Statewide quality improvement initiative to implement immediate postpartum long-acting reversible contraception.

Women face barriers to obtaining contraception and postpartum care. In a review of Tennessee birth data from 2014, 56% of pregnancies were unintended, 22.7% were short-interval pregnancies, and 57.9% of women who were not intending to get pregnant were not using contraception. Offering long-acting reversible contraceptive methods in the immediate postpartum period allows women who desire these effective methods of contraception to obtain unobstructed access and lower unintended and short-interval pregnancy rates. We report the experience of Tennessee's perinatal quality collaborative that aimed to address unintended and short-interval pregnancy by increasing access to immediate postpartum long-acting reversible contraception through woman-centered counseling and ensuring reimbursement for devices. This followed a policy change in November 2017 that allowed women who were insured under Tennessee Medicaid programs (TennCare) to achieve access to immediate postpartum long-acting reversible contraception. From March 2018 to March 2019, 6 hospital sites participated in this statewide quality improvement project that was based on the Institute of Health Improvement Breakout Collaborative model. An evidence-based toolkit was created to provide guidance to the sites. During the year of implementation, monthly huddles occurred, and each facility took a differing amount of time to implement immediate postpartum long-acting reversible contraception. Various statewide and hospital-specific barriers occurred and were overcome throughout the year. In total, 2012 long-acting reversible contraception devices were provided to eligible and desiring women. All but 1 institution was able to offer immediate postpartum long-acting reversible contraception by March 2019. Reimbursement was the biggest statewide barrier because rates were low initially but improved through intensive intervention by dedicated team members at each site and the state level. Even with dedicated team members, false assurances were given repeatedly by billing and claims staff. A statewide quality improvement project can increase access to immediate postpartum long-acting reversible contraception. Implementation and reimbursement require a dedicated team and coordination with all stakeholders. Verification of reimbursement with leaders at TennCare was essential for project sustainment and facilitated improved reimbursement rates. The impact on unintended and short-interval pregnancies requires long-term future investigation.

Lacy MM ，McMurtry Baird S ，Scott TA ，Barker B ，Zite NB ... -  《-》

An initiative to implement immediate postpartum long-acting reversible contraception in rural New Mexico.

Over the past decade, many states have developed approaches to reimburse for immediate postpartum long-acting reversible contraception. Despite expanded coverage, few hospitals offer immediate postpartum long-acting reversible contraception. Immediate postpartum long-acting reversible contraception implementation is complex and requires a committed multidisciplinary team. After New Mexico Medicaid approved reimbursement for this service, the New Mexico Perinatal Collaborative developed and initiated an evidence-based implementation program containing several components. We sought to evaluate timing of the implementation process and facilitators and barriers to immediate postpartum long-acting reversible contraception in several New Mexico rural hospitals. The primary study outcome was time from New Mexico Perinatal Collaborative program component introduction in each hospital to the hospital's completion of the corresponding implementation step. Secondary outcomes included barriers and facilitators to immediate postpartum contraception implementation. In this mixed-methods study, conducted from April 2017 to May 2018, we completed semistructured questionnaires and interviews with 20 key personnel from 7 New Mexico hospitals that planned to implement immediate postpartum long-acting reversible contraception. The New Mexico Perinatal Collaborative introduced program components to hospitals in a stepped-wedge design. Participants contributed baseline and follow-up data at 4 time periods detailing the steps taken towards program implementation and the timing of step completion at their hospital. Qualitative data were analyzed using directed qualitative content analysis principles based on the Consolidated Framework for Implementation Research. Investigators conducted 43 interviews during the 14-month study period. Median time to complete steps toward implementation-patient education, clinician training, nursing education, charge capture, available supplies, and protocols or guidelines-ranged from 7 days for clinician training to 357 days to develop patient education materials. Facilitators of immediate postpartum contraception readiness were local hospital clinical champions and institutional administrative and financial stability. Of the 7 hospitals, 4 completed all Perinatal Collaborative implementation program components and 3 of those piloted immediate postpartum long-acting reversible contraception services. Two publicly funded hospitals currently offer immediate postpartum long-acting reversible contraception without verification of payment for the device or insertion. The third hospital piloted the program with 8 contraceptive devices, did not receive reimbursement due to identified flaws in Medicaid billing guidance and does not currently offer the service. The remaining 3 of the 7 hospitals declined to complete the NMPC program; the hospital that completed the program but did not pilot immediate postpartum long-acting reversible contraception did so because Medicaid billing mechanisms were incompatible with their automated billing systems. Participants consistently reported that lack of reimbursement was the major barrier to immediate postpartum long-acting reversible contraception implementation. Despite the New Mexico Perinatal Collaborative's robust implementation process and hospital engagement, most hospitals did not offer immediate postpartum long-acting reversible contraception over the study period. Reimbursement obstacles prevented full service implementation. Interventions to improve immediate postpartum long-acting reversible contraception access must begin with implementation of seamless billing and reimbursement mechanisms to ensure adequate hospital payments.

Palm HC ，Degnan JH ，Biefeld SD ，Reese AL ，Espey E ，Hofler LG ... -  《-》

Policy change is not enough: engaging provider champions on immediate postpartum contraception.

