States Work to Improve Postpartum LARC
By Ellen Schleicher Pliska, MHS, CPH
Family and Child Health Director, ASTHO
Claire Mariel Rudolph, MPH, CHES
Senior Analyst, Maternal and Child Health, ASTHO
Unintended or mistimed pregnancies are associated with poor maternal and child health outcomes such as delayed prenatal care, prematurity, and negative physical and mental health effects for children. With 50 percent of pregnancies in the United States being unintended, it is paramount that women who want to prevent pregnancies have access to effective and reliable contraceptives. Despite the ease of use, safety, and effectiveness of long-acting reversible contraception (LARC), fewer than 9 percent of U.S. women were using LARC in 2009 (Guttmacher). Approximately half of women attend the postpartum visit six weeks after birth (J Gen Intern Med) and, despite recommendations to wait six weeks, many women resume sexual activity without a highly effective form of birth control. An option for new mothers is to discuss family planning desires during the prenatal period and make plans to receive a LARC (an IUD or implant) in the hospital before discharge.
ASTHO established a multistate LARC learning community to help identify opportunities, challenges and technical assistance needs to improve state ability to implement LARC, particularly immediately postpartum (IPP). ASTHO, with support from CDC, CMS, and Office of Population Affairs (OPA) convened the learning community to help select states (Colorado, Georgia, Iowa, Massachusetts, New Mexico and South Carolina) with Medicaid payment policies or pilots in place to implement IPP LARC initiatives. The learning community will convene over 18 months to provide technical assistance and identify promising practices to increase IPP LARC insertion.
Since the learning community kick-off on Aug. 18, 2014, states have succeeded in developing training and guidance, enhanced partnerships and conducted outreach. Colorado created an IPP LARC provider training protocol. Georgia conducted successful trainings at residency programs throughout the state and is developing a return on investment (ROI) article to support its work. Iowa sponsored student physician practicums in Georgia to investigate best practices in IPP LARC training that could be replicated in Iowa. In Massachusetts, two physician champions advocated for providing IPP LARC, garnering nearly 200 provider signatures for a formal letter to Medicaid to change the reimbursement structure. In fall 2015, New Mexico will launch a provider education campaign in coordination with Medicaid Managed Care Organizations to educate providers on IPP LARC reimbursement. South Carolina hospitals are working to improve hospital capacity for IPP LARC by ensuring that clinical staff are familiar with the procedure and Medicaid policies for reimbursement.
While these states achieved many successes when it comes to supporting IPP LARC, participants in the learning community also faced some challenges. Based on needs identified by the participating states, ASTHO and the CDC provided guidance to participants on domains and sample topics such as training, pay streams, consent, stocking and supply, outreach, partnerships, service locations, and data, surveillance and evaluation through virtual learning sessions and direct technical assistance.
ASTHO and the CDC look forward to continuing LARC work in the future. Cohort Two of the learning community will be selected soon, with a second round kick-off in fall 2015. These states will participate in key informant interviews to collect potential technical assistance needs and tools required to move from their recent Medicaid policy changes to fully increasing access to LARC IPP in their states. Cohort Two will join Cohort One in an additional series of virtual learning sessions. Progress made by states in implementing IPP LARC in their states will be documented online and in a publically available final report at the end of the project.
ASTHO IPP LARC Learning Community Resources: http://www.astho.org/Programs/Maternal-and-Child-Health/Long-Acting-Reversible-Contraception-LARC/
Forging a Comprehensive Birth Outcomes Initiative in Kansas
By Rachel Sisson, MS
Bureau of Family Health and Title V Director, Kansas Department of Health & Environment, Division of Public Health, Bureau of Family Health
Heather Smith, MPH
Special Health Services and Special Health Care Needs Director, Kansas Department of Health & Environment, Division of Public Health, Bureau of Family Health
The Title V MCH five-year needs assessment is designed to be an opportunity to review data, gather input from stakeholders, build capacity and identify priorities. The Kansas Department of Health and Environment (KDHE) spent the past year conducting the needs assessment with an approach focused on not only creating a meaningful, responsive action plan, but also building a strong platform to maximize resources, develop and sustain mutually reinforcing relationships, and deliver outcomes.
In an effort to collect comprehensive input while also increasing partner awareness, KDHE launched an initiative aimed at improving the health of Kansas mothers and infants. Using a collective impact framework, KDHE partnered with the March of Dimes Greater Kansas Chapter (MOD) and AMCHP to engage more than 200 stakeholders across the state between May 2014 and February 2015. This effort was not exclusively about health care, but instead focused on forging partnerships to collectively and comprehensively address issues families face in the context of their communities throughout the course of life. The primary goal has been to develop collaboration at the state and local levels, assessing what's working and what's not, and utilizing existing resources to guide the process. Conversations kicked off in southeast Kansas, a region that experiences the worst rates of preterm birth and smoking during pregnancy and has higher infant mortality than the state overall. Tools created for the initiative included an online inventory of services (conducted in advance), assets, priorities, and partnerships; a facilitated day-long meeting with networking and interactive exercises for public health professionals and partners including managed care organizations, early intervention and behavioral health providers, and hospitals; a pre and post assessment; meeting evaluation; and, follow up materials and resources. The group exercises engaged participants in interpreting data, identifying partnership opportunities, reflecting on services in relation to the Health Impact Pyramid, and thinking about promising MCH practices.
The AMCHP birth outcomes compendium, Forging a Comprehensive Initiative to Improve Birth Outcomes and Reduce Infant Mortality, was a key resource. It was used to frame the type of information collected on the inventory; to shape the small group exercises; and, provided an opportunity to familiarize local partners with an important tool to help guide decision making around MCH priorities and services. The compendium continues to be referenced for actionable strategies and effective coordinated efforts to reduce disparities and improve outcomes. Participant feedback and pre/post assessment results indicate the initiative was successful. There was a positive change in every area measured. Partners reported increased awareness, feeling part of a "shared" agenda to improve birth outcomes, confidence in partnerships to address population health needs, and ability to impact change. Keys to success included personal outreach of the Title V director to regional stakeholders, both to complete the inventory and to attend the meeting; MOD promoting the Healthy Babies are Worth the Wait model; and technical assistance from AMCHP with meeting and materials design, data synthesis, and pilot facilitation. The Kansas initiative is well-timed to position KDHE to fully benefit from national activities such as the CoIIN to reduce infant mortality and transformation of the MCH Services Block Grant.