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 《-》

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 ... -  《-》

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 ... -  《-》

Immediate Postpartum Long-Acting Reversible Contraception: Review of Insertion and Device Reimbursement Policies.

Previous assessment of statewide policies on long-acting reversible contraception (LARC) indicate that an increasing number of states are implementing policies specifically for provision immediately postpartum, supported by current clinical guidelines. Less is known about how state policies describe payment methodologies for the insertion procedure and device costs. We conducted a systematic, web-based review of publicly available statewide policy language on immediate postpartum LARC among all 50 states. We examined the payor/s identified in the policy and policy type, if the policy included language on the global obstetric fee, whether providers and/or facilities were authorized to bill for procedure or device costs, and if the billing mechanism was identified as inpatient and/or outpatient services. Three-fourths of states (76%; n = 38) had statewide policies on immediate postpartum LARC. All policies identified Medicaid as the payor, although two also included non-Medicaid plans. Language allowing for reimbursement separate from the global obstetric fee for insertion procedures was present in 76% of states; 23 states permit it and 6 do not. Device cost reimbursement separate from the fee was identified in more state policies (92%); 31 states allow it and 4 do not. More policies included inpatient or outpatient billing mechanisms for device costs (82%; n = 31) than insertion procedures (50%; n = 19). Medicaid reimbursement policies for immediate postpartum LARC services vary by state reimbursement process, type, and mechanism. Observed differences indicate payment methodologies more often include the cost of the device than provider reimbursement (31 states vs. 23 states). Fewer than one-half of states offer reimbursement for provider insertion fees, a significant systems barrier to contraceptive access for women who choose LARC immediately postpartum.

Kroelinger CD ，Okoroh EM ，Uesugi K ，Romero L ，Sappenfield OR ，Howland JF ，Cox S ... -  《-》

Stage-based implementation of immediate postpartum long-acting reversible contraception using a reproductive justice framework.

The immediate postpartum period is a favorable, safe, and effective time to provide long-acting reversible contraceptives, yet it is not available widely. We describe an innovative hospital-based approach to immediate postpartum long-acting reversible contraceptives that includes (1) an emphasis on multidisciplinary teambuilding and identification of champions, (2) a focus on the use of implementation science at every stage of the process to develop a systematic and replicable strategy, and (3) an imperative to apply a reproductive justice framework to immediate postpartum long-acting reversible contraceptive implementation. Our model was developed with the use of implementation science best practices. Implementation teams comprised of diverse stakeholders were formed and included champions to promote progress. Our team assessed the implementation context for immediate postpartum long-acting reversible contraceptives and used the findings to develop a readiness assessment for hospitals. A stage-based implementation checklist was then developed to outline necessary infrastructure to support an immediate postpartum long-acting reversible contraceptive initiative. A reproductive justice lens guided planning and implementation. The 3 innovative aspects of our implementation process resulted in a systematic, multidisciplinary, and culturally appropriate model for immediate postpartum long-acting reversible contraceptives that can be replicated across hospitals. Implementation teams and champions moved the work forward at each hospital, and 3 of the 5 participating hospitals moved beyond the exploration stage of implementation during the engagement. Patient education materials and provider training incorporated person-centered and reproductive justice frameworks. Our hope is to continue to partner with stakeholders to better understand how our efforts to support hospital provision of immediate postpartum long-acting reversible contraceptives can increase reproductive health equity rather than perpetuate disparity.

Harper KD ，Loper AC ，Louison LM ，Morse JE ... -  《-》