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NASHP Roundtable: Georgia and Illinois Work to Improve Maternal Health Outcomes
In partnership with the Blue Cross Blue Shield Association, the National Academy for State Health Policy (NASHP) recently held a virtual roundtable discussion of state officials to discuss maternal health initiatives in Illinois and Georgia and explore strategies to improve maternal health outcomes for Medicaid enrollees.
Despite spending more than other developed nations on hospital-provided maternity care, about 700 US women die each year from pregnancy-related complications.
- Women of color have significantly higher rates of maternal morbidity and mortality, and Black women are approximately four-times more likely than White women to die of pregnancy-related causes.
- In comparison to women covered by private insurance, pregnant women enrolled in Medicaid have increased rates of severe maternal morbidity and mortality and are more likely to have risk factors affecting their pregnancies.
One approach proposed by a number of states is extending Medicaid postpartum coverage for women beyond the current 60-day period. As highlighted in NASHP’s interactive map and chart, Each State’s Efforts to Extend Medicaid Coverage to Postpartum Women, 23 states and Washington, DC have initiated efforts to extend postpartum coverage, and currently four states are in the process of seeking federal approval to do so through a Section 1115 demonstration waiver.
Georgia’s Extension of Postpartum Coverage
Georgia is one of those states and the state’s Medicaid director explained during the discussion that they are planning to submit a waiver proposal to the Centers for Medicare & Medicaid Services in December to extend postpartum coverage there. The state’s efforts began in 2010 when Georgia was ranked 50th in the nation for maternal mortality rates. Officials first formed an advisory committee to focus on the issue. As they examined specific maternal mortality data and rates, Georgia found that close to 60 percent of the maternal deaths were actually preventable. In 2019, the Georgia House passed a resolution to create a committee to study maternal mortality, which led directly to the state’s current efforts to pursue an extension of postpartum Medicaid coverage.
While Georgia’s study committee initially suggested extending postpartum coverage for 12 months, due to budget constraints the state was unable to pursue that recommendation. Instead, the state opted to seek extended coverage for individuals with income up to 225 percent of the federal poverty level for four months, which when added to Medicaid’s 60-day postpartum coverage period, will provide a total of six months (180 days) of coverage postpartum. Overall, the state legislature allocated $59 million for the proposed five-year demonstration project.
Services under the extended postpartum coverage will be provided through managed care, and after Medicaid’s 60-day postpartum period, individuals will be seamlessly transferred to coverage under the waiver. During the first year, the state anticipates that there will be approximately 151,000 enrollees, and it is expected that enrollment will grow to about 186,000 by the final year of the demonstration.
Blue Cross Blue Shield of Illinois Pilot Program
The discussion also featured maternal and child health improvement initiatives in Medicaid that Blue Cross Blue Shield of Illinois (BCBSIL) is currently pursuing. BCBSIL is conducting a 12-month, multi-pronged pilot program in partnership with community organizations and medical providers that is designed to address factors that negatively impact health outcomes in the maternal and child population. The goals of the pilot program are to reduce the number of elective, non-medically necessary Caesarian sections (C-sections) and newborn intensive care unit (NICU) admissions, as well as improve Healthcare Effectiveness Data and Information Set (HEDIS) rates in both prenatal visits and child immunizations.
Under the pilot program’s first goal of reducing unnecessary C-sections, BCBSIL plans to enhance care coordination efforts between providers, Medicaid agencies, and community organizations. As part of its second goal to improve prenatal and postpartum care visit rates, BCBSIL will target efforts in areas of Illinois with high rates of maternal and child health disparities. Within these regions, BCBSIL will identify at least three obstetrics practices that are willing to partner with BCBSIL. These providers will be connected with BCBS care coordinators to help ensure access to care delivery resources, because often providers lack the capacity to provide social service referrals for their members. BCBS enrollees will also have the opportunity to engage in an incentive program that will offer rewards for completion of prenatal care visits.
In addition to promoting better maternal health outcomes, the BCBSIL pilot program is also working to improve pediatric immunization and dental care rates. Through partnerships with Chicago public schools and community organizations, the pilot program will disseminate information about the importance of immunizations and preventive dental care and also create a referral system for children in need of these services and other preventive health care. The planning phases of the pilot program began this fall, and the initiative will continue through the end of 2021.
