NPM. Percent of very low birthweight infants born in Level III NICU/ higher facilities

 

 

Objective 1. Support community health and place-based workforce

Strategy 1. Expand Medicaid reimbursement for doula and home visiting staff

 

The Family Health Bureau Maternal Child Health Epidemiology Program (MCH Epi) and the Maternal Health Program (MHP) will work to advance strategies for expanded Medicaid reimbursement options, especially for community-based workers operating in rural or underserved areas. In NM, reimbursement to doulas and home visiting staff could be accomplished by amending 1115 waivers. Several NM home visiting programs have been piloted and vetted for reimbursement to date and there is support among a cross-section of organizations to include doula or other perinatal support options. Evidence-based programs can be added to state waivers and this includes Parents as Teachers (PAT), Nurse Family Partnership and could include other NM models such as the Johns Hopkins Family Spirit program, Family Connects and First Born (pending review).

 

Prior state-level evidence generated by Title V staff and Arizona State University faculty and students to study Return on Investment demonstrated how doula care could save NM money by positively impacting outcomes such as elective C-section mode of delivery and longer breastfeeding duration. That information was shared with doulas and indigenous health professionals working to expand evidence and awareness of doula-based expertise, and they have developed the tools to educate consumers and policy makers on the benefits of doula expansion and economic savings https://tewawomenunited.org/wp-content/uploads/2020/08/TWU-Expanding-Access-to-Doula-Care-March-2020.pdf

 

These cost-savings discussions will be directed to our Human Services Department, Medicaid Assistance Division (HSD/MAD), medical societies and early childhood advocates. Title V programs have maintained strong ties with doula professional groups in the state, and with home visiting collaboratives to engage those partners as the true effective body to encourage innovation in payment models. These discussions with HSD/MAD are most effective when place-based professionals ‘go to bat’ for advocating their successes in providing human-centered care to maternal/family populations.

 

NM Title V worked with Medicaid in 2008 to introduce a Birthing Options Plan to serve Medicaid-eligible pregnant and birthing women. The BOP allowed home birthing as an option and created the possibility of claims reimbursement to Licensed Midwives (LMs) in the state who preside over home birth settings as the primary provider. Now, approximately 50 LMs practice within the state and in 2018, LM’s were primary attendants for approximately 243 NM births. This example of bringing choice and improved access to Medicaid-eligible pregnant women is coupled with 2017 legislation that set up rules for the licensing of birth centers to become eligible for both provider and facility claims reimbursement. Since then, four birth centers were established around the state and become licensed. Two more are pending in 2020.

 

Seeking reimbursement for doulas and home visitor staff would be one more progressive step to creating an alternative experience of birthing and facilitating more community settings (i.e., home or birth centers) when medically appropriate. Livable wages, fair compensation and diversity of the workforce are criteria for Title V Maternal Child Health planning over the next five years.  Ensuring reasonable compensation for the workforce and sustainability of federal funding for reimbursement help ensure that the workforce is local, culturally competent and representative of the populations they serve.

 

Strategy 2. Complete and scale curriculum for perinatal training for Community Health Worker (CHW) and health promotions promotora certification

 

In Fall 2017, NM Title V and La Clinica de Familia Healthy Start teamed up to join a small cohort of border states addressing a COIIN-sponsored 3-year design and implementation project to increase first trimester prenatal care access for pregnant women living in Dona Ana County (DAC), an international border county with Mexico as well as the western border of Texas/El Paso). NM Vital Records data indicated that just 60% of DAC women accessed prenatal care in the first trimester. Between 2010-2018, first trimester care ranged from 51% among Black and Native American women to 58 and 65% among Hispanic and non-Hispanic white women, respectively. Barriers included not being aware of pregnancy when it occurred, transportation or payment challenges and inability to secure a first-trimester appointment with a prenatal care provider. The initial plan with the COIIN project was to work with preconception and pregnant client populations at one federally qualified health center (FQHC) system with multiple clinic sites in Dona Ana County. There was significant coalition effort to create and evaluate a media plan and web-based application with perinatal resources and a coordinated referral system between NMDOH, community-based providers and federally qualified health clinics. Unfortunately, the lead FQHC staff had to drop out of the project before launching the web-based applications and referral components.

 

Faced with shifting partnerships in 2019, a local coalition member agreed to take the project lead but with a different plan to address first-trimester care access. New Mexico has a strong tradition and capacity to connect community health workers or promotoras to deliver supportive and wrap-around health care in client homes, clinic-based and non-clinical settings. They have been organized and trained as support staff at FQHC’s providing education and support to clients in areas of oral health, chronic disease management and less often in reproductive or prenatal care. The new project lead is a respected, well-known lay midwife and Health Extension Rural Officer (HERO) working with Dona Ana Community College (DACC) to develop a preconception and prenatal curriculum for CHWs to gain either entry level knowledge or to fulfill continuing education requirements as set down by the DOH Office of Community Health Workers. The launch of this course was in February 2020 with 16 attendees, who completed pre-test and post-test knowledge on reproductive health and justice, social determinants of health and perinatal health education.

