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Reproductive Health Services for Women in Treatment

State: OH Type: Promising Practice Year: 2019

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Columbus Public Health
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Reproductive Health Services for Women in Treatment

Columbus Public Health (CPH) serves as the local health department for the nation's 15th largest city, Columbus, Ohio with a population of almost 900,000 residents. Located in Franklin County, CPH identifies and addresses public health threats, enforces laws that protect health, and prevents and controls disease. Over forty 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 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 evidence-based reproductive health and wellness services to residents in order to improve the overall health and well-being of men, women and teens in the community.  Services provided include same-day contraception, cancer screening, smoking cessation, and preventative healthcare. The WHWC serves a diverse population comprised of 46% African American, 30 - 40% Hispanic, and 10% adolescent clients. Also 45% of clients are uninsured with more than ¾ at 100% or below the Federal Poverty Line. Since 2014, the center steadily improved access to reproductive health services and contraception, including Long-Acting Reversible Contraception (LARC) as part of a larger strategy to prevent unintended pregnancy and to support infant mortality reduction initiatives such as safe birth spacing.

Infant Mortality remains at a crisis level in Ohio. In 2016, Ohio ranked 7th worst in overall infant mortality rates while national levels fell. On average, 2-3 babies die before their first birthday every week in Franklin County. CPH works with a number of community partners, including the Ohio Better Birth Outcomes Committee (OBBO) to reduce infant mortality in the community.

In addition, Ohio has the 5th largest number of drug overdoses in the United States with unintentional drug overdose the leading cause of injury-related death. The literature reports low uptake of contraceptive use with high rates of Sexually Transmitted Infections (STIs) and pregnancy termination rates among female opiate users. Opioid use has far-reaching effects for women and families, including neonatal abstinence syndrome (NAS), increased numbers of children entering foster care, and skyrocketing healthcare and social service costs.

In 2017, the collaborative work between CPH, OBBO, and community partners shifted to address infant mortality in the context of opioid dependency and recovery.  At that time, the idea for a reproductive health and wellness clinic on-site at a treatment facility was born.

The goal of this project was to increase access to reproductive health and wellness services to women in substance abuse recovery by opening a clinic on-site at a local treatment center. The practice was implemented by 1) identifying a partner substance abuse facility 2) completing a series of planning meetings 3) initiating services 4) ongoing evaluation through satisfaction surveys, focus groups, and metrics.

On February 21st, 2018, CPH opened the clinic at CompDrug in Columbus to provide a full