Transforming Maternal Health and Safety

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Manda Hall, M.D.

Associate Commissioner, Community Health Improvement

Department of State Health Services (DSHS)

Lesley French, J.D.

Deputy Executive Commissioner, Health, Developmental , and Independence Services

Health and Human Services Commission (HHSC)

2018 UT Healthier Texas Summit ● October 25, 2018 ● Austin, TX

Layers of Influence on Health

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Improved Health Outcomes

IndividualPatient

CLIENT SERVICES

PUBLIC HEALTH

Learning Objectives

1. Statewide Data Trends

2. DSHS Public Health Initiatives

3. HHSC Client Service Programs

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Statewide Data Trends

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Cause of Death

While

Pregnant

0-7

Days

Post-

partum

8-42

Days

Post-

partum

43-60 Days

Post-

partum

61+ Days

Post-

partum Total

Amniotic Embolism 1 9 0 0 0 10

Cardiac Event 2 12 9 5 27 55

Cerebrovascular Event 0 8 9 1 9 27

Drug Overdose 0 3 7 5 49 64

Hemorrhage 3 12 2 0 3 20

Homicide 2 1 5 2 32 42

Hypertension/Eclampsia 0 7 4 0 7 18

Infection/Sepsis 1 3 14 3 11 32

Pulmonary Embolism 2 3 4 2 2 13

Substance Use Sequelae

(e.g., liver cirrhosis)0 0 2 0 3 5

Suicide 0 1 2 2 28 33

Other 5 5 6 3 44 63

Total 16 64 64 23 215 382

Maternal Deaths by Timing and Cause of Death, 2012-2015

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Demographic Risk Factors for Maternal Death, 2012-2015

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Low Socioeconomic Status

Health Risk Factors for Maternal Death, 2012-2015

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Role of Opioid Overdoses in Maternal Deaths, 2012-2015

• Drug overdose leading cause of maternal death,

mostly occurring after 60 days postpartum

Ø Combination of drugs involved in 66% Ø Opioids detected in 58%

• Demographic groups at higher risk:

Ø White womenØ Ages 40+Ø Medicaid at delivery (low socioeconomic status)Ø Urban counties Ø Region 2/3 (includes Dallas-Forth-Worth) and

Region 1 (Panhandle)

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Depression during Pregnancy-related hospitalization by race/ethnicity, 2014

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Percent of Postpartum Depression Reported by Recent Texas Mothers by Race/Ethnicity, 2012-2015

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Severe Maternal Morbidity

• Unexpected outcomes of labor and delivery resulting in significant short- or long-term consequences to a woman’s health

• Identified using specific ICD codes for delivery hospitalizations

• Examples include:Ø Hemorrhage

Ø Eclampsia

Ø Emergency hysterectomy

Ø Thrombotic embolism

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Severe Maternal Morbidity, Overall and Top Causes, 2014

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Obstetric Hemorrhage Rates by Race/Ethnicity, 2005-2014

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122.2

147.4

157.9 157.7

187.8

175.9179.8

195.3

176.9167.7

93.4

105.6112.0

113.0

129.4 129.7 129.3

133.9128.3 129.8

0

20

40

60

80

100

120

140

160

180

200

220

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Ca

ses

pe

r 1

0,0

00

de

live

ry h

osp

ita

liza

tio

ns

White Black Hispanic Other Texas

ICD-9 procedure code 99.0x (Blood and Blood Component Transfusion) was used to estimate/calculate rates of severe

maternal morbidity due to hemorrhage in obstetric hospitalizations.

Data Source: Hospital Inpatient Discharge Public Use Data File, 2005-2014

Prepared by: Maternal & Child Health Epidemiology

Percent of Hospitalizations due to Obstetric Hypertension by Race/Ethnicity, 2005-2014

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12.412.8 12.8

13.4

14.515.1

16.015.4

15.9 16.2

8.8 8.9 8.89.2

9.810.4

10.8 11.011.3 11.5

0

2

4

6

8

10

12

14

16

18

2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Pe

rce

nt

of

All D

elive

ry H

osp

ita

liza

tio

ns

White Black Hispanic Other Texas

ICD-9 diagnosis code 642.xx was used to calculate proportions of hypertensive disorders in delivery

hospitalizations.

