Your Choice
• Your Health Now
• The Skin You’re In
• Inner Health
• Healthy Checklist

 

Design of the workbook has been created with the intention of it lending itself for use in a variety of settings where providers have varying degrees of opportunity to work through the workbook with a woman. The intention is that for a case management or home visitation service provider, the workbook can be revisited over the course of several visits for completion, reflection, and progress monitoring, whereas only targeted sections of the workbook might be completed by a provider in a busy medical clinic, Title X clinic, etc. While use of the workbook can be customized by each type of service provider, it provides standardized tools and a consistent approach for encouraging women of reproductive age to set life and health goals during a well-woman visit on an annual basis.

 

The booklet screening questions will be tied to more in-depth screening tools that a provider can access depending on how a woman answers the screening questions. For example, the “Your Health Now” section includes screening questions on tobacco, alcohol, and substance use. The appendices attached to the section will include substance exposure resources pages and more in-depth screening tools and links to SBIRT (screening, brief intervention, and referral to treatment process) resources. Currently, the workbook is being field tested with Cradle Kansas City Community Action Board. The goal is to have the Reproductive Life Plan workbook available for use by the end of 2019. The plan is to continue testing and collect community feedback to have the booklet ready for release by the end of 2019. Later in 2020 we will work with organizations to implement the booklet into practice. A training webinar will be held targeting local MCH agencies including Title X and Universal Home Visiting staff. Title V will continue to offer technical assistance to agencies as they work to implement. The importance of Reproductive Life Planning and the booklet will also be marketed several times throughout the plan period at events such as the LARC Grand Rounds event, cohort two OKQ training, and the Governor’s Public Health Conference 2020.

 

Kansas Perinatal Community Collaboratives (KPCC)/Becoming a Mom® (BaM): As part of Kansas Title V’s commitment to the continued development and expansion of perinatal collaboratives utilizing the March of Dimes Becoming a Mom® prenatal education curriculum, there is continued commitment to the development and implementation of additional “integration” components that allow for the strengthening of particular priority areas within the curriculum and program delivery model. One area of focus over the next year will include training of BaM sites on the comprehensive integration of personal health plans, including greater utilization of the reproductive life plan completed by each woman participating in BaM, and greater familiarity with the OKQ initiative. Once the Reproductive Life Plan workbook development is complete, it will be integrated into the BaM curriculum, either complementing or replacing the current resource “Show Your LOVE – Steps to a Healthier me!” by the CDC. Participants will be encouraged to take their reproductive life plan to their provider for discussion during the remainder of their prenatal care and their postpartum check-up. Additionally, as a part of this “integration” component during session six of the program, sites will be encouraged to invite a Health Care Exchange Navigator from their community to participate as a guest presenter on the topic of accessing health care coverage following the loss of Medicaid coverage 60 days postpartum. Ideally, this navigator will be available before and after the session to assist participants in navigating the federal insurance exchange and enrolling in an insurance plan that will increase the likelihood of the women receiving annual well-woman exams following pregnancy. With release of the Well-Woman Integration Toolkit that is planned for summer 2020, work will be done to integrate this into the BaM curriculum as well.

 

Objective: Increase the number of communities utilizing the MCH collaborative model and prenatal education curriculum by at least 5 annually by 2020.

 

KPCC/BaM: As mentioned in the report, resources needed for regional and statewide implementation of KPCCs utilizing the MODs BaM curriculum have been under development over the past two years to insure both growth and future sustainability of the initiative, and phase two of the website development that includes redesign and expansion of the public Perinatal Community Collaboratives website as an access point to introductory information about the initiative has been completed. Final phase 2 revisions to the private BaM website will be under way in May 2019, which will provide additional training and implementation resources for communities once they have signed the MOU and are ready to begin implementation. Enhancements to the resources will include online training webinars for program coordinators and group facilitators. Additional training webinars are scheduled for production in May 2019 with state partners (Oral Health Kansas, Kansas Breastfeeding Coalition, and the Kansas Infant Death and SIDS Network) to complete enhancements to the Integration Toolkits specific to BaM implementation of Oral Health, Breastfeeding, and Safe Sleep components. The toolkits have already been integrated, as written about in the report, but to date, training of new sites has required resources to bring in-person training to each new KPCC/BaM location. By providing all training components online, it will allow new sites to receive the training in a timely manner, at their own pace and according to their own schedule, vs. waiting on KDHE staff availability to provide training in person, further supporting long term sustainability of KPCC/BaM expansion efforts. Promotional material templates will also be expanded to include materials for provider outreach, as well as other materials developed and shared by existing sites. All efforts are aimed at decreasing burden on new sites embarking upon implementation and existing sites facing staff turnover.