Along with tracking states’ initiatives to expand postpartum Medicaid coverage, NASHP has a wide range of resources related to maternal health and healthy child development, and will be continuing to follow states’ efforts to improve maternal and child health outcomes.
The online meeting and this blog were sponsored by Blue Cross Blue Shield Association,
with content development at the sole discretion of NASHP. To view a slide deck highlighting materials from the online meeting, please click here.
New Jersey’s Project ECHO Builds Provider Capacity to Support Maternal and Child Health during COVID-19
Confronted with a pandemic that impacts the health of women and children – ranging from pregnancy and delivery to access to substance abuse treatment – a consortium of New Jersey state and health care experts launched a Project ECHO (Extension for Community Healthcare Outcomes) initiative to share COVID-19 expertise between specialists and primary care to meet the needs of women during the crisis.
Originally, the Rutgers Project ECHO partnered with the Robert Wood Johnson Medical School, New Jersey’s departments of Health, Human Services, and Attorney General, Division of Consumer Affairs, Rutgers Medical School, and The Nicholson Foundation to develop a Project Echo that focused specifically on maternal and child health (MCH) and opioid use disorder (OUD). This ECHO was to be funded through a federal Substance Abuse Prevention and Treatment Block Grant, but with COVID-19’s increased demands on community providers, New Jersey’s Department of Mental Health and Addiction Services agreed to postpone that effort and refocus on a COVID-19-specific ECHO.
This temporary change enabled the Rutgers team to address treatment issues, access to health care services, and how to meet the needs of specific populations of women during the crisis. The initiative has increased the workforce’s capacity to address the impact COVID-19 on pregnant and parenting women and advanced best care practices.
How Project ECHOs Work
Project ECHO, initially developed by the University of New Mexico to address hepatitis C, is a national model that focuses on building provider capacity across a region or state by connecting experts/specialists to local providers. This model, funded through a mix of public and private funds, encourages a virtual, bi-directional exchange of information between peers and subject matter experts on a particular topic. University hospitals are often the convening entity, with providers registering to join the events. Project ECHOs can allow any provider join in order to maximize local capacity building.
Discussion topics can be determined in collaboration with other stakeholders, such as the state Medicaid or public health agencies. Creating a Project ECHO for primary care providers, obstetricians, midwives, and others allows for informative discussion about maternal and child health and COVID-19 topics. For example, some providers may be particularly concerned about increases in maternal depression and/or anxiety and the intersection of COVID-19 and maternal mortality.
How New Jersey’s Project ECHO Works
New information continues to emerge about the impact of COVID-19 on pregnant women, strategies for limiting infection exposure during labor and delivery, and telehealth and other strategies to address SUD treatment during a time of physical distancing. Federal and state agencies are continuously releasing new guidance for providers and hospitals about billing and coding, telehealth, access to services, and most recently, guidance to medical facilities to allow non-emergency procedures. Maternal and child health (MCH) providers may want to seek additional support from other providers about limiting COVID-19 exposure and understanding the latest state-specific provider guidance for serving pregnant or postpartum women during this pandemic.
Responding to COVID-19, New Jersey’s Project ECHO devoted seven sessions between April and the first week of June 2020, to support MCH providers. It created the opportunity for participants to discuss interventions and increased their ability to respond to emergent needs. With support from the Nicholson Foundation, these Project ECHO sessions provided a forum to disseminate and share information and an opportunity for providers to ask questions and learn from each other.
During these sessions, providers heard from a number of experts who offered guidance and policies to address emerging issues.
- Representatives from the Division of Mental Health and Addiction Services explained guidance on 28-day supplies of take-home medication and the impact of COVID-19 on opioid treatment programs;
- Representatives from Cooper University Health Care discussed SUD treatment for pregnant and parenting women;
- Medicaid representatives discussed the enhanced telehealth flexibilities the state was offering;
- Experts discussed birth and delivery protocols, a concern in many states as providers seek to limit potential COVID-19 exposure to mother and child;
- Social determinants of health, such as food security and housing, and their role in health outcomes; and
- The potential impact of COVID-19 on the maternal mortality
These sessions provided an opportunity for providers to discuss challenges and share solutions to best support pregnant and parenting women. Other states can use a similar model to disseminate information and scale innovative practices to improve care for maternal and child health populations.
