Columbus Public Health
Women's Health & Wellness Center: Increasing Access to Same-day LARC (Long-acting reversible contraception)
Columbus Public Health (CPH) serves as the local health department for the nation's 15th largest city, Columbus, Ohio. CPH identifies and addresses public health threats, enforces laws that protect health, and prevents and controls disease. Forty distinct programs are supported by a $46 million budget and 400 employees. CPH is governed by a Board of Health whose members are appointed by the Mayor of Columbus. A health commissioner and three assistant health commissioners (a Medical Director, a Chief Nursing Officer, and an Administrator) provide leadership to the agency. In March 2014, CPH became one of the few nationally accredited public health departments with the Public Health Accreditation Board (PHAB).
The Women's Health and Wellness Center (WHWC) at Columbus Public Health (CPH) provides reproductive health and wellness services to vulnerable populations in order to improve the overall health and well-being of men, women, and teens in the community. CPH serves a richly diverse population of residents. Currently, the WHWC base is comprised of 46% African American, 30 - 40% Hispanic, and 10% adolescent clients. Also 45% of clients are uninsured with more than Â¾ at 100% or below the Federal Poverty Line.
The CPH WHWC provides comprehensive reproductive health and wellness services based on the Centers for Disease Control and Prevention's 2016 Providing Quality Family Planning Servicesâ€ guidelines and Ohio Department of Health (ODH) guidance. This program operates as a sub-recipient of the Reproductive Health and Wellness Program through the state health department, ODH, providing services on a sliding fee scale based on Title X program guidelines.
Infant mortality, defined as the death of an infant before the first birthday, is a health crisis in Ohio. As of 2016, the infant mortality rate in Ohio increased to 7.4 per 1,000 live births while the national average is under 5 and continues to decline (ODH). According to the National Campaign to Prevent Teen and Unplanned Pregnancy (2010), approximately 55% of all pregnancies are unplanned in Ohio, which imposes an $825 million burden.
A major focus of the center is to improve access and decrease barriers to contraception for women and adolescents, including LARC as part of a larger strategy to prevent unintended pregnancy and to support infant mortality reduction initiatives such as safe birth spacing.
Since 2014, the center aimed to increase overall LARC uptake and same-day insertion rates. This is a multi-faceted approach and is accomplished by offering evidence-based contraceptive education, including motivational interviewing, and use of a Reproductive Life Plan with all clients.
The center also provides a full contraceptive menu of options on-site, including same-day LARC insertion based on the U.S. Selected Practice Recommendations for Contraceptive Useâ€. All WHWC providers possess expert level LARC skills. The WHWC established itself as a referral resource for community organizations such as the Ohio Better Birth Outcomes (OBBO) collaborative, which is dedicated to reducing the local infant mortality rate. On average, the clinic receives between 10 -15 LARC referrals per month from outside providers for patients that would otherwise not have access to these methods.
In 2014, the center provided 147 LARCs to clients in the WHWC. From January to November 2017, 462 LARCs were provided with an overall same-day insertion rate of 94%; this represents a 214% increase. By 2017, approximately 40% of all women requesting birth control at the center chose a LARC by the end of their visit.
Factors and activities that led to this change include:
? Leadership support which includes infant mortality reduction as a strategic goal
? Staff training on LARC-first contraceptive counseling that includes safe birth spacing education and motivational interviewing
? Use of Reproductive Life Plan and One Key QuestionÂ®
? Use of evidence-based guidelines as practice protocols
? Stocking a full inventory of methods for same-day provision
? Developing a streamlined referral process
? LARC-specific patient education and marketing materials
? Creative and flexible scheduling including walk-in appointments and designated after hours availability for adolescents
? Services provided low cost or no cost based on sliding fee scale and household size
? Targeted outreach to vulnerable populations
The potential public health impacts are reduction of unintended pregnancy and reduction of infant mortality through safe birth spacing, overall improved maternal and fetal outcomes and lower healthcare costs. Guttmacher estimates that 25,500 unintended pregnancies are averted and $226 million is saved annually through publicly funded family planning programs in Ohio, such as the WHWC at CPH.