 

Initial conversations are under way with clinical service providers in rural southwest Kansas to identify local issues and needs for the region around the KPCC model and BaM implementation. As spoken to in the report, this region has a significant Hispanic population, many of whom are undocumented and/or uninsured. Four counties provide the bulk of clinical services for women of child-bearing age in the region, requiring pregnant women to travel for services, including BaM prenatal education. Virtual implementation has been piloted in the Northcentral region of the state and is an option available for this region as well, however there is interest in possibly adapting the model in other ways that will better lend itself to access by this largely rural population. Conversations with local stakeholders are planned for early FY20.

 

As mentioned in the report, review of MCH Aid-to-Local applications for FY19, identified 32 communities/applicants that included BaM interest in their application. Plans are in place to engage these interested communities through an introductory email providing the URL for the recently enhanced public Perinatal Community Collaborative website. This will allow each interested community to explore the initiative and engage in conversations with community partners on their own timeline, utilizing TA resources provided online. Again, this approach is hoped to better meet the needs of local communities who are interested in enhancing perinatal services, while reducing burden on KDHE Title V staff, which will improve expansion and sustainability efforts long term.

 

In 2019/2020, we hope to continue preliminary discussions that began with our state’s Medicaid MCOs in 2016 regarding expanded partnerships to support existing BaM programs, as well as expansion of the program in targeted areas of the state. These discussions will include: potential funding partnerships related to the development of a regional model approach to program delivery in small rural communities where birth numbers are too small to justify a full scale independent BaM program; program incentives; printing of standardized curriculum for consistency of curriculum delivery across all program sites; the idea of partnering in the implementation of telehealth for the delivery of specialized care and monitoring of high risk OB patients in rural/frontier communities across the state. Although some of this work has already begun, as described in the report section, we wish to further develop these conversations and secure commitments from all three MCOs in the next year.

 

Objective: Increase the percent of pregnant women on Medicaid with a previous preterm birth who receive progesterone to 40% by 2018 and increase annually thereafter.

 

Fiscal Years 18-19 focused on foundational issues primarily related to providers. Barriers identified in the 2017 provider assessment supported the state expansion plan. This year, systems and processes for risk identification, screening and referrals were established and promoted through provider webinars. Patient education (17P) was incorporated into existing prenatal education programs with the associated evaluation components added to the DAISEY system. Medicaid coverage and payment systems were expanded to support treatment in multiple settings and the OPTUM OB Homecare home administration program was expanded to include nine additional counties. Bringing these components together into a comprehensive package is the next step and main FY20 priority.

 

The FY20 emerging issues that need to be addressed focus largely on clinical and public health partnerships. Patient messaging related to preterm birth and progesterone utilization has been developed but is primarily delivered through prenatal education programs. This same messaging needs to be adopted by clinical providers to insure consistency and promote 17P utilization. Cross-referral systems between clinical and public health providers for prenatal education are in place in most KPCC communities, but they are not 17P specific. A standardized provider referral form incorporating 17P screening has been drafted and is ready for review. A comprehensive provider algorithm will also be developed to support this cross-agency partnership. Over the last year Kansas has established a toolkit system to support implementation of programming for targeted issues. A toolkit specific to 17P is currently under development with launch anticipated in early fall 2019.

