Perinatal Health Plan for Application Year 2023

 

Priority: Grow and sustain an equitable birth and family care workforce

 

NPM 3: Percent of very low birthweight infants born in Level III + NICU

 

Objective 1. Support a community health and a place-based perinatal workforce

 

New Mexico is a predominantly rural and micropolitan state and the fifth largest state in the U.S. New Mexico Level III and IV neonatal intensive care units (NICU), including the state’s only academic medical center, are concentrated the north-central part of the state, hundreds of miles and hours by land from many NM communities. The same birthing facilities that provide acute care and the highest level of care for very low birthweight infants have become referral centers for critically ill COVID-19 patients. The pandemic has reinforced what community-based providers have long sought to address: to achieve risk- appropriate care we must support community-based and local options for birthing families who do not require the resources of remote multi-specialty hospitals.  Evidence suggests that local providers, including those offering a range of wrap-around services, may also help prevent conditions that result in very low birthweight infants.

 

Title V staff will continue to elaborate on the following activities and strategy areas:

-Collaborate with NM Medicaid and community partners to address Medicaid coverage -gaps for community-based perinatal services offered by midwives and doulas

-Collaborate with the NM Department of Health Community Health Worker (CHW) Program and community-based experts to adapt and scale perinatal training for and health promotion / promotora certification

-Collaborate with perinatal quality improvement, midwifery, and community leaders to increase midwifery integration into the statewide perinatal care network 

 

Strategy- Collaborate with NM Medicaid and community partners to address Medicaid coverage gaps for community-based perinatal services offered by midwives and doulas

 

ESMs-

Establishment of an appropriate Medicaid reimbursement model for NM doulas.

 

Number of LMs who are enrolled as Medicaid providers and accept Medicaid reimbursement for community birth services.

 

 

 

 

Supporting NM doulas and midwives in sustainable place-based care

 

According to an analysis conducted by the Kaiser Family Foundation, in 2020 NM Medicaid covered the third highest percentage of births (54%) in the nation. NM Medicaid is aware of the evidence demonstrating that doula care is a cost-effective service that can improve outcomes and save lives. Medicaid is also aware of the momentum nationally to promote doula care as a vital maternal mortality prevention strategy. Adding coverage for doula care has been identified as a high priority for the current fiscal year. New Mexico has a strong and organized professional organization, the NM Doula Association, that is well integrated in New Mexico and will increase access to traditional and respectful care. 

 

Title V staff have participated directly in strategic planning led by the NMDA, and we will continue to collaborate and support community-led efforts to obtain Medicaid coverage for doula services. Title V staff can leverage our strong relationships with NMDA and other community partners to make sure that Medicaid does not create a doula benefit without substantial input from partners who have the most insight into how to be successful in terms of appropriate reimbursement and enrollment mechanisms for a provider groups that continues to work predominantly on an independent contractor basis and not within the corporate structures through which the majority of healthcare services are now delivered and billed. 

 

Title V staff also have a significant role to play to assure that doulas and midwives are considered in future public health emergency planning. During the previous application year, COVID-19 not only disrupted collaborative efforts and momentum in place to advance this work; it interrupted consumer access to the standard prenatal in-person services and to in- hospital birthing support. Doula care was nearly universally prohibited early in the pandemic as hospitals sought to limit the number of “visitors” who may be infected with the virus. Doulas were not identified as essential healthcare workers, and anecdotal family and professional input suggests that lack of access to their services has had a negative impact on birth experiences. The NMDA has monitored this situation closely and continues to report a lack of consistency in hospital policy, and intermittent exclusion of doulas from hospital units depending on COVID-19 case levels. 

 

Title V epidemiology staff will continue to collaborate with NMDA and other community partners to refine retrospective assessments of birthing for COVID- infected pregnant and delivering people, as well as a PRAMS live birth surveillance assessment, based on the CDC/CSTE COVID supplement. In collaboration with reproductive health organizations and tribal epidemiology centers across the state, we will prioritize and publish indicators to assess out of hospital birth outcomes, hospital and birthing center births with doula care, and the impact of birthing companion models which unite birthing families and doulas at delivery and postpartum.

 

As the healthcare system and our state public health infrastructure continue to experience significant challenges reinforced by the lingering pandemic, our direct-service work with New Mexico families and community-based providers reminds us how great the social and medical needs of families are in ‘normal’ and in emergency times. We will continue to advocate for Medicaid coverage and expansion of doula services because our communities stand to benefit from access to this care, and our strong collaborative relationships afford us opportunities to demonstrate sustainability and return on investment for equitable and inclusive models of reimbursement and place-based care.