Funding opportunities for Project ECHOs have been identified through existing programs, philanthropic partnerships, as in the case of New Jersey, and with university support. Emergency Section 1135 and Section 1115 waivers can also be used to authorize matching federal Medicaid funds for Project ECHO sessions. Medicaid agencies can also work with managed care organizations to use or adjust existing contracts to explicitly provide financial support for these instructive sessions.
State Medicaid, public health, behavioral health, and social service agencies can leverage Project ECHO, in addition to state and federal guidance on COVID-19, to disseminate timely information and to facilitate the scaling of practices that are beneficial for women and children. The potential exchange of knowledge and information with other peers and subject matter experts can be beneficial as states open their economies and allow for non-emergency medical procedures. Sharing approaches that promote infection control and other safeguards for prenatal and postpartum care appointments can help them resume as states develop procedures to encourage these critical appointments.
CMS Releases State Funding to Improve Integrated Care for Children and Pregnant and Postpartum Women Enrolled in Medicaid and CHIP
Last week, the Centers for Medicare & Medicaid Services (CMS) released two highly anticipated initiatives — the Maternal Opioid Misuse (MOM) Model and the Integrated Care for Kids (InCK) Model — which will provide multi-year funding to states to improve integrated care for maternal and child health populations enrolled in Medicaid and the Children’s Health Insurance Program (CHIP).
NASHP has been tracking these important initiatives since they were first announced by the CMS Center for Medicare and Medicaid Innovation (Innovation Center) last year and has compiled and promoted exemplary integrated care delivery models, strategies, and innovations for pregnant and postpartum women and children that states can consider as they develop their applications for these initiatives.
The MOM Model is designed to:
- Improve quality of care and reduce costs for pregnant and postpartum women with opioid use disorder (OUD) and their infants;
- Expand access, service-delivery capacity, and infrastructure based on state-specific needs; and
- Create sustainable coverage and payment strategies that support ongoing coordination and integration of care.
The CMS Innovation Center will award a maximum of $64.5 million through up to 12 cooperative agreements with state Medicaid agencies and their care delivery model partners for a five-year period. Applications for the MOM Model are due to CMS by 3 p.m. (EST), May 6, 2019. A CMS webinar about the MOM Model Notice of Funding Opportunity was held Feb. 21, 2019. The recording, slides, and transcript from the webinar are available here.
The InCK Model is designed to reduce expenditures and improve the quality of care for children under 21 years of age covered by Medicaid and CHIP through prevention, early identification, and treatment of behavioral and physical health needs. States and local organizations will work to conduct early identification and treatment of children with health-related needs across settings to:
- Increase behavioral health access;
- Respond to the opioid epidemic; and
- Improve child health outcomes.
The CMS Innovation Center will award a maximum of $128 million through eight cooperative agreements with state and local participants for a seven-year period (awarding up to $16 million per recipient). Applications to implement the InCK Model are due to CMS by 3 p.m. (EST), June 10, 2019. A CMS webinar about the InCK Model NOFO is scheduled for 2:30 to 4 p.m. (EST) Tuesday, Feb. 19, 2019.
Virginia’s BabyCare Program: Working to Improve Birth Outcomes through Medicaid
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Nationally, Medicaid finances 45 percent of births and is a critical resource to improve maternal health and birth outcomes and lower avoidable costs. With an increasing number of initiatives focusing on pregnant and postpartum women, such as the federal Maternal Opioid Misuse (MOM) Model, states can learn from innovative programs, including Virginia’s BabyCare initiative. This new NASHP report explores how Virginia utilizes Medicaid’s reach to improve birth outcomes through behavioral risk screening, case management services, and expanded prenatal services.
View or download: Virginia’s BabyCare Program: Working to Improve Birth Outcomes through Medicaid
To learn about other state initiatives, visit NASHP’s Healthy Child Development State Resource Center.
