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Special Edition: Title V Technical Assistance MeetingExpand Special Edition: Title V Technical Assistance Meeting
Title V Technical Assistance Meeting

 The Well-Woman Visit in the Title V Performance Measurement Framework: Access, Content or Quality?

ashley.pngBy Ashley Hirai, PhD
Senior Health Scientist, Office of Epidemiology & Research, Maternal and Child Health Bureau, HRSA

Andria Cornell, MSPH
Senior Program Manager, Women's Health, AMCHP

Carolyn McCoy, MPH
Senior Policy Manager, Health Reform Implementation, AMCHP

Why Include Well-woman Visits in the Title V Performance Measurement Framework?
In the new Title V performance measurement framework, states will select eight of 15 National Performance Measures (NPMs) that are most relevant to a given state's needs and priorities across six population domains. To better document the impact of Title V, states will be developing and tracking Evidence-based/informed Strategy Measures (ESMs) to improve their selected NPMs and related longer- term National Outcome Measures (NOMs). The well-woman visit (NPM-1) was included as a women's/maternal health performance measure on the basis of a number of factors, including alignment with the HRSA and Title V mission of promoting access to preventive services, a key emphasis in the Affordable Care Act, and the opportunity to leverage and strengthen many public and private partner initiatives that promote access and quality of well-woman care as a driver of preconception health and improving maternal, perinatal, and infant health outcomes. A well-woman or preconception visit provides a critical opportunity to receive recommended clinical preventive services, including screening, counseling, and immunizations, which can lead to appropriate identification, treatment, and prevention of disease to optimize the health of women before, between, and beyond potential pregnancies.

About the Measure
The well-woman visit, NPM-1, is defined as the percent of women aged 18-44 with a past-year preventive medical visit. The measure is based on self-report to the following survey question: "About how long has it been since you last visited a doctor for a routine checkup? A routine checkup is a general physical exam, not an exam for a specific injury, illness, or condition." The data source is the Behavioral Risk Factor Surveillance Survey (BRFSS), which is population-based and available annually for all states, DC, Guam, and Puerto Rico. To reduce reporting burden and improve standardization, the data are pre-populated in the Title V Information System. Data are provided both by year to inform objective-setting and by various demographic stratifiers to identify program targets and opportunities for improvement. At the national level, 65.2 percent of women reported receiving a past-year preventive visit in 2013 – a rate that has remained within 64.0 percent to 66.4 percent for the past five years and indicates considerable room for improvement. For more information about this and other measures, including national estimates and SAS code to facilitate more detailed exploration in your state/jurisdiction, please visit the Federally Available Data (FAD) Resource Document.

How Does it Align with the ACOG and QFP guidelines?
NPM-1 is a measure of access, rather than quality or content of the health care visit. The American College of Obstetricians and Gynecologists (ACOG) released comprehensive guidelines and recommendations for obstetricians-gynecologists and others caring for women on the content of the annual well-woman visit , including screening, laboratory testing, evaluation and counseling, and immunizations, based on a committee opinion that was reaffirmed in 2014. Also in 2014, the CDC and the U.S. Office of Population Affairs (OPA) released the Providing Quality Family Planning (QFP) recommendations that describe the services to be provided in a family planning visit. These guidelines are intended to be complementary, detailing aspects of high quality and comprehensive care for women across the life span, including during adolescence, and assist the various providers that may see these patients. Although the Title V performance measure on well-woman visit focuses on access, states are encouraged to explore opportunities to enhance the quality and comprehensiveness of care in concert with efforts to improve access to preventive health care for women and adolescents. Certain dimensions of content and quality may be measurable in BRFSS, Medicaid, or Title X data (e.g. having a personal doctor, diabetes, blood pressure, depression, and cervical cancer screening, vaccination, and contraceptive counseling) and could serve as complementary state performance measures.

What are your strategies to support this NPM? What are the levers you are using in your state/jurisdiction to improve well-woman visit utilization? Please consider submitting your activities to the AMCHP Innovation Station, so others can benefit from what you've learned. Also see the recent issue brief entitled Opportunities and Strategies for Improving Preconception Health through Health Reform: Advancing Collective Impact for Improved Health Outcomes, which highlights activities of three state Title V MCH programs, in an action learning collaborative working to enhance preconception health and preventive care for women.

Technical Assistance Available
Monitoring and analysis of how health reform implementation/ACA will affect MCH populations is of highest priority to AMCHP's health reform implementation team. The preventive health services coverage of well-woman visits with no cost-sharing or co-pay should lift many barriers to women accessing these services while also remaining the payor of last resort for women who remain uninsured. As you develop and refine your strategies to improve access to care for women across the life span, the following MCHB-sponsored technical assistance resources are available to you:

ResourceBrief Description
Infant Mortality CoIIN –
Pre- and Interconception Care Learning Network
Provides technical assistance (QI, innovation, data/measurement) and a platform for collaborative learning to promote optimal women's health before, after, and between pregnancies by improving utilization and quality of postpartum and adolescent well visits with a focus on improving effective contraceptive use
Alliance for Innovation on Maternal Health (AIM)Aligns national, state, and hospital level efforts to improve maternal health and safety through technical assistance and quality improvement efforts around maternal safety bundles, including the development of standards of care for the interconception and postpartum visit
Healthy Start EpicProvides technical assistance, training, and capacity building to ensure program effectiveness for the 100 community-based Healthy Start Projects in 37 states working to improve birth outcomes through a focus on women's health, quality of care, family resilience, and collective impact
MCH National Workforce Development Center
Offers state and territorial Title V leaders training, collaborative learning, coaching and consultation in implementing health reform through a variety of platforms, including an analysis to determine the best areas for Title V to support the implementation of insurance protections and states' work on the well-woman visit NPM
Strengthening the Evidence Base for MCH Programs (website coming soon!)
Cynthia Minkovitz, MD, MPP
Provides support and resources to assist state Title V MCH programs in developing evidence-based or evidence-informed State Action Plans to address selected National Performance Measures, State Performance Measures, and related National Outcome Measures