 

Advocating for improvements to the Birthing Options Program (BOP) for midwifery reimbursement

 

NM has already demonstrated leadership in promoting access to community birth by credentialing direct-entry Licensed Midwives (LM) as Medicaid providers through the NM Birthing Options Program (BOP). This state policy innovation was highlighted in a report published in April 2022: Improving Birthing Outcomes through Midwifery Care: New Mexico - The National Academy for State Health Policy (nashp.org) However, barriers related to allowable billing codes and delivery costs, and inconsistency in the administration of the BOP by Medicaid Managed Care Organizations (MCO)  significantly hamper LMs and create a considerable hardship in providing services to Medicaid-insured clients. We are concerned that highlighting policy innovation without addressing obvious and persistent flaws in the model serves to reinforce barriers to participation for midwives and diminish accountability for state agencies responsible for promoting equitable access to perinatal services.

 

In FY23, we will leverage the attention generated by the NASHP report and continue to work towards collaboration with NM Medicaid on a transparent process to update the regulations governing the BOP to reduce the administrative burden and allow equitable reimbursement for the comprehensive community and home-based services that midwives provide. This process must include input from the midwives who provide care for birthing people and families covered by Medicaid, and it must include mechanisms to assure that the MCOs contracted to administer Medicaid benefits will be held accountable for implementing the BOP in the manner it was intended- to increase access to care and improve outcomes. Although NM Medicaid must lead the redesign of the BOP, we will prioritize efforts to move this work forward. Initial steps include relationship development with new Medicaid leadership and engagement with MCOs that are bidding for the opportunity to participate in New Mexico’s Centennial Care Program.

 

Livable wages, fair compensation and diversity of the workforce are  for Title V Maternal Child Health planning over the next five years. Ensuring reimbursement for these evidence-based, community-level strategies will promote equity help to establish them as essential services that need to be considered and leveraged for pandemic planning and beyond. Medicaid coverage for doula services, along with redesign of the BOP, represent definitive steps to sustain the birthing workforce.

 

 

Strategy- Scale curriculum for perinatal training for Community Health Worker (CHW) and health promotions- promotora certification

 

Pre-pandemic, NM Title V and La Clinica de Familia Healthy Start in Las Cruces, NM teamed up to join a small cohort of border states addressing a HRSA-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. 

 

 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 FQHCs 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 expand access to  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, including 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)

 

Activities:

-Continue dissemination of LOCATe report products and work with DOH communications to identify opportunities to share findings with stakeholders

-Use identified levels of care to inform ongoing perinatal quality improvement programming

-Use LOCATe findings and tools to contextualize the fragility of community hospital-based perinatal services and consider policy solutions

-Develop framework for birthing landscape report to provide a comprehensive picture of perinatal health resources statewide
 

Strategy- Operationalize the findings of the CDC LOCATe survey of maternal and neonatal levels of care in NM birthing hospitals to plan and continually assess risk-appropriate care and perinatal care delivery at all levels

 

ESM:-Number of state-level analyses that incorporate LOCATe level into evaluation of perinatal outcomes

 

The Maternal Health Program uses the CDC Levels of Care Assessment Tool (LOCATe) survey to define and evaluate maternal and neonatal levels of care provided at New Mexico birthing hospitals. The tool was designed as a self-report by hospital representatives to assess available staffing, infrastructure, and services to assign a level of care offered from I (most basic and appropriate for all births) to IV (highly complex multi-specialty care resources). The levels are not intended as a grading system, rather they represent a standardized means of identifying resource distribution  to inform strategies to improve maternal and neonatal outcomes. Every birthing hospital in New Mexico has participated in the survey, and following some clarification based on CDC analysis, agreed to the level of care assigned. 

 

Since the completion and informal dissemination of the LOCATe analysis, the ongoing pandemic along with longstanding pressures on community hospitals have conspired to shrink the number of hospitals that provide perinatal services and remain open for births. Currently, New Mexico has 28 birthing hospitals to cover a territory that spans more than 121,000 square miles. Three of these birthing hospitals are Indian Health Service facilities that serve a defined population who meet eligibility requirements, and at least 3 other hospitals provide services intermittently depending on staffing. Within the past three years, two hospitals have permanently discontinued birthing services. The distribution of levels of care as identified through LOCATe confirm that Level 1 facilities offering the most basic levels of maternal and newborn care are geographically widely distributed and therefore essential. However, they are also the most vulnerable to closure without specific policies and support in place to maintain services. 

 

In FY23, the Maternal Health Program will work towards using LOCATe to contextualize the vulnerability of hospital-based services and demonstrate what is at stake if the trend of Level 1 hospital unit closures continues. We will also work to follow through on our established plan to use the LOCATe framework to create a ‘birthing landscape report’ which will display both healthcare provider and healthcare system capacity to provide adequate and high-quality maternal and newborn care.