Data Source: Hospital Inpatient Discharge Public Use Data File, 2005-2014

Prepared by: Office of Program Decision Support

DSHS Public Health Initiatives

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Healthy Texas Mothers and Babies

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Individual and Public Awareness and

Knowledge

Perinatal Quality Improvement

Network

Individual and Public Awareness and Knowledge

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• To emphasize importance of:Ø Healthy livingØ Timely prenatal careØ Role of health disparitiesØ Chronic disease risk factors

• Key initiatives:Ø Someday Starts NowØ Preconception Peer EducationØ One Key Question

Perinatal Quality Improvement Network

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• To drive adoption and diffusion of quality improvements for maternal and infant

health and safety

• Key initiatives:Ø Risk appropriate maternal care

Ø Maternal safety bundles

Risk Appropriate Care

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• To ensure pregnant women at high risk receive care in facilities prepared to

provide required level of specialized care

• DSHS is responsible for establishing rules for maternal level of care designation

• DSHS will also be calculating maternal health outcome measures for ongoing

monitoring and re-designation

Risk Appropriate Maternal Care

House Bill 15 83rd Legislature, Regular Session

Sec. 241.183. LEVEL OF CARE DESIGNATION RULES.(a) The executive commissioner, in consultation with the department, shall adopt rules:

(1) establishing the levels of care for neonatal and maternal care to be assigned to hospitals;(2) prescribing criteria for designating levels of neonatal and maternal care,

respectively, including specifying the minimum requirements to qualify for each level designation;

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AIM Maternal Safety Bundles

• Instructions, checklists, and supplies for health care staff to effectively prepare, identify, and prevent severe maternal morbidity due to specific causes

• Evidence-based best-practices for maternity care endorsed by many national organizations, including ACOG

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Implement AIM Maternal Safety Bundles

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• Goal:Ø Reduce severe maternal morbidity using

evidence-based systems to enhance maternal care

• Implementing AIM bundles for:Ø Obstetric hemorrhageØ Severe hypertension in pregnancyØ Obstetric care for women with opioid use

disorder

TexasAIMMaternal Safety Bundles

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TexasAIM Basic

• Complete intake assessment

• Form improvement team

• Report measures to AIM data portal

• Network with participating hospitals

• Receive technical assistance

• Can attend selected TexasAIM Plus webinars

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TexasAIM Plus

• TexasAIM Basic

+

• Join learning collaborative that better assesses improvement and creates support network from partnering hospitals

• Report up to 5 additional measures

• Attend in-person learning sessions

• Participate in learning collaborative meetings, coaching and training calls, and site visits

• Access peer-to-peer mentoring, targeted support, and additional resources and partnerships

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TexasAIM Plus Learning Collaborative

Regional Cohorts

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TexasAIM Milestones and Activities

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• TexasAIM Implementation Workgroup

• TexasAIM Informational Presentations & Webinars

• TexasAIM Leadership Summit & Orientation

• TexasAIM Plus Learning Collaborative

(began in August)Ø Monthly webinars and in-person action meetings

Ø Targeted technical assistance on Maternal Early Warning Signs (MEWS)

TexasAIM for Opioid Use Disorder

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• Goals:Ø Improve identification and care of women with opioid use

disorder through screening and linkage to care,

Ø Optimize medical care of pregnant women with opioid use disorder,

Ø Increase access to medication-assisted treatment for pregnant and postpartum women with opioid use disorder,

Ø Prevent opioid use disorder by reducing the number of opioids prescribed for deliveries, and

Ø Optimize the care of opioid-exposed newborns by improving maternal engagement in infant management.

• Settings: Ø Inpatient and outpatient facilities to improve clinical care

AIM Bundle for Opioid Use Disorder

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• Workgroups:Ø Provider Education Ø Clinical Pathways & Quality Improvement Ø Metrics Ø Community Outreach & Engagement

• Status:Ø All tasks completed by workgroups Ø AIM preparing bundle for formal release

• Partners:Ø Texas Hospital Association

Ø HHSC and DFPS

Ø Many other statewide champions

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TexasAIM for Opioid Use Disorder

• Implementation strategy:

Ø Partnering with HHSC Behavioral Health Services to pilot in Mommies program hospitals

Ø Also piloting AIM bundle in other hospitals on cutting edge of treatment surrounding maternal opioid misuse

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• Texas timeline:

Ø September 2018 — National AIM released implementation resources

Ø Fall 2018 — National implementation

Ø Winter 2020 — Statewide implementation

AIM Bundle for Opioid Use Disorder(continued)

TexasAIM Key Partners

• Texas Hospital Association

• Texas Medical Association

• TexasAIM Implementation Workgroup

• Maternal Mortality and Morbidity Task Force

• Texas Collaborative for Healthy Mothers and Babies

• Regional Advisory Councils

• Alliance for Innovation on Maternal Health

Executive Team

• ACOG National and District XI Representatives

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Senate Bill 17 85th Legislature, 1st Special Session

Sec. 34.0156. MATERNAL HEALTH AND SAFETY INITIATIVE.

(a) Using existing resources, the department, in collaboration with the task force, shall promote and facilitate the use among health care providers in this state of maternal health and safety informational materials, including tools and procedures related to best practices in maternal health and safety.