 

17P Toolkit Components

• Fact Sheet
• Provider Education Webinars
• Professional Resources (ACOG, ASTHO, MOD, OPTUM)
• Patient Education Resources (BaM/Cb, brochures, videos, etc.)
• Policies and procedures document
• Flow Chart/Algorithm
• Standardized Referral Form
• Medicaid (Coverage Summary, Prior Authorization, Billing Codes)
• Demonstration Models (IN, NC, SC, OH)

 

In order to increase 17P utilization several capacity issues must also be addressed. Providers have expressed concern about insurance coverage (public/private), medication access (Makena/compounded) and treatment efficacy. Kansas Medicaid now provides coverage for the Makena drug and administration. Private insurance carriers must be surveyed to determine coverage, processes and gap analysis. Kansas has many compounding pharmacies statewide, but these must be assessed to determine 17P inclusion. Mail order options must also be reviewed. Makena is readily available both through the OPTUM program and direct physician prescribing authority, but the expense often makes this prohibitive. Understanding what is available, how to access it and how to pay for it are fundamental questions that must be answered. The third concern is over the efficacy of prophylactic progesterone treatment. It is due primarily to conflicting endorsements and follow up studies. ASTHO, the March of Dimes and ACOG have all endorsed 17P as an effective treatment to reduce the reoccurrence of spontaneous preterm birth. Numerous states have also launched initiatives to expand utilization. That said, there is a conflicting study from the University of Texas Southwestern Medical Center published in the American Journal of Obstetrics and Gynecology in 2017. Current research has not yielded any new information; however, a more in-depth article review is warranted.

 

All of the strategies outlined above should be further developed with provider, patient and insurer input. We will assemble a multi-tiered workgroup to review other state strategies, medical research and state capacity issues to develop a comprehensive 17P expansion plan for Kansas. In FY20, targeted interventions will be developed with several strong Perinatal Community Collaborative sites (Sedgwick, Lyon, Saline and Reno counties) to test ideas for replication.

 

Local MCH Agencies: Local agencies continue to work to reduce the number of preterm births in Kansas by reducing the number of pregnant women who smoke. In addition, integrated screening tools and case management services to identify and support women eligible for progesterone therapy will be utilized. Improved prenatal care and prenatal education should decrease the risk of preterm deliveries. Local agencies will assure that women have access to and receive coordinated, comprehensive care and services before, during and after pregnancy. Women will be screened for preterm birth history and the associated risk factors.

 

 

NPM 14: Smoking (during pregnancy and household smoking)

 

Objective: Increase the proportion of smoking women referred to evidence-based cessation services to 95% or higher by 2020.

 

Kansas has made tremendous progress building a comprehensive tobacco cessation campaign. System linkages (state and local) are in place and will be nurtured over time. Services are available through numerous media (social media, texting, videos, peer-to peer and trained counseling support). Capacity-building to increase utilization is a priority and a key part of that is public awareness and promotion. The BHP and the BFH have aligned tobacco cessation components of their state plans. Universal promotional tools will be developed in FY19 to support communities in their efforts. Templates that can be customized to meet specific community-level needs will be developed and shared widely. Promotional materials will also be developed for MCO and Bureau use with special emphasis on cross-agency promotion.

 

In the last two years, KDHE BFH has developed the systems and infrastructure to launch comprehensive tobacco cessation programming statewide. This infrastructure included provider toolkits, educational resources, website access and evaluation systems (DAISEY). A new referral tool, IRIS, is being implemented in Kansas across systems including public health, health care/medical, behavioral health, oral health/dental, and early childhood. This infrastructure provides a solid foundation (plug-n-play) for program implementation on a broad scale. During the last year, emphasis was placed on provider training to promote use of the available resources in a collaborative format. Collaboration between clinical and public health providers is still an issue in many communities with numerous requests for technical assistance. One piece of this involves establishing effective referral systems for early and repeat interventions. To better understand provider issues KDHE will resurvey KPCC, CDRR, SCRIPT, and Baby & Me—Tobacco Free (BMTF) sites. This information will be compared to the initial survey conducted in 2017 and will include follow-up phone calls for personal input. In addition, a patient survey tool will be developed for all providers to use in their initial screening. This will provide information needed to meet the perinatal patient’s unique needs.

 

Kansas has developed universal tobacco screening tools and standardized processes for the public health setting which are currently in use within BaM program sites and being spread to MCH local agencies statewide These tools are now available via the web to clinical providers and public health sites that are not part of a larger collaborative (beyond BaM). Data related to screening and referrals is tracked through DAISEY, ATL, reports and BaM reports so continuous oversight to identify successes, challenges and emerging issues is now possible. The BFH staff will continue to monitor and support local needs.