Rates of short-interval pregnancies that result in unintended pregnancies remain high in the United States and contribute to adverse reproductive health outcomes. Long-acting reversible contraception methods have annual failure rates of <1%, compared with 9% for oral contraceptive pills, and are an effective strategy to reduce unintended pregnancies. To increase access to long-acting reversible contraception in the immediate postpartum period, several State Medicaid programs, which include those in Iowa and Louisiana, recently established reimbursement policies to remove the barriers to reimbursement of immediate postpartum long-acting reversible contraception insertion. We used a mixed-methods approach to analyze 2013-2015 linked Medicaid and vital records data from both Iowa and Louisiana and to describe trends in immediate postpartum long-acting reversible contraception provision 1 year before and after the Medicaid reimbursement policy change. We also used data from key informant interviews with state program staff to understand how provider champions affected policy uptake. We found that the monthly average for the number of insertions in Iowa increased from 4.6 per month before the policy to 6.6 per month after the policy; in Louisiana, the average number of insertions increased from 2.6 per month before the policy to 45.2 per month. In both states, the majority of insertions occurred at 1 academic/teaching hospital. In Louisiana, the additional increase may be due to the engagement of a provider champion who worked at both the state and facility level. Recruiting, training, engaging, and supporting provider champions, as facilitators, with influence at state and facility levels, is an important component of a multipart strategy for increasing successful implementation of state-level Medicaid payment reform policies that allow reimbursement for immediate postpartum long-acting reversible contraception insertions.

Okoroh EM ，Kane DJ ，Gee RE ，Kieltyka L ，Frederiksen BN ，Baca KM ，Rankin KM ，Goodman DA ，Kroelinger CD ，Barfield WD ... -  《-》

Coverage of immediate postpartum long-acting reversible contraception has improved birth intervals for at-risk populations.

In 2012, South Carolina revised the Medicaid policy to cover reimbursement for immediate postpartum long-acting reversible contraception. Immediate postpartum long-acting reversible contraception may improve health outcomes for populations at risk with a subsequent short-interval pregnancy. We examined the impact of the Medicaid policy change on the initiation of long-acting and reversible contraception (immediate postpartum and postpartum) within key populations. We determined whether immediate postpartum long-acting and reversible contraception use varied by adequate prenatal care (>7 visits), metropolitan location, and medical comorbidities. We also tested the association of immediate postpartum and postpartum long-acting, reversible contraception on interpregnancy interval of less than 18 months. We conducted a historical cohort study of live births among Medicaid recipients in South Carolina between 2010 and 2017, 2 years before and 5 years after the policy change. We used birth certificate data linked with Medicaid claims. Our primary outcome was immediate postpartum long-acting and reversible contraception, and our secondary outcome was short interpregnancy interval. We characterize trends in long-acting and reversible contraception use and interpregnancy interval over the study period. We used logistic regression models to test the association of key factors (rural, inadequate prenatal care, and medical comorbidities) with immediate and outpatient postpartum long-acting and reversible contraception following the policy change and to test the association of immediate postpartum and postpartum long-acting and reversible contraception with short interpregnancy interval. Our sample included 187,438 births to 145,973 women. Overall, 44.7% of the sample was white, with a mean age of 25.0 years. A majority of the sample (61.5%) was multiparous and resided in metropolitan areas (79.5%). The odds of receipt of immediate postpartum long-acting and reversible contraception use increased after the policy change (adjusted odds ratio, 1.39, 95% confidence interval, 1.34-1.43). Women with inadequate prenatal care (adjusted odds ratio, 1.50, 95% confidence interval, 1.31-1.71) and medically complex pregnancies had higher odds of receipt of immediate postpartum long-acting and reversible contraception following the policy change (adjusted odds ratio, 1.47, 95% confidence interval, 1.29-1.67) compared with women with adequate prenatal care and normal pregnancies. Women residing in rural areas were less likely to receive immediate postpartum long-acting and reversible contraception (adjusted odds ratio, 0.36, 95% confidence interval, 0.30-0.44) than women in metropolitan areas. Utilization of immediate postpartum long-acting and reversible contraception was associated with a decreased odds of a subsequent short interpregnancy interval (adjusted odds ratio, 0.62, 95% confidence interval, 0.44-0.89). Women at risk of a subsequent pregnancy and complications (inadequate prenatal care and medical comorbidities) are more likely to receive immediate postpartum long-acting and reversible contraception following the policy change. Efforts are needed to improve access in rural areas.

Liberty A ，Yee K ，Darney BG ，Lopez-Defede A ，Rodriguez MI ... -  《-》

Special report: implementing immediate postpartum LARC in Florida.

Women are often highly motivated to obtain contraception during the immediate postpartum period. However, not all women receive contraception, particularly long-acting reversible contraceptive methods, during this time. One barrier to immediate postpartum contraception is the cost of placing long-acting reversible contraceptives, because such devices have a large upfront cost and historically could not be charged separately from the global delivery fee. In 2017, Florida Medicaid unbundled the fee for the long-acting reversible contraceptive device and insertion from the Diagnosis Related Group and encouraged Medicaid Managed Care plans to do the same. The Florida Perinatal Quality Collaborative, in recognition of guidance put forth by other states, designed the Access LARC initiative to have 2 phases: the preimplementation phase and the implementation phase. After completing all steps in the preimplementation phase, 1 pilot hospital placed 195 long-acting reversible contraceptives during the first 5 months of the initiative. During this trial period, setbacks in the reimbursement process occurred for both the hospital and payer groups. The Agency for Health Care Administration was instrumental in providing assistance to overcome these setbacks. Although there were obstacles and setbacks along the way, this initiative was finally a success for our providers and patients. We encourage other hospitals and states to implement their own postpartum long-acting reversible contraceptive initiative with the use of the guidelines set forth by Florida's Access LARC initiative.

Brown JA ，Greenfield LT ，Rapkin RB 《-》