In Ohio, the infant mortality rate was almost 40% higher than the national average in 2016. Ohio infant mortality rates for all ethnicities increased from 2015 to 2016, with black infants dying nearly three times more than white infants (ODH, 2016). According to the Ohio Department of Health, prematurity is the leading cause of infant deaths in Ohio. The CDC recommends prevention of unintended pregnancy and birth spacing of 18 months or more as strategies to prevent prematurity. LARCs can be used to provide highly effective, yet reversible, contraception for most women and adolescents and also promote safe birth spacing.
Our target population is women and adolescents of child-bearing age, specifically populations who incur disparity, poverty, are uninsured, or are considered vulnerable. These populations include those individuals living in high-risk infant mortality zip codes.
Historically, access to contraception proved challenging. In 1970, President Nixon enacted Title X, the first federal family planning program, a Reproductive Health and Wellness Program aimed at providing services to low-income women and families. Since that time, women are using contraception at a record high rate with the pill being the most commonly used method according to the Guttmacher Institute (2016). On the contrary, only 12% of women were using a long-action method of contraception in 2012 (Guttmacher, 2016).
In past years, contraception education focused primarily on the education of patients about the pill and/or condom use. Our approach entails not only educating the patient and family, but the provider. Staff of the WHWC receives ongoing education on contraceptive methods, efficacy, and motivational interviewing strategies. They provide LARC-first, efficacy based education to each patient that presents for a visit. The aim of the Women's Health and Wellness Center at CPH is to provide respectful and personalized family planning care. This is achieved through motivational interviewing and completion of an individual reproductive life plan. A reproductive life plan (RLP) is a tool that assists individuals in decision related to having children or not having children. RLPs examine one's health, other children, and overall life goals such as those related to school and career.
The current practice at CPH is patient-centered and individualized which has resulted in more women and adolescents choosing the most effective methods of contraception available. For a majority of women, they are able to receive their birth control, including LARC, with one visit to the center. This is accomplished through open concept scheduling and accepting walk-in visits for all services, including LARC, along with use of evidence-based practice guidelines.
These strategies represent interventions to support Healthy People 2020 family planning objectives FP-16 -Increase the percentage of adult females aged 20 to 44 years who are at risk of unintended pregnancy that adopt or continue use of the most effective or moderately effective methods of contraception and FP-16.2 -Increase the percentage of adolescent females aged 15 to 19 years who are at risk of unintended pregnancy that adopt or continue use of the most effective or moderately effective methods of contraception.
Evidence that supports this practice:
Gavin, L. (2014). Providing quality family planning services: recommendations of CDC and the US Office of Population Affairs, MMWR, 2014, 63 (4): 1â€“54. Retrieved from https://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf
Curtis, K. M. (2016). US medical eligibility criteria for contraceptive use, 2016. MMWR, 65, 1-104. DOI: http://dx.doi.org/10.15585/mmwr.rr6503a1
Curtis, K. M. (2016). US selected practice recommendations for contraceptive use, 2016. MMWR, 65. DOI: http://dx.doi.org/10.15585/mmwr.rr6504a1
Columbus Public Health (CPH) is charged with assuring conditions in which people can be healthy. CPH is made up of a range of programs providing clinical, environmental, health promotion, and population-based services. The mission of Columbus Public Health is to protect health and improve lives in the community. Public health goals are to identify and respond to public health threats and priorities, collaborate with residents, community stakeholders and policy-makers to address local gaps in public health, empower people and neighborhoods to improve their health, and establish and maintain organizational capacity and resources to support continuous quality improvement. The agency's strategic priorities encompass reducing infant mortality, reducing overweight and obesity, reducing the spread of infectious diseases, improving access to public health care, and implementing departmental reorganization.
The practice of offering highly effective contraception such as same-day LARC supports Columbus Public Health's strategic priority of reducing infant mortality through safe birth spacing and prevention of unintended pregnancy.
Goals and objectives:
Increase overall LARC provision utilizing evidence-based practices
Increase the % of women choosing LARC for a method of contraception
Reduction of barriers to same-day insertion
The center achieved the goals and objectives through staff education, development of educational materials, reinforcement of evidence-based guidelines, auditing of practices, incorporating LARC-first counseling into the clinic flow, pre-stocking full FDA approved menu of choices, using a sliding fee scale for services based on the FPL, and a formal outreach plan.