 

The plan for next two years is to create and deploy an online version of this course to adapt to the new learning methods and venues for students during the COVID pandemic response period. There will also be a step of taking this curriculum to other community college settings in the state to expand the potential CHW and doula or birth worker audience. The next steps include bilingual, Spanish-language curriculum development, birth equity and indigenous and trauma-informed care modules.

 

 

Objective 2. Improve support system for rural and under-resourced birth settings (hospitals, birth centers, home)

 

Strategy 1.  Operationalize the findings of CDC/NM LOCATe to plan and continually assess a model of risk-appropriate care

 

The Maternal Health Program is completing the follow up phase of reviewing findings of the CDC-sponsored LOCATe Survey which started to assess NM and bordering birth hospitals in the Winter of 2016. A CDC analysis of the hospital respondent findings showed that there was significant discordance between a hospital’s self-analysis and the CDC analysis based on specific survey responses. With this discordancy in both neonatal and maternal/obstetric levels of care, the MHP team embarked on a negotiating phase with each discordant hospital to come to a final accurate and official level. The conversations with each hospital led to capacity-building discussions and general planning for the NMDOH supporting some of the rural hospitals to sustaining adequate birthing services with a coordinated transfer planning approach for improving maternal and neonatal care across the state.

 

A key to the 31 NM birth hospital levels of care will be published in late 2020 and interpreted to interested stakeholders such as the state’s perinatal collaborative and the maternal mortality review committee to inform maternity care planning. It will also provide a systems-based mechanism to track infant and maternal morbidity and mortality health outcomes. There is a related plan to integrate the findings along with midwifery homebirth data recently obtained by the MHP to create a ‘birthing landscape report’ which will display both healthcare provider and health care system capacity to provide adequate and high-quality maternal care. This effort will be a key underlying assessment to start the taskforce described in the ESM - Establish task force that addresses birthing capabilities in rural and metro regions. This task force would include representatives from legal, health care, legislative, business, community and government sectors as NM’s hospital network is multi-faceted in terms of location, populations served, distance to care, resource challenges and business models.

 

Strategy 2. Integrate expertise in midwifery and doula care in rural settings (hospital and out of hospital settings) ESM. Complete at least two listening sessions between health providers and consumers

 

This strategy builds on existing expertise and literature on midwifery and doula care in (both in hospital and out of hospital settings), in rural and primary care settings where patient transfer is challenging, and it responds to findings from risk appropriate care analyses. NM ranks well in high integration of midwifery care into its maternal health care systems https://doi.org/10.1371/journal.pone.0192523. The birthing options landscape in NM offers more opportunities to reclaim fewer medicalized births while still strengthening specialty and acute medical care coordination The US Health Secretary’s Advisory Committee on Infant Mortality (SACIM) instructed that birthing care be provided under a ‘Midwifery Care Model’ as a means of addresses the inequities frequently identified in maternal care literature.

 

NMDOH Midwifery licensing supports two professional midwife groups, licensed midwives (LMs), and certified nurse-midwives or CNM.  With these strengths and opportunities in NM, the Title V will support the varied and effective models of care and innovative projects undertaken by midwife professionals in the state. An example is Centering Pregnancy and similar group prenatal care provided by a group of midwives located at one of our larger urban hospitals in Albuquerque. To explore the benefits and feasibility of offering these outside the metro area, Title V staff will embark on listening sessions that potentially could be coordinated by midwife professionals who work in both urban and rural settings and/or manage a birth center in those same areas. The attendees would come from a broad spectrum of health professionals: home visitors, CHWs and promotoras, doulas, midwives, family practice trained clinicians, obstetricians and perinatologists and with a heavy focus on consumer representation as well. The qualitative data collection opportunities that such listening sessions could provide would set the next 5 years on a sound course to improve the state’s network of maternal birthing/infant/family care services.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPM- Proportion of eligible families receiving a plan of care for their substance-exposed newborn

Priority- Build statewide capacity to prevent perinatal substance use and advance equitable, culturally appropriate treatment options.

Objective-All birthing hospitals are reporting plans of care to NMDOH and CYFD by the end of 2021

Strategy- Assess barriers to reporting through coordinated and focused conversations with hospital leadership

Strategy- Evaluate hospital trainings and community-based trainings with a multi-disciplinary team

Strategy- Evaluate family experiences, receptivity to services, and impact of plans of care on family well-being

 

Comprehensive Addiction Recovery Act: New Mexico

Since 2018, Title V has partnered with the Children, Youth and Families Department (CYFD) to ensure that every baby born with substance exposure has a Plan of Care (POC) developed with their family, to include needed referrals to services such as Early Intervention, Mental Health, or Home Visiting. The plans are developed in the hospital after delivery and prior to discharge.