 

The BMTF program is currently provided in five Kansas communities. We will continue to monitor program results reported in the DAISEY system, however there are no current plans to launch additional program sites at this time, however several locations have blended BMTF with SCRIPT and their BaM program and increased the incentive timeframe to ease staffing requirements and provide a more cost-effective, sustainable program. The BFH will work with program sites making this transition and share information among these program sites to promote promising practices as they emerge.

 

KDHE assessed Quitline utilization among BaM program sites in 2017 to identify both practice and patient issues. Since that time, a warm referral process was established whereby sites could directly enroll women via fax, web or cell phone. Enrollment at Community Baby Showers is now standard practice as part of the tobacco cessation education provided by Quitline staff/representatives. Monthly utilization reports are provided to KDHE and program sites with targeted pregnancy utilization data available upon request. Despite these efforts, Quitline utilization among pregnant women is low. Establishing system and process credibility among stakeholders is an ongoing issue; repositioning the Quitline as one intervention in a multi-faceted arsenal is key. The direct counseling services provided through this medium can have a significant impact on patient compliance, particularly when partnered with intervention programs such as SCRIPT and BMTF. In FY20 we will launch two pilot partnerships to integrate Quitline counseling into a comprehensive cessation program thereby increasing utilization and compliance.

 

Nicotine replacement therapy during pregnancy is not universally endorsed among obstetricians or family practice providers and is not covered by Kansas Medicaid. In October 2017 ACOG released limited guidance on the use of NRT during the perinatal period and recommended caution when used during this time. Numerous additional randomized trials (pro and con) now exist with a wide variety of recommendations for NRT use among pregnant women. A new assessment of provider NRT utilization will be conducted in 2019 to determine statewide use during and after pregnancy. It’s important to note that NRT can be an important treatment option for women to maintain abstinence after delivery and it is covered by Kansas Medicaid postpartum. Because there are changing guidelines regarding the use of NRT, KDHE will share our provider assessment results with Kansas ACOG and ask for guidance in promoting NRT utilization prenatally.

 

Refining our multi-tiered approach (universal screening and referral, education, counseling and medical interventions) continues to be a priority. Launching the comprehensive tobacco cessation campaign began in early 2018 with provider webinars, however this needs to be updated and used to bring new providers on board. This updated webinar will educate additional partners statewide and promote campaign resources and the new tobacco cessation toolkit throughout 2019. The new tobacco cessation toolkit will be deployed statewide as one part of integrating this comprehensive campaign. Resources will be made available to all sites interested in launching tobacco cessation programming on the KDHE BFH website.

 

Building state and local referral systems is a significant priority. The investment that has been put forward to create tobacco cessation initiatives will be lost if women are not participating. Referral systems and processes to be developed at the state level include the Medicaid Managed Care Organizations (MCO). Medicaid currently pays for 30% of all pregnancies in Kansas and will often receive the first notification when a woman is pregnant. This coupled with tobacco usage data provides a solid pool of potential early referrals. The BFH has established a data sharing agreement between Medicaid and Vital Stats birth record data. The next step is to create a referral system to enable MCO’s to easily promote existing intervention programs (BaM, SCRIPT, BMTF, Quitline, etc.). Local referral systems that also need to be developed include public health (MCH services, WIC, home visiting), clinical providers, FQHCs and hospitals. The BFH will continue to provide technical assistance for established stakeholder groups (Perinatal Community Collaboratives, Community Coalitions, CDRR sites) to create their local systems and will share promising practices as they develop.

 

KDHE will work with the Kansas MCH Council and the Kansas Chapter of the American Academy of Pediatrics to identify current tobacco cessation resources that are applicable to the pediatric setting. In Kansas, Medicaid stops coverage for postpartum women 60 days after delivery however babies are covered for the long-term. Because of this, pediatricians often see postpartum women along with their new baby more frequently than primary care physicians. This may provide a vehicle to support women to stay quit.