The WHWC collaborates with various internal departments throughout the agency:
Sexual Health Clinic & Maternal Child Health â€“ Referrals for preventative and contraceptive services
Office of Public Affairs and Communications â€“ Developed fact-based educational materials of an appropriate literacy level; Conducted patient focus groups; Planned and implemented marketing activities
Office of Minority Health - Translation of patient education materials into other languages and provision of interpretation services
Financial Services and Billing â€“ Created sliding fee scale and schedule of discounts for center services; Maintains 3rd party contracts and bills appropriately
Building Services â€“ Ensures inventory of LARCs
Office of Planning and Quality Improvement â€“ Maintains dashboard metrics that include LARC
Access to Care Program â€“ Insurance enrollment assistance
Columbus Public Health partners with multiple community stakeholders, two of which are CelebrateOne and the Ohio Better Birth Outcomes project:
CelebrateOne, formerly the Greater Columbus Infant Mortality Task Force (GCIMTF): CPH partnered with Columbus City Council and Nationwide Children's Hospital (NCH) to establish the GCIMTF. In 2014, The GCIMTF developed a community-wide plan to reduce infant mortality by 40% and cut the racial disparity gap in half by 2020. CPH is actively engaged as a strategic partner in supporting and informing the work of GCIMTF (now known as CelebrateOne). CPH is assigned as the lead entity for improving social and economic conditions that drive disparities across our community and in highest risk neighborhoods. Services provided by the Women's Health and Wellness Center (WHWC) include outreach, education, and direct services to women that reside in the 8 infant mortality high risk zip codes.
Ohio Better Birth Outcomes (OBBO) collaborative: Housed at NCH, OBBO is a clinical and quality based prevention program designed to reduce preterm birth and infant mortality in Franklin County. OBBO unites central Ohio's four hospital systems, the Central Ohio Hospital Council, PrimaryOne Health, and CPH. CPH serves on the OBBO steering committee and CPH staff serves on multiple OBBO work groups including that which addresses reproductive health and access to LARC. Furthermore, the Women's Health and Wellness Center develops goals related to LARC access and provision as part of an ongoing larger OBBO quality improvement initiative.
Collaborations have proven crucial to the success of the WHWC LARC program through support of a common goal, sharing of knowledge and resources, and assistance with goal-setting and data analysis. In particular, development of a referral system and establishment of referral sources from community providers, along with innovative outreach such as services for women in opiate treatment, has surfaced from this work.
The Women's Health and Wellness center is funded, in part, by a multi-year grant from the Ohio Department of Health's Reproductive Health and Wellness program. This project supports quality family planning care and encompasses reproductive life planning and contraceptive services. Approximately 15% of the center's total budget is spent on the purchase of long-acting reversible contraceptives; this represents 49% of all supply costs.
In the last 3 years, there has been an increase of over 200% in the number of LARCs provided at Columbus Public Health. Between 2016 and 2017, the Women's Health and Wellness Center is on track to increase LARC provision by 85%. Currently over 90% of LARCs are provided within one visit to the center, and almost half of all women that desired birth control left with a long-acting reversible method, such as an IUD or implant.
The primary source of data is collected through custom templates and reports in the existing electronic health record, in addition to an interface with a data collection and warehousing firm. Secondary sources of collection include billing reports, clinic logs, and customer satisfaction surveys.
Women's Health and Wellness-specific metrics are:
# of women receiving any contraceptive method
# of women receiving a LARC
Type of method
If method provided same-day
Results are analyzed through monthly reporting, quarterly dashboard metrics, and control chart comparing monthly, quarterly, and yearly changes.
Supplementary to this data, infant mortality, LARC usage, and safe birth spacing statistics for all of Franklin County is monitored through community collaboration work with CelebrateOne and OBBO.
Through the use of evidence-based clinical guidelines and decreasing barriers to care, the Women's Health and Wellness Center at CPH has achieved a marked increase in the uptake of long-acting reversible contraception (LARC) in women and adolescents seen in the health center. The provision of LARC supports the agency's strategic goal of infant mortality reduction work through promotion of safe birth spacing and prevention of unintended pregnancy. To further support sustainability, program work focused on increasing visit numbers, utilization of patient assistance programs when applicable, strengthening partnerships and referral sources, enrollment assistance for uninsured patients, marketing and outreach to promote more community members, and improvement of clinic efficiencies as an overall plan to support long-term sustainability. Additionally, alternate funding sources will be explored to supplement current grant funding.
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