Implementing Interconceptional Care: A State Example

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Implementing Interconceptional Care A State
Example

• Ralph Schubert, M.Sc., M.A.
• Illinois Department of Human Services
• Anne Marie Murphy, Ph.D.
• Illinois Medicaid Director
• June 21, 2005

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Illinois . is the state most demographically
representative
of the nation as a whole
Source U.S Census Bureau 2000
Illinois
USA
USA
Illinois

• Persons below poverty ( 1999) 10.7
  12.4

• Persons under 5 years old 7.1 6.8

• Persons under 18 years old 26.1 25.7

• Female persons 51.0 50.9

• H.S. graduates more than 25 years
  old 81.4 80.4

• White - not of Hispanic origin 73.5 75.1

• African American not Hispanic origin 15.1
  12.3

• Hispanic 12.3 12.5

• Asian 3.4 3.6

• Native American 0.2 0.9

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Maternal and Child Health in Illinois

• 180,000 live births per year
• 45 of live births covered by Medicaid
• Disproportionate number of high risk births
  covered by Medicaid
• 66 of Medicaid births are unplanned
• 30 of Medicaid births are to undocumented women
• If you want to improve birth outcomes,
• Medicaid is the place to start !!

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Other Maternal and Child Health Programs
Intertwined with Medicaid in Illinois

• Title V Maternal and Child Health Block Grant
• Title X Family Planning
• Family Case Management Program
• Targeted Intensive Prenatal Program
• WIC
• Perinatal HIV Testing and Counseling
• Smoking Prevention
• Mental Health Treatment
• Alcohol and Substance Abuse Prevention and
  Treatment

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A Majority of Medicaid Births are Unintended or
Unplanned
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A Majority of Medicaid Births are not a Womans
First Birth
In CY01, 65 of Medicaid births were subsequent
births
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Medicaid Covers a High Proportion of
African-American Births
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Hispanics and Latinas Births Are Also More Often
Covered by Medicaid
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Prenatal Care
Approximately 71 of Medicaid women enter
prenatal care in the first trimester. (CY 2001)
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Very Low Birth Weight Rate Medicaid 1.7 (CY 01
Birth File Match)
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Low Birth Weight RateMedicaid 9.5(CY 01 Birth
File Match)
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CY 2001 Percent of VLBW By Chicago Community
Area  
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CY 2001 Percent of LBW By Chicago Community
Area  
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Incidence of Non-Normal Medicaid Births By
County (1999-2001)  
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Adequacy of Prenatal Care

• Approximately 75 of Illinois pregnant women are
  receiving as much prenatal care services as they
  should (Kessner 74.5 Kotelchuck 77.5)
• Approximately 62 of Illinois Medicaid pregnant
  women receive adequate prenatal care (Kessner)
• Those enrolled in WIC or FCM achieve better
  compliance (65 vs. 53 Medicaid population
  without WIC/FCM)

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Medicaid Delivery Claims

• Approximately 16 of Illinois Medicaid
• women who delivered with complications did
• not receive any Medicaid-funded prenatal
• care.
• Approximately 14 of Illinois Medicaid
• women who delivered without complications
• did not receive any Medicaid-funded prenatal
• care.

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Where does that leave us?

• Many women are receiving prenatal care but still
  not having good birth outcomes.
• Some women are not getting into prenatal care.
• This implies that we need
• New approaches to outreach
• New models of care including pre or
  interconceptional care.
• Analysis of the quality of prenatal care needed

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Needs Assessment

• Perinatal Periods of Risk
• Interpartum interval and VLBW
• Change in birthweight distribution
• Prevalence of medical risk factors
• Fetal and Infant Mortality Review
• Perinatal Task Force

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Map Feto-infant Mortality
Post neonatal
Neonatal
Fetal
Maternal Health/ Prematurity
500-1499 g
Maternal Care
Newborn Care
Infant Health
1500 g
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Focus on Overall Feto-Infant
MortalityBlacks, IL, 2000
Maternal Health/ Prematurity 7.8
Total feto-infant mortality rate 18.4
(633/34,314)x 1000
Maternal Care 4.2
Newborn Care 2.0
Infant Health 4.5
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Excess Feto-infant MortalityBlacks, 2000
IL Blacks
Reference
Excess
7.8
2.9
4.9
-

4.2
2.0
4.5
1.9
1.3
1.1
2.3
0.7
3.4
-

18.4
7.2
11.2
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Very Low Birth Weight Rates

• The very low birth weight rate goes up as
  interpartum interval goes down
• All women with a prior birth 1.2
• 12-17 Months - 1.3 percent
• 18-23 Months - 0.9 percent
• ?24 Months - 1.0 percent
• Illinois, 2001 - 2003

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Interpartum Interval Among Very Low Birth Weight
Infants

• Among VLBW infants born to women with a prior
  birth
• 14 born within 12 months of the prior birth
• 16 born between 12 and 17 months
• 11 born between 18 and 23 months
• 59 born more than 23 months