 

Kansas collects a wealth of data and we are just beginning to use it on a scale that extends beyond state needs to support community level evaluation and planning. What we have started and plan to continue in FY20 is conduct surveys and focus groups to talk with individuals about what they need to help them stop tobacco use. We need to ask for their feedback on the tools, resources and programs we currently provide and need to ask what is missing. We can’t miss this opportunity to ask women what motivates them to quit and if they have declined services what drivers keep them smoking. This personal evaluation/survey will be developed by KDHE and initiated in communities with existing cessation programs. Several cohorts of teens will be surveyed to capture their unique viewpoint.

 

Tobacco Use Survey (Screening Form in DAISEY)

 

Local MCH Agencies: Local agency staff, including home visitors, will continue to assess all pregnant women of smoking status (through use of the screening form mentioned/shared) and educate them about the dangers of smoking during pregnancy. Tobacco use after pregnancy is also assessed during clinic visits as well as during home visits. Information and resources will continue to be given related to smoking during pregnancy, as well as second- and third-hand smoke exposure. Title V will continue to provide technical assistance to local agencies and encourage them to offer evidence-based tobacco cessation interventions in their organizations. Referrals will be made to the Kansas Tobacco Quitline, BMTF, and/or SCRIPT depending on the status and readiness of the individual. The screening, referral, and education information will be captured in DAISEY. Funding support continues in FY20 for the KIDS Network and the KBC to support Community Baby Showers where tobacco cessation education, resources, and even referral is provided on site, for example enrollment into Kansas Quitline (KanQuit). KDHE will continue to track statewide utilization of the Quitline by pregnant women and continue to solicit feedback from KPCC programs and make recommendations to the Quitline staff as appropriate.

 

Objective: Implement the Vermont Oxford Network (VON) Neonatal Abstinence Syndrome (NAS) Universal training program statewide in partnership with the Kansas Perinatal Quality Collaborative (KPQC) and birthing centers (Target: 65 centers).

 

Kansas Perinatal Quality Collaborative: In FY20 the Kansas Perinatal Quality Collaborative (KPQC) will continue supporting substance exposed babies and their mothers by working with partners to build awareness and reduce stigma outside of the birthing facilities while ensuring practices and policy changes are sustained. The KPQC will work with early childhood providers as well as substance use treatment providers to enhance supports to babies and their mothers as well as extended families. KDHE-BFH partnered with the BHP to develop an innovative prevention project for the Data Driven Prevention Opioid Grant that was submitted to CDC in May 2019; if funded, grant funds will be used to support a universal home visiting pilot targeting two locations with high substance-exposed infant births. This program will build on the current MCH home visiting curriculum and will include lessons learned from MIECHV-funded programs related to topics such as safe sleep, breastfeeding, developmental screening, and specific content that relates to supporting addiction recovery and caring for substance exposed infants.

 

The KPQC will work more collaboratively with the Kansas Maternal Mortality Review Committee (KMMRC) in FY20 to disseminate committee findings and identify the next QI initiative related to maternal and perinatal health. Kansas will enroll as an Alliance for Innovation on Maternal Health (AIM) state before 2020 and will identify an AIM bundle, identified by data gleaned from completed maternal mortality reviews as well as other MCH priority data for implementation.

 

AIM is a national data-driven maternal safety and QI initiative for states and hospitals and partners from participating states (focus on consistent obstetric practices). AIM is based on proven implementation approaches to improving maternal safety and outcomes in the U.S.

AIM works through state teams and health systems to align national, state, and hospital level QI efforts to improve maternal and perinatal health outcomes. Any state can join AIM as part of a state-level PQC quality efforts/initiatives. States that enroll in AIM receive:

• Access to 12 “safety bundles”
• Access to Patient Safety Tools
• Access to the AIM Community of States

 

AIM Bundles – Learn more at: https://safehealthcareforeverywoman.org/aim-program/

State Perinatal Quality Collaboratives (PQCs) and MMRCs function to improve maternal and perinatal health (investing in the mother’s health leads to a healthier birth/pregnancy outcomes). Roles are difference but complementary:

• PQCs: Focus on efforts during the maternal and perinatal periods intended to improve birth outcomes and strengthen perinatal systems of care for mothers and infants
• MMRCs: Focus on reviewing maternal and pregnancy-associated deaths (pregnancy through one year after delivery) to identify gaps in health services and make actionable recommendations to prevent future deaths, improving maternal and perinatal health