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HHSC Client Service Programs

Healthy Texas Women

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The HTW program provides family planning services and other women’s health services that contribute to preconception care and better birth outcomes

Women may be eligible for benefits if they:

• Are age 15 to 44 (Women age 15 to 17 must have parental or legal guardian consent)

• Are U.S. citizens or eligible immigrants• Have an income at or below 200% of the Federal Poverty

Level

• Live in Texas• Do not have health insurance

• Are not pregnant

Healthy Texas Women: Enrollment

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• 93,020 total clients enrolled in July 2016

• 246,854 total clients enrolled as of May 2018

• 165.4% increase in program enrollment

0

50,000

100,000

150,000

200,000

250,000

300,000

July

201

6

Nov 2

01

6

Feb 2

01

7

May 2

01

7

Au

g 2

01

8

Nov 2

01

7

Feb 2

01

8

May 2

01

8

Healthy Texas Women

Total Client Enrollment

Healthy Texas Women: Auto-Enrollment

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With the launch of HTW, HHSC began automatically enrolling eligible Medicaid for Pregnant Women clients to HTW upon conclusion of Medicaid coverage

Client covered under Medicaid for Pregnant Women

Pregnancy endsHHSC system

triggered for HTW auto enrollment

Medicaid coverage terminates

approximately 60 days postpartum

Woman begins receiving HTW

coverage

Family Planning Program

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The Family Planning Program provides family planning services to women and men at little to no cost

Women and men may be eligible for benefits if they are:

• A resident of Texas• Age 64 or younger

• At or below 250% of the Federal Poverty Level

Breast and Cervical Cancer

Services

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The Breast and Cervical Cancer Services (BCCS) program helps fund clinic sites across the state to provide quality,

low-cost, and accessible breast and cervical cancer screening and diagnostic services to women

Women may be eligible for benefits if they:

• Are a resident of Texas• Are 18 or older• Do not have health insurance• Are at or below 200% of the Federal

Poverty Level

Clients Served: Fiscal Years 2017-2018

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Program FY 2017 FY 2018

Family Planning Program 97,653 N/A

Healthy Texas Women 132,464 N/A

Breast and Cervical Cancer Services 32,092 N/A

TOTAL CLIENTS SERVED 262,209 N/A

*Some clients may have received services from more than one program in a year.

Medicaid for Pregnant Women and CHIP Perinatal

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Medicaid for Pregnant Women

• Medicaid for Pregnant Women provides coverage to eligible pregnant women with household incomes at or below 198 percent of the Federal Poverty Level

• Coverage ends approximately 60 days after the women gives birth

CHIP Perinatal

• CHIP Perinatal (CHIP-P) provides coverage to unborn children in households with incomes at or below 202 percent of the Federal Poverty Level

• Women are eligible for two postpartum visits

Title V Maternal and Child Health

Fee-for-Service

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The Title V Maternal & Child Health (MCH) Fee-for-Service Program provides pregnant women with prenatal medical

services for up to 60 days during the CHIP Perinatal program enrollment process, and prenatal preventive and therapeutic dental services up to three months postpartum

Women may be eligible for benefits if they:

• Have a gross family income at or below 185 percent of the Federal Poverty Level

• Are a Texas Resident• Are not eligible for insurance or other program benefits

providing the same services

Long Acting Reversible Contraception (LARC) Initiatives

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HHS must increase access to LARCs• 2018-2019 General Appropriations Act, Senate Bill 1, 85th

Legislature, Regular Session, 2017 (Article II, Rider 102)

Clients served who received LARC (of total clients receiving contraceptives)

Program FY 2015 FY 2016 FY 2017

Medicaid Clients36,997 38,352 44,595

21.1% 22.1% 25.6%

Texas Women's Health Program Clients/ Healthy Texas Women

Clients*

6,567 6,104 10,160

11.4% 11.3% 15.0%

Family Planning Program Clients2,811 3,564 7,673

13.2% 14.6% 14.9%

*The Healthy Texas Women program launched on July 1, 2016.

Substance Use Prevention

and Treatment Services

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SUDs are a growing public health concern, and rising rates are likely related to the nationwide increase in the use of

prescription opioid pain relievers

• Pregnant Postpartum Intervention (PPI) programs provide community-based, gender-specific outreach and intervention services for pregnant women and parenting individuals with SUDs or who are at risk of developing SUDs

• In May 2017, HHSC was awarded $27.4 million to combat opioid disorders through a grant provided by the Substance Abuse and Mental Health Services Administration

• HHSC expanded its Medicaid substance use screening benefit in July 2016 to include screening, brief intervention and referral to treatment (SBIRT)

Better Birth Outcomes Initiatives

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To ensure a continued focus on infant and maternal health, HHSC leads the Better Birth Outcomes (BBO) workgroup, in collaboration with DSHS

• BBO initiatives seek to meet a woman’s health care needs impacting her ability to have a healthier pregnancy and

baby and focus on the life course perspective, providing services and care to families during the preconception and interconception period through the prenatal and

postpartum periods

• BBO currently has over 30 initiatives

Thank you

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