Identifying Priority Strategies for Implementing Policies on - PowerPoint PPT Presentation

Centers for Disease Control and Prevention Identifying Priority Strategies for Implementing Policies on Immediate Postpartum Long-Acting Reversible Contraception in the United States 10 th ANNUAL CONFERENCE ON THE SCIENCE OF DISSEMINATION AND IMPLEMENTATION IN HEALTH December 5, 2017 Charlan Kroelinger, PhD Acting Chief Women’s Health and Fertility Branch Division of Reproductive Health National Center for Chronic Disease Prevention and Health Promotion

Unintended Pregnancy in the United States  Almost half (45%) of all pregnancies in the U.S. are unintended

Long-Acting Reversible Contraception (LARC)  Most effective type of reversible birth control • Safe for most women and teens • No effort after correct insertion • Effective for 3-10 years • High rates of satisfaction and continuation • Immediate return to fertility  Nationally, use of LARC is low, but increasing CDC. U.S. medical eligibility criteria for contraceptive use, 2010. MMWR Recomm Rep 2010;59(No. RR-4):1 – 86. Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397 – 404. Boulet SL, D’Angelo DV, Morrow B, et al. Contraceptive Use Among Nonpregnant and Postpartum Women at Risk for Unintended Pregnancy, and Female High School Students, in the Context of Zika Preparedness — United States, 2011 – 2013 and 2015. MMWR Morb Mortal Wkly Rep. ePub: 2 August 2016. DOI: http://dx.doi.org/10.15585/mmwr.mm6530e2.

Despite Increases LARC Use Remains Low Even though it appears to be a large increase, LARC methods are used by only 7.2% of women aged 15-44 Branum, AM and J Jones. Trends in Long-Acting Contraception Use Among U.S. Women Aged 15-44. 2015 NCHS Data Brief . No. 188.

Contraceptive Use in the US: Postpartum Women 2011-2013 PRAMS/MIHA Percentage of Use by Effectiveness Surveillance Population System High Moderate Less None < 1% 6% - 10% > 10% Postpartum PRAMS & MIHA women at risk 6.9% — 25.8% — 15.6% — 3.5% — – US for unintended 30.5% 42.7% 37.6% 15.3% pregnancy Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397 – 404. Boulet SL, D’Angelo DV, Morrow B, et al. Contraceptive Use Among Nonpregnant and Postpartum Women at Risk for Unintended Pregnancy, and Female High School Students, in the Context of Zika Preparedness — United States, 2011 – 2013 and 2015. MMWR Morb Mortal Wkly Rep. ePub: 2 August 2016.

Contraception Access During Health Care Engagement • Immediate postpartum period – Fewer insurance barriers – Safe and effective – Reduces risk of rapid repeat pregnancy – Continuation rates are similar to insertions at other times • Association of State and Territorial Health Care Officials (ASTHO) and CDC partnered with states to understand barriers to policy implementation for systems change Hathaway, M., Torres, L., Vollett-Krech, J., & Wohltjen, H. (2014). Increasing LARC utilization: any woman, any place, any time. Clin Obstet Gynecol, 57 (4), 718-730. Curtis, K. M., Tepper, N. K., Jatlaoui, T. C., Berry-Bibee, E., Horton, L. G., Zapata, L. B., . . . Whiteman, M. K. (2016). U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR Recomm Rep, 65 (3), 1-103. Thiel de Bocanegra, H., Chang, R., Howell, M., & Darney, P. (2014). Interpregnancy intervals: impact of postpartum contraceptive effectiveness and coverage. Am J Obstet Gynecol, 210 (4), 311 e311-318. Woo, I., Seifert, S., Hendricks, D., Jamshidi, R. M., Burke, A. E., & Fox, M. C. (2015). Six-month and 1-year continuation rates following postpartum insertion of implants and intrauterine devices. Contraception, 92 (6), 532-535.