 

Lessons learned over time have resulted in the national recommendation (from CDC) for states to intentionally and strategically align the review efforts (MMRC) with the action/QI efforts (PQC), creating a “culture of safety”. Kansas’ enrollment in the AIM initiative (with Title V as lead) will result in statewide adoption of a “patient safety bundle”. This will be done in partnership with the KPQC, MMRC, and key MCH partners at the state and local levels. The tentative date to launch a bundle is summer 2020 (or sooner if ready). It is imperative that the first KPQC initiative focused on NAS is stable and fully integrated for return on investment. KDHE/Title V applied for CDC funding in May 2019 to support this work.

 

Diagram Showing the Role of the KMMRC and KPQC

The KMMRC will continue reviewing cases for 2017 and 2018 with the goal of reviewing all maternal deaths that occur in the state within two years from the date of death. Data will be shared with the CDC as it is entered into the Maternal Mortality Review Information Application or MMRIA; sharing data in this way connects Kansas to other maternal mortality review committees and allows a deeper understanding of maternal deaths and opportunities for prevention.

 

Count the Kicks® Stillbirth Prevention Initiative: Title V entered into a formal partnership with Healthy Birth Day, a nonprofit lead for an intervention known as Count the Kicks (CTK) in 2018. CTK is a campaign to prevent stillbirth by educating providers and patients about monitoring fetal movements during the 3rd trimester of pregnancy. This is taking place across Kansas at no cost to providers who will have full access to videos and educational materials (including posters, brochures, and, appointment cards in English and Spanish). Kansas plans to keep the momentum of the Count the Kicks (CTK) campaign going in Kansas by continuing social media blasts and sharing data and information with the MCH network (provided by Healthy Birth Day, Inc.). We will again mark October 2019 as Stillbirth Awareness Month to encourage local MCH agencies to spread awareness in their communities and encourage moms to count those kicks! Other states such as Iowa have reduced stillbirth rates annually since implementing. Learn more at https://www.countthekicks.org. Read about Kansas’ progress to date in the Women/Maternal Report.

 

Count the Kicks Materials (note Kansas MCH branding at bottom)

Long Acting Reversible Contraceptives (LARC): Title V will continue our collaboration with Title X and other state partners to increase access to LARCs for women. The LARC workgroup (read more in the Women/Maternal Report) is currently developing a LARC toolkit that includes:

• Case for Change (data for decision makers that approve service provision; cost of unintended pregnancy; return on investment for preventing preterm birth, low birthweight, etc.)
• Clinical Indications (LARC types/descriptions, evidence, myths, side effect, treatment)
• Billing and Coding (guidance for successful, maximum reimbursement)
• Resources (sample MOU for referral, resource guide, algorithm for workflow including OKQ)

 

The LARC workgroup also plans to recruit physicians for a LARC Preceptor Network (peer support) which will allow trained physicians to serve as preceptors for newly trained providers that need experience. A training event, LARC Grand Rounds, has been scheduled for September 27, 2019. This event will be a full day of learning and discussion around LARC. The training will include sessions on billing and coding and the LARC tool kit as well as an expert panel discussion with Q&A time. A live IUD and implants insertion training will also be provided.

 

Title V plans to continue the energy around LARC after this training event by hosting “lunch and learn” online events where organizations can call in for a short didactic session about a specific LARC topic (such as LARC myths and how to educate about them) followed by a Q&A session where participants can discuss LARC cases and get expert and peer advice. Title V and Title X will continue to offer technical assistance to organizations around LARC and assist identifying innovative ways to overcome barriers they may have to offering or referring for LARC.