The New Mexico Legislature passed House Bill 230 (HB230) in February 2019, and it was signed into law that April.  The law required hospitals to create Plans of Care for every baby born with exposure to substances and required Medicaid Managed Care Organizations to provide direct care coordination for these babies. It also clarified that substance exposure was not automatic grounds for child abuse referrals or investigations, although all cases are still reported to CYFD and screened to assess whether there is a need for CYFD involvement.

The training team from NMDOH, CYFD, UNM Pediatrics began training hospital staff and medical providers in their roles and responsibilities under the law and protocols to report and refer for POC. Starting July 1, 2019, the team started the training with two facilities and continued with training the majority of the 31 birthing facilities and the Medicaid Managed Care Organizations (MCO) Care Coordination Units. The CARA leadership team began working on evaluation plans with Title V Epidemiology staff and charted a course to understand the impact of training and plans of care. Trainings were also presented at annual provider conferences for the NM Pediatric Society and the NM Family Practice Association, as well as the NM Perinatal Collaborative.

 

 

Strategy- Assess barriers to reporting through coordinated and focused conversations with hospital leadership

Early evaluation data and tracking indicate that 27 out of 31 birthing facilities are reporting plans of care, with the remaining hospitals being unresponsive and/or seemingly resistant to the idea.  In addition to this barrier, screening tools for perinatal substance exposure are not universal, and currently almost all coordination for family services is being done by the implementation team, not MCO care coordinators, even though the law says they should have that responsibility.  It has been difficult to get the MCOs to assign care coordinators within 24 hours, especially on the weekends. During COVID, some facilities who initially reported, stopped reporting sporadically or entirely. Some of the facilities not currently reporting are Indian Health Service hospitals, and it is unclear whether Northern Navajo Medical Center and Gallup Indian Medical Center refer to Navajo Nation child protective services and social services. Although staff from these hospitals attended NM CARA trainings, it is not clear that they responded positively to the procedures for the state of New Mexico. Conversations with the leadership and Navajo Department of Health will help determine any barriers, concerns and possible duplication that may be at play.

 

Between October 2019 and July 2020 there were 622 plans of care developed in New Mexico and about 980 since the plans began. Based on analysis of perinatal substance exposures from January through June 2020, 45.3% of exposures involve alcohol and/or illicit drugs, 34.6% involve marijuana only, the remaining 20.1% involve some other combination of non-alcohol and non-illicit drugs. 18.4 percent of all exposures involved opioids. PRAMS data indicate that about 10% of NM women with live birth use marijuana just prior to pregnancy, and at least half of those continue using it during pregnancy. These data show that there is likely an underreporting for this type of exposure. Working with our chief medical officer, the NM Hospital Association and some evaluators, we will communicate with non-reporting or sporadically reporting hospitals to understand what barriers should be addressed and how to optimize the policies and practices at those facilities.

 

Strategy- Evaluate hospital trainings and community-based trainings with a multi-disciplinary team

One way to improve and boost participation in hospital plans of care and community referrals is to expand evaluation plans to understand the receptivity of staff trained in CARA screening and plans reported to CYFD/DOH. Currently, we have a limited understanding of how facilities interact with families and Medicaid managed care coordinators. Additionally, we are interested in evaluating equity and bias concerns in the trainings we perform, so the CARA team has been working with one contractor to build conceptual content and evaluate bias among providers interacting with staff or families. The team also intends to make trainings available online via webinar modules, and those will be launched over the next year. The webinar trainings will then be evaluated as well.

Many clinical and non-clinical stakeholders contribute to the CARA plans and implementation of best practices, so Title V is an important convener of interested experts and navigation of complex support to families.

 

Strategy- Evaluate family experiences, receptivity to services, and impact of plans of care on family well-being

A key strategy to improving plans of care is to understand how well they are working. To assess how families feel about their experiences with prenatal care, care coordination, and the Plan of Care we will conduct brief surveys at six weeks and at six months, postpartum. This component will help triangulate findings from the evaluation of provider bias in their care for pregnant women with substance use disorder, as well as measure the need for more assistance or alternate forms of support, especially for families who declined a Plan of Care.

To measure the impact of Plans of Care on family well-being we will also compare the number and duration of CYFD investigations related to infant substance exposure prior to Plan of Care implementation and after implementation. We will also evaluate the differences in CYFD involvement in cases that received services and in cases that declined. To evaluate the effect the Plan of Care has on ED utilization we will analyze trends in visits related to infants suffering from withdrawal symptoms, as well as infants affected by noxious substances through placenta or breast milk. In addition to longitudinal analysis, we will also utilize a matched comparison design to evaluate differences in ED utilization between families that accept Plan of Care services and those that decline. This information will help us determine next steps and to assess the need for support among families later in their postpartum phase.