Immediate Postpartum LARC Learning Community  State team engagement for policy implementation – 13 states with policies – State Health Officials/Officers, Medicaid Medical Directors, Title V/Title X Directors, ACOG/Family Planning Provider, Hospital Administrators, Program Staff  Identification of 8 domains  Strategy development to address barriers and leverage facilitators  Peer-to-peer learning, shared resources, technical assistance, virtual learning sessions http://www.astho.org/Maternal-and-Child-Health/Long-Acting-Reversible-Contraception/LARC-Immediately-Postpartum-Learning-Community-Background/ Increasing Access to Contraception Learning Community: Nine Focus Areas for Success Fact Sheet. Association of State and Territorial Health Officials. http://www.astho.org/Maternal-and-Child-Health/Increasing-Access-to-Contraception/Learning-Community/Nine-Focus-Areas-for-Success/

Immediate Postpartum LARC Learning Community 8 Domains Domain Description Provider Training Implementing skill building for providers on immediate postpartum LARC insertion, training pharmacy staff on stocking and billing, and training administrative, pharmacy and clinical staff on billing and coding for non-pharmacy use of LARC devices Pay Streams and Understanding how Title X family planning programs approach immediate postpartum LARC, the variability Reimbursement in how private insurers approach reimbursement services, the relationship of 1115 family planning waivers and state plan amendments with immediate postpartum LARC reimbursement under Medicaid, and the billing and coding process for Medicaid claims Informed Consent Defining timing and content of informed consent Stocking and Supply of Providing concrete examples of device-stocking procedures and supply policies in both hospital pharmacies Devices and clinics Outreach Recruiting advocates to develop and implement postpartum LARC policy by identifying effective strategies for contracting providers and policymakers , and providing examples of successful communication strategies to use with the public and clients Service Locations Differentiating strategies for rural settings including developing engagement strategies with federally qualified health centers, from least to most intense day amil on subject of the training y planning clinics, and the role of telehealth to reach providers in states Data, Monitoring and Developing more information regarding appropriate quality assurance and improvement indicators for Evaluation immediate postpartum LARC, measurement of uptake, and documentation on how to access existing data, particularly on safety monitoring and insertion rates Stakeholder Partnerships Identifying ways to engage national and federal partners on the issues of immediate postpartum LARC and determining which internal and external state partnerships are essential for successfully implementing policy

Methodology  Qualitative, descriptive study  Semi-structured key informant interviews with state teams (2015-2016) – Interviews audio recorded and transcribed  Excerpts identified and independently double-coded by strategy into the eight areas of focus using Dedoose software – Strategies were reviewed and summarized – States implementing strategies in each domain counted  Domains used by the most states identified, including cross-cutting domains Kroelinger, CD, LF Waddell, DA Goodman, et al, Working with State Health Departments on Emerging Issues in Maternal and Child Health: Immediate Postpartum Long- Acting Reversible Contraceptives. J Women Health. 2015; 24.9:693-701. Rankin, KM, CD Kroelinger, CL DeSisto, et al, Application of Implementation Science Methodology to Immediate Postpartum Long-Acting Reversible Contraception Policy Roll-Out Across States. Matern Child Health J. 2016; 20:S173-S179. DeSisto, CL, C Estrich, CD Kroelinger, et al, Using a Multi-State Learning Community as an Implementation Strategy for Immediate Postpartum Long-Acting Reversible Contraception. Implemen Science. 2017; 12:138-147.

Results Health System Domains and Strategies: Cross-Cutting STAKEHOLDER PARTNERSHIPS Facilitate partnerships among private and public insurers, device manufacturers, and state agencies • Improve acquisition management • Streamline service provision Our main clinical • Increase efficiency in product champion [is] our chair of the state ACOG [chapter], purchase a professor, and the Medicaid medical director. • Reduce per capita costs She has great reach through those different • Identify champions professional streams.

Health Systems Domains and Strategies Train healthcare providers on current insertion and removal techniques for LARC • Support use of CDC’s evidence -based contraceptive guidance, and provide quality family planning services • Identify champions to promote best practices • Promote contraceptive counseling • Increase healthcare provider awareness on Making sure that residents and clinicians are well trained in appropriateness of LARC for most clients of all LARC placement postpartum is something that we really want to ages, and dispel myths focus on because of the connection with expulsion rates of LARC, and the experienced providers or clinicians having lower expulsion rates.

Health Systems Domains and Strategies Increase provider and consumer awareness of contraception • Develop toolkits and resources for providers, facilities, and One thing that we’re working clinics with resources on LARC on very closely with the valley area, is what are the myths • Implement public/private that surround LARCs and what can we do to address those and educate the education campaigns and population…we conducted a focus group…it was quite develop patient-friendly astonishing the myths that surround LARCs right now, resources and shows how much work we have to do. • Develop social media campaigns • Assess client satisfaction with service delivery