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Change in the Birthweight Distribution
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Are women healthy?
The most common health problems of
African-American women in Chicago who had a very
low birth weight infant were

• infections
• drug abuse
• asthma
• hypertension

• anemia
• premature labor
• prior pre-term birth

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FIMR Findings

• 62 Lifestyle Issues stress, unplanned
  pregnancy, alcohol/drugs/smoking, no PNC,
  domestic violence, jail
• 22 Medical Issues prior pre-term birth or fetal
  loss
• 12 Systems Issues poor communication, lack of
  referrals, lack of resources
• 4 Environmental Issues poor social support

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FIMR Categories
4 4 Environmental
22 Medical
12 12 System
662 Lifestyle
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FIMR Lifestyle Factors
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FIMR Medical Issues
Management of pre-existing medical conditions and
issues related to current pregnancy or
post-partum period

• Maternal pre-existing conditions
• Medical conditions related to current pregnancy
• Multiple birth pregnancy
• Lack of pregnancy evaluation during sick
  physician visits

• Congenital anomaly
• Depression
• Family Planning issues
• Lack of risk assessment
• Infections
• Incompetent cervix
• Previous pre-term labor
• Pre-term labor

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Perinatal Report

• Public Act 93-0536
• Passed with the aim of improving birth outcomes
• Perinatal Task Force other state agencies
  experts in perinatal care
• Priority Recommendations to the General Assembly
  www.illinoishealthywomen.com/report
• Report required every 2-years

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Perinatal Report (continued)

• Priority Recommendations and Initiatives
• Expansion of FamilyCare
• Expansion of Family Planning Waiver
• Addition of Targeted Intensive Prenatal Case
  Management for High Risk Pregnancy Sites
• Development of a Smoking Cessation Program
• Pilot for outreach to locate hard to reach
• Creation of a Statewide Mental Health
  Consultation Service
• Development of interconceptional care
• Medicaid reimbursement for Preconception Care

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Current Strategies for Providing
Interconceptional Care

• Folic Acid Campaign
• Title X Family Planning
• Illinois Healthy Women
• FamilyCare
• Family Case Management and Healthy Start
• WIC
• Closing the Gap

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Folic Acid Campaign

• Collaboration between WIC and Illinois March of
  Dimes
• Distribute prenatal vitamins through WIC and some
  Title X agencies
• Screen postpartum women in WIC on folic acid
  intake counsel
• Birth Defects Awareness Month activities
• WIC Food Package provides folic acid
• IDPA coverage of folic acid and multivitamins
  with folic acid

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Title X Family Planning Program

• Key component of interconceptional care
• Preconceptional education
• Model protocols have standardized content but
  different target groups
• Negative pregnancy tests
• New clients

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Title X Family Planning Program History

• 1993 Training for QA staff
• 1994 Grants to agencies for protocols, resources
  and training curriculum
• 1994 Agencies with approved protocols receive
  reimbursement for preconceptional education
• 2001 protocols updated

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Title X Family Planning Program Protocol

• Nutrition
• Lifestyle (behavioral risk factors)
• Family History
• Medical History
• Reproductive History
• Medication Use

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Title X Family Planning Program Status

• 1/3 of local agencies have approved protocols
• These agencies receive additional 5.50
• All agencies required to provide minimal
  preconceptional counseling
• 2004 21,160 preconception education and
  counseling sessions (up from 17,101 in 2003)

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Illinois Healthy Women

• 5 year Medicaid Waiver for Family Planning
• Began 4/04
• Women ages 19 through 44
• No longer eligible for medical assistance
• Limited coverage family planning and related
  reproductive health (STI testing treatment,
  mammograms and folic acid)

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Illinois Healthy Women (continued)

• Our View Improves Birth Outcomes
• CMS View Birth Control
• Amendment 1
• multivitamins/folic acid (currently state only
  funds)
• Amendment 2 250 of poverty
• application process internet, point of
  service, community agencies
• Need for coverage of preconception visit,
  smoking cessation products, maternal depression
  screening

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Illinois Healthy Women (continued)

• Current Status (5/05)
• 113,998 women sent a 3-month card
• 11,399 had undeliverable addresses
• 25,752 enrolled for the full year of
• coverage
• 1,342 reenrolled for the second year
• 15,200 program participants (utilized
  services)

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FamilyCare

• Comprehensive health care coverage to parents or
  relatives living with their children 18 years or
  younger
• Income up to 185 of poverty (FY 06)
• U.S. Citizen or Meets Immigration Requirements
• Very modest co-pays no co-pay for family
  planning

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Family Case Management

• 277,300 Pregnant Women and Infants Served
  Annually with budget of 44 million
• Intertwined with Medicaid and WIC
• Operates statewide through local health
  departments, federally qualified health centers
  and community based organizations.
• Outreach and Case Finding
• Assessment and Care Plan Development
• Referral and Follow-up
• Advocacy