How States Are Meeting the Needs of Children and Families Affected by the Opioid Epidemic
The opioid epidemic is having a devastating impact on children and families and placing a significant strain on states as they work to develop effective programs and find new funding to respond to this crisis.
To address the crisis and promote healthy child development, states are implementing innovative whole-family approaches to prevention and treatment (see below). On the federal level, new funding is available and recently the federal Center for Medicare and Medicaid Innovation announced its Integrated Care for Kids model, which states can use to improve care and outcomes while reducing costs through early identification, integrated care coordination, and case management for physical and behavioral health care and non-clinical local services.
Need more information?
- Read NASHP’s new report, State Strategies to Meet the Needs of Young Children and Families Affected by the Opioid Crisis.
- Attend a webinar exploring New Hampshire’s strategies to support families affected by OUD is scheduled for 2-3 p.m. (EST) Thursday, Sept. 27, 2018.
- Check out presentations from #NASHPCONF18’s Turning the Tide: State Strategies to Meet the Needs of Families Affected by Substance Use Disorder.
- Additional reports and webinars exploring state efforts to support pregnant and parenting women and children affected by the opioid epidemic will be published here in the weeks ahead.
Children can experience many negative consequences as a result of their parents’ opioid use disorder (OUD). Prenatal opioid exposure can cause neonatal abstinence syndrome in infants, which is usually treated by costly hospitalizations and may increase the risk of developmental disabilities. Children affected by parental substance misuse are at increased risk of adverse childhood experiences and trauma, which can have significant short- and long-term physical, mental, and behavioral consequences.
A new National Academy for State Health Policy (NASHP) issue brief, written in partnership with the Alliance for Early Success, identifies the following promising state strategies developed by Kentucky, New Hampshire, and Virginia to support children and families:
- Facilitate access to and coverage of services by improving identification of at-risk infants and children, enabling rapid access to treatment, expanding coverage of services, and enhancing provider capacity. For example, New Hampshire’s Project First Step embeds licensed alcohol and drug counselors (LADCs) within its Division of Children, Youth, and Families (DCYF) district offices. The LADCs train child welfare and juvenile justice staff about substance misuse — including screening and facilitating access to treatment — to enable DCYF staff to better meet the needs of children and families affected by OUD.
- Implement family-focused care delivery models, such as providing family-centered treatment approaches for the family unit, offering care at home and in the community, coordinating care, and providing trauma-informed care. Virginia’s Medallion 4.0 Medicaid managed care program contract requires Medicaid managed care organizations to provide specialized care coordinators for substance-exposed newborns and align a mother’s and infant’s care plan. Additionally, Virginia’s Medicaid 4.0 contracts promote delivery of trauma-informed care, particularly for children impacted by the foster care system.
- Align and maximize resources across systems by sharing data and leveraging diverse funding sources. Kentucky’s Sobriety Treatment and Recovery Team (START) program is a family-centered, service delivery model within the state’s child welfare system that pairs families affected by substance use disorder (SUD) with a child protective services (CPS) worker and a family mentor who has lived experience with SUD. The CPS workers and family mentors coordinate care, offer rapid access to treatment, and provide comprehensive wrap-around services. The program weaves together funding from a Title IV-E waiver demonstration, Medicaid, the Temporary Assistance for Needy Families block grant, and state general funds. The state has also established a data-sharing agreement to advance the program between its Department for Community Based Services and its Department for Behavioral Health, Developmental, and Intellectual Disabilities.
An additional report and webinar exploring state strategies to support pregnant and parenting women affected by substance use disorders, including opioid use disorder, will be published in the weeks ahead.
For individuals living with complex, often chronic conditions, and their families, palliative care can provide relief from symptoms, improve satisfaction and outcomes, and help address critical mental and spiritual needs during difficult times. Now more than ever, there is growing recognition of the importance of palliative care services for individuals with serious illness, such as advance care planning, pain and symptom management, care coordination, and team-based, multi-disciplinary support. These services can help patients and families cope with the symptoms and stressors of disease, better anticipate and avoid crises, and reduce unnecessary and/or unwanted care. While this model is grounded in evidence that demonstrates improved quality of life, better outcomes, and reduced cost for patients, only a fraction of individuals who could benefit from palliative care receive it. 