 

Women/Maternal Behavioral Health Integration Activities:

 

Local MCH Agencies: Public health providers across MCH programs serve a unique role in screening, referring, and providing follow-up to our perinatal women and their infants/children. With the appropriate training, resources, and support of local clinical partners, screening for depression can be done in a caring and confidential manner within a group setting in the context of the mental health and pregnancy/postpartum discussion. With guidance, local MCH agency public health staff are increasingly screening for perinatal/postpartum depression in home visitation and clinical services. Expansion of MCH services in our state to include the BaM collaborative perinatal education and support program has prompted the need for such guidance on screening prenatally as well as in a group setting. Maternal mental illness is a more common health concern than previously thought and many cases of what has been called postpartum depression actually started during pregnancy. Left untreated, this can be detrimental to the well-being of both mother and child. Additionally, research shows correlation between untreated prenatal depression and increased risk of an infant being born preterm and at a low birth weight.

 

The mental health integration toolkit, with guidance and resources, was developed and finalized with support from the KS MCH Council for the Perinatal Community Collaborative utilizing the BaM curriculum. The toolkit has been adapted and shared with MCH ATL grantees across the state. Title V will continue to update and revise this toolkit to make sure it contains the most recent recommendations and resources around prenatal and postpartum mood and anxiety disorders. We will continue to market the toolkit for use in local organizations and continue to offer technical assistance to organizations who want to utilize the toolkit to integrate depression screening, referral and treatment into their organizations.  

 

Edinburgh Report: The Edinburgh Report went live May 2019 and was designed to allow users to quickly identify clients with positive screening scores and track their scores over time. Data in these reports come from Edinburgh screenings in DAISEY, and focus over the next year will remain on utilizing these types of reports to ensure referrals and connections are made to address the needs of MCH populations, specifically mothers experiencing depression. The Most Recent Activities Report can be filtered by Start and End Date, Organization, Score Classification, and Completeness Classification.

The Most Recent Activities dashboard displays the most recent screening data for all caregivers who have an Edinburgh entered in DAISEY with a Date of Activity within the selected Start and End Date. It includes an overall visualization of positive vs negative scores for your organization, and a table showing each caregiver’s most recent Edinburgh score, the response left for question 10, and whether or not the questionnaire was completed.

As noted on the report, a result of positive means that a score of 10 or higher and/or thoughts of self-harm were indicated on the client’s most recent screening. All positive scores are highlighted in red in the client data. Screenings in which one or more questions were not answered (incomplete) are highlighted in purple in the client data.

The All Activities for Client Report includes one filter to view all screenings for a particular client. This filter can be used by scrolling through the client list or typing the client’s name or ID in the white search bar that appears at the top of the dropdown. Once a client is selected, the chart will show all screenings completed for that client. Positive screenings will continue to be highlighted in red. Furthermore, hovering over each score box will provide additional information including the exact date of the screening, Q10 response, completeness, and the organization that completed the screening.

Kansas Connecting Communities: As mentioned in the Women/Maternal Report, the KDHE BFH was recently awarded the HRSA’s Screening and Treatment for Maternal Depression and Related Behavioral Disorders Program Cooperative Agreement funding. The funding/project provides the opportunity to increase health care providers’ capacity to screen, assess, treat, and refer pregnant and postpartum women for depression, anxiety, and substance use disorders. This project is titled Kansas Connecting Communities (KCC) and is directed/managed by the BFH/Title V Behavioral Health Consultant.

 

This work is critical, resulting in universal assessment and linkages across the MCH domains through expanded community support networks. The project has five overarching goals centered around increasing capacity and improving mental health and substance use screening and services for pregnant and postpartum women. Goals include:

1. Develop and Disseminate Trainings and an Integration Toolkit for the Edinburgh Postnatal Depression Scale (EPDS) and Screening, Brief Intervention, and Referral to Treatment (SBIRT) process;
2. Utilize Telehealth and/or Community Resources (e.g., Community Mental Health Centers (CMHCs) and behavioral health telehealth providers) to deliver real-time psychiatric consultation and access to care;
3. Develop linkages and care coordination across providers;
4. Provide services through telehealth or community providers following initial consultation; and
5. Enhance alignment of state and local partnerships including peer support groups.

 

The initiative can create an immediate impact not only for Kansas’ mothers but also for their children and families. Maternal depression has significant influence on children, even from the moment a woman becomes pregnant. During pregnancy, a mother’s physical and mental health impacts both the immediate and long-term health of her child. For example, it has been found that children whose mothers are depressed while pregnant are at an increased risk for being born preterm and at a low birth weight. The percent of preterm births is an MCH state performance measure. By taking a more holistic or whole-person approach to maternal health care, Kansas anticipates a reduction in these risks and related performance measure rates and an improvement in children’s developmental health as indicated through developmental screenings and school readiness assessments over time.