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Chicago Healthy Start Initiative

• Targets 6 communities around the Loop
• Supports 4 Healthy Start Family Centers
• Eligibility based on medical or social risk
• Outreach, Case Management, Health Education,
  Depression Screening
• Interconceptional Care began in 2002

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Chicago Healthy Start Initiative

• Service Coordination
• Service plan focused on mothers goals
• Measure referral for family planning and use of
  well child care immunizations
• Health Education
• Womens health after pregnancy
• Substance abuse prevention
• Domestic violence
• HIV / STD prevention

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Closing the Gap Racial Health Disparities at
Birth Project Funded by HRSA

• Illinois 1 of 4 states
• Targeting communities on Chicagos west and south
  sides
• Working with 2 existing federally-funded Healthy
  Start Projects
• Focus on system building rather than direct
  services

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Closing the Gap

• Strategies
• Public information campaign
• Peer counselors to change community norms on
  prenatal care and infant sleeping arrangements
• Coordinating other federal, state and city-funded
  infant mortality projects
• Blending state and federal funds to finance
  prenatal and interconceptional case management

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Quality of Medical Care

• Closing the Gap areas
• Racial Disparities in birth outcomes
• Michael Reese Health Trust Grant (local funding)
• Medicaid federal match
• Partnership between DHS, DPA, DPAs Peer Review
  Organization and UIC Endorsement from ACOG
• Provider Survey
• Medical Record Abstraction Tool Development
• Development of Quality Indicators/Score
• Study Design
• Medical Record Abstraction Findings
• Quality Improvement/Provider Education

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Special Supplemental Nutrition Program for Women,
Infants and Children (WIC)

• 508,250 Women, Infants and Children Served
  Annually with budget of 34 million food
• Quality nutrition education and services
• Breastfeeding education and support
• Supplemental nutritious foods
• Access to health care services
• Women eligible for 6 months post-partum up to
  one year if breastfeeding

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Additional Interconceptional Services

• Smoking Cessation
• Depression Screening

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Smoking Cessation

• Protocol (The 5 As)
• Curriculum (Make Yours A Fresh Start Family, et
  al.)
• WIC Visit
• Monitor through Cornerstone

• Medicaid provider notice
• Medicaid reimbursement of pharmaceuticals
• Tobacco QuitLine

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Depression Screening

• Gubernatorial Task Force
• Healthy Start
• Satellite Training
• Medication Guidelines
• Consultation Line Provider Training
• Brochure
• Medicaid reimbursement

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Barriers To Program Expansion

• Competing demands for money
• Focus on infant
• Loss of Medicaid eligibility
• Immigration status
• USDA WIC eligibility policy
• CMS Policy
• - Need waivers or other funding to test
  strategies

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Ideas on the Drawing Board

• DPA Proposal for Interconceptional Care Pilot
• Public-Private Partnerships
• Reconfigure Nursing Follow-up
• Illinois Healthy Women Expansion
• Role of Federally-Qualified Health Centers
• Privately-funded WIC Expansion
• Simplify Title X protocol
• Interconceptional care for the undocumented

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Public-Private Partnerships

• Foundations providing matchable funds
• Target high risk women
• fetal or infant loss
• prior VLBW infant
• Outreach, incentives, interconceptional care
  coordination, behavioral risk reduction

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IDPA Pilot Proposal for Interconceptional Care

• Population women with recent fetal or neonatal
  death
• Area City of Chicago
• Program Components outreach, education,
  interventions, evaluation
• Interventions provided for 2 years
• Case Management
• Family Planning
• Preconception Care
• Medical Care/Management high-risk conditions
• Support services grief counseling, lifestyle,
  high-risk behaviors

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Refocus Nursing Follow-up

• Part of birth defects surveillance system
• PHN visits for 2 years
• Developmental assessment, anticipatory guidance,
  link to community services
• Prioritize visits to high-risk women

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Role of FQHCs

• Growth in Presidents budget for HRSA
• Explicit links to other parts of the public MCH
  system
• Provide medical care for uninsured and
  publicly-insured women
• Physical and mental health services for women and
  their children

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Illinois Healthy Women Expansion

• Expand eligibility for Illinois Health Women to
  250 percent of the Federal Poverty Level

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Extending WIC Postpartum

• Nutrition education and risk reduction (smoking
  cessation, folic acid supplementation)
• Private funds to pay for maternal nutrition
  education after 6 months postpartum
• Children continue in WIC

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Revised Title X Protocol

• Simplify Preconceptional counseling protocol
• Standardize target group
• Basic protocol for all grantees
• Conduct training
• Monitor implementation
• Encourage providers

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Summary

• Additional Emphasis on Interconceptional period
  is justified
• Components of interconceptional care can be
  provided through existing programs with existing
  funds
• Foundation funding and Medicaid / SCHIP waivers
  as strategies for expansion funding