Delaware is Improving Birth Outcomes with Support from ASTHO

July 10, 2019|2:58 p.m.| ASTHO Staff

Karyl RattayKaryl Rattay, MD, MS, is director of the Delaware Division of Public Health. Since joining ASTHO’s Increasing Access to Contraception Learning Community in 2015, Delaware has focused on developing a sustainable plan for improving access and choice around effective contraception for all women of reproductive age. ASTHO spoke with Rattay about these efforts and Delaware’s statewide plan to reduce infant mortality and improve birth outcomes.

How has the Delaware Division of Public Health partnered with state entities to increase access to contraception in the state?
Partnerships are key to increasing access to contraception in Delaware, including the Delaware Contraceptive Access Now (DE CAN) initiative, a statewide program launched in January 2016 by former Delaware Gov. Jack Markell. DE CAN, a public-private partnership between the state and Upstream USA, focuses on reducing unintended pregnancies and improving access to contraceptives, including long-active reversible contraception (LARCs), by addressing barriers related to cost, education, and access. The goal is to ensure all women of reproductive age, regardless of insurance or ability to pay, have same-day access to the full range of contraceptive methods at low or no cost. Having the governor encourage policy changes, including separate reimbursement for immediate postpartum (IPP) LARC devices and allocating additional funding through Delaware’s Division of Public Health, catalyzed action.

In January 2015, the Delaware Division of Medicaid and Medical Assistance started allowing separate billing for LARC devices through a Medicaid pharmacy benefit when co-occurring with child-birth related services. This enabled hospitals to provide IPP LARC to Medicaid patients by ensuring separate reimbursement for the device, leading to IPP efforts being implemented in all but one of Delaware’s birthing hospitals. Most notably, the Christiana Care Health System maternity unit, where approximately half of all deliveries in the state occur, started offering IPP LARC services to their Medicaid patients with no contraindications. Additionally, in May 2015, the division of public health made public funding available to purchase LARC devices for both Title X agencies and create a stock for the state pharmacy. As a result, Title X sites were able to obtain LARC devices at no cost from the state pharmacy. In June 2017, a Delaware Medicaid State Plan Amendment was approved to provide a mechanism for FQHCs to obtain compensation for LARC devices, allowing them to maintain adequate stock and replacing the need for direct state purchase of devices.

Upstream USA is working with DPH and the DE CAN initiative to ensure sustainability, including stocking methods, patient education materials, billing and coding practices, and policies and procedures. In addition, the governor just signed the FY20 budget for the division of public health which includes $1.5 million to support DE CAN by funding contraception, training, and technical assistance for all Title X sites.

What advice do you have for public health leaders who want implement similar programs to increase access?
Executive leadership and sponsorship – In 2014, Gov. Jack Markell and Upstream USA began a public-private partnership to reduce Delaware’s high unintended pregnancy rate, a high priority for his administration. Leadership from the Delaware Department of Health and Social Services, including the Delaware Division of Medicaid and Medical Assistance and the Division of Public Health, were committed to the success of Delaware CAN. The cabinet secretary and division directors, including myself, were excited about this opportunity to lead an effort to address an issue that would have far reaching effects for generations. In addition, the governor appointed DE Healthy Mother and Infant Consortium identified DE CAN as one of their strategic priorities to reduce infant mortality and improve birth outcomes.

Commitment of health centers and non-profit organizations – Healthcare leadership commitment and engagement is key along with the support of operational leaders, clinicians, and support staff who made the changes on the ground. In addition, part of DE CAN’s strategy was to engage community organizations that serve women who might not receive care from a DE CAN-trained health center or any health center. DE CAN trained organizations addressing domestic violence and substance use disorder. They also trained organizations that provide foster care and home visiting programs.

Public and private partnership with Upstream USA – There are a myriad of benefits from our public-private partnership Upstream USA. Upstream brought the tools and resources needed to be successful, including training and technical assistance, quality improvement, evaluation, and marketing. They provided funding for health centers and hospitals. In early 2016, we launched the training component of DE CAN. Upstream hosted 130 trainings, training nearly 3000 clinicians and staff from 41 partners representing 185 sites across Delaware. During the quality improvement phase of the initiative, Upstream and health centers work together to remove barriers, implement patient-centered contraceptive counseling, integrate pregnancy intention screening into the electronic health records, and set up data collection to assess impact. From May 2017 through October 2018, Upstream’s Be Your Own Baby digital marketing campaign expanded access and choice by providing free birth control to thousands of women across Delaware.

How is Delaware working to improve access to contraception for women with opioid use disorder?
Two of Delaware’s largest substance use disorder treatment agencies are partners in the DE CAN initiative along with a smaller agency serving lower Delaware, Kent, and Sussex Community Services. DE CAN has trained 15 providers and 411 support staff from these three agencies. In addition, after completing training, we provide onsite coaching for counselors to assure that staff is providing the support and information that clients need to make the right decision. As with our other health centers, female clients aged 15-44 are asked a pregnancy intention screening question, documented in their electronic health record system. Depending on their answer, the client receives preconception care or their contraception method of choice, including the choice of no contraception. As a result, all three agencies provide patient-centered contraceptive counseling and referrals to a DE CAN trained health center. DE CAN also offers ongoing support through technical assistance, including a women's health navigator that facilitates referrals so the client has a positive experience accessing birth control.

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