 

KCC will increase statewide access, using a regional phased approach, to screening, assessment, and treatment for maternal depression, anxiety, and substance use disorders. The project is initially targeting ten counties in Southeast Kansas. The need in this region is the highest in Kansas, with three of the five maternal depression risk factors between 7 and 9 percent higher than the state average. While grant activities will be focused in this region for the first three years of the award, all resources and capacity building opportunities will be made available to the statewide MCH network.

 

According to the Kansas PRAMS 2017 Surveillance Report, approximately 1 in 8 Kansas mothers (12.4%) exhibited signs of postpartum depression. This further demonstrates the importance of leveraging the resources and opportunities created by Kansas Connecting Communities to advance Title V MCH work in these areas. Some of these opportunities include:

• Mental Health Integration Toolkit (mentioned above): The toolkit includes resources for both families and providers and is available for download here: https://www.myctb.org/wst/KansasMCH/tools/Pages/default.aspx. The toolkit also includes algorithms for crisis and non-crisis situations, sample policies, and information about the Edinburgh Postnatal Depression Screen (EPDS), which is the recommended screening tool by both the BFH and the MDS Workgroup. The toolkit has been shared and discussed with Title V MCH local agencies/grantees on several occasions: as part of a webinar/TA event, the Kansas Governor’s Public Health Conference, and Regional Public Health Meetings. The toolkit will also be introduced at an upcoming regional event (details below).
• Regional Training Event: The KCC regional training event will be held July 23, 2019, in Southeast Kansas. The theme is: Kansas Connecting Communities: Every Mom Thrives! The KCC project is partnering with two subject matter experts to facilitate the training. First, Melissa Hoffman, DNP, APRN, PMHNP-BC is the founder of Build Your Village and President of Postpartum Support International’s Kansas Chapter. Melissa will provide information related to maternal mental health. Second, Christina Boyd, LSCSW, LCAC, is the CEO of Hope and Wellness Resources and the Western Kansas MSW Program Director at the University of Kansas School of Social Welfare.
• Project ECHO (Extension for Community Healthcare Outcomes) uses subject-matter experts and video conferencing technology to mentor, expand capacity, and promote consistency in care and practice. KCC is partnering with the University of Kansas Medical Center for Telemedicine and Telehealth Project ECHO team to sponsor four ECHO sessions in September 2019; any medical or social service provider in Kansas can participate in the sessions at no cost. The sessions will cover the importance of screenings, brief interventions, referrals and treatment, implementation strategies, and problem solving to address implementation barriers.
• Maternal Depression Work Group: As mentioned in the Women/Maternal Report, Title V and other state and local partners came together to form a Maternal Depression Screening (MDS) Workgroup that leveraged state Medicaid funding to support work group activities. This workgroup serves as an advisory council for the KCC project by reviewing resources and tools such as the Mental Health Integration Toolkit and providing feedback on training and promotion activities. Overall, the workgroup works to increase knowledge about prenatal and postpartum mood disorders and topics including screening, referral, and treatment. The group is also presently focused on policy change to allow for reimbursement of depression screening in the public health setting as well as at well-child checks in the pediatric setting. Conversations with Medicaid are underway, and KAAP is actively engaged/supporting the proposals. The work of this group will continue in FY20.
• Screening, Brief Intervention, and Referral to Treatment (SBIRT) Work Group: Also mentioned in the Report, the SBIRT work group was formed with Medicaid dollars to support activities and initiatives to increase knowledge of substance use disorders and the evidenced based SBIRT process. This group also serves in an advisory role to the KCC project. The group’s current efforts are focused on the development of an SBIRT Toolkit for MCH programs. The SBIRT Toolkit will include information about substance use screenings, interventions, motivational interviewing, referrals, treatment, implementation guidelines, crisis and non-crisis algorithms, and available training opportunities like the Kansas Department of Aging and Disabilities (KDADS)/Medicaid-approved SBIRT training.