 

Multiple states have integrated the LOCATe findings to promote perinatal regionalization by confirming levels of care and formalizing guidelines and pathways for transport and resource-sharing between levels. Given the unfolding crisis in hospital service provision, Title V staff will accelerate our efforts to explore the viability of this approach for New Mexico. Our plan will address the resources needed to accomplish an assessment of perinatal regionalization, consider future surveys to verify and confirm hospital self-assessments used to identify levels of care, identify uses for resulting data, and clarify how the data may be leveraged to support excellent outcomes and outstanding care at every resource level.

 

Strategy - Integrate the expertise of midwives and doulas providing care in rural settings into statewide quality improvement initiatives (hospital and community settings)

 

Activities:

-Meet with midwives (CNM and LM) and doulas to review existing policies related to community provider access to hospital settings, including guidelines and resources. Identify the need for updates and create new and revised tools.

-Collaborate with NM Perinatal Collaborative to assure ongoing community birth providers in site-based trainings for Critical Access Hospitals.

-Continue efforts to recruit midwives to participate in the Improving Perinatal Health ECHO program and assure that content is relevant to community-based midwifery practice.

 

ESMs-

 Number of rural site-based trainings that include community midwives and doulas in drills and simulations.

 

Release of perinatal guidelines and resources for transfer from community to hospital birth

 

This strategy leverages existing rural expertise and capacity for greater midwifery and doula integration.  Midwifery integration is associated with better birth outcomes, including decreased rates of low birthweight and increased rates of neonatal survival (Vedam, 2018). However, research has also demonstrated that NM’s high degree of midwifery integration is primarily an urban, hospital-based phenomenon even though licensed direct-entry midwives have the greatest geographic reach of any perinatal care provider type. Furthermore, the COVID-19 pandemic has further compromised integration in rural communities because hospital COVID protocols have disallowed doula services and made it much more difficult for community-based providers to access or refer clients to hospitals for consultation or screening services, such as newborn hearing screening.

 

Specific activities will focus on ways to promote integration through existing and emerging forums for collaboration and best-practice sharing. Title V staff will collaborate with community midwives, the NM Coalition of Midwives, the NM Doula Association, and the Licensed Midwife Board to identify barriers and facilitators of integration and to develop resources such as updated collaboration and transfer guidelines and COVID-specific resources for community-based providers.

 

The NM Perinatal Collaborative’s Outreach team and Improving Perinatal Health ECHO program will provide opportunities to provide updates and training with a focus on the needs of hospital teams to receive transfers appropriately and collaboratively. Hospital levels of care, as identified through the LOCATe process described in Strategy 1, will inform the specific training goals and objectives.

 

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

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

 

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

 

Comprehensive Addiction Recovery Act (CARA) in New Mexico

 

NM rules and procedures in CARA take a non-punitive approach to plan of care notifications, and the plans of care are meant to provide treatment and support for families who struggle with addiction. A team from the Children Youth and Families Department (CYFD), Department of Health Title V and University of New Mexico Pediatrics Department have designed the CARA process and protocols, and evaluation helps measure impact and effectiveness. Improvements in hospital reporting and in family engagement have been evaluated during the reporting period, and future plans build upon the lessons learned.

 

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

 

 ESM- Number of hospital responses to coordinated conversations of surveys

In 2023 we will continue to assess the completeness and consistency of hospital reporting. Additionally, the CARA team has been working on ways to increase prenatal case identification and start communicating with families about their needs prior to delivery. Although this is not required in the way delivery screening is mandated in legislation, providers are still encouraged to notify Department of Health if they are treating or providing health services to substance using pregnant people.

 

 

Strategy- Evaluate hospital trainings and community-based trainings with a multidisciplinary team

 

The CARA team has begun to make some training components available online and they are expanding opportunities to evaluate the results of training modules.

 

 

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

 

A key strategy to improving CARA implementation has been evaluating family knowledge of the Plan of Care, experiences engaging with health care providers and care coordinators, as well as assessing the efficacy of services families are receiving. These assessments will continue in the application year.

 

Future considerations and monitoring:

The CARA evaluation team has been matching Medicaid claims with CARA plans of care to assess the patterns of case notification and completeness of referrals at delivery. While the team has just begun this analysis, the ICD-10 codes in Medicaid claims imply that more children have been referred for a plan of care than have substance exposures in the delivery and early postpartum period. We theorize this is because many hospitals conduct verbal screening and do not rely on toxicology or umbilical cord testing. A great majority of people with a plan of care have some involvement with cannabis, and 65% of plans from 2020-early 2022 involved marijuana use. While marijuana is important to address during pregnancy and postpartum, the evidence for neonatal harm is greatest in other substances such as nicotine/tobacco, alcohol, methamphetamines and opioids. The CARA team will continue evaluating the efficacy of supporting families with marijuana use, and they are not planning to discontinue support since many families express gratitude and interest in receiving program referrals even if their only substance use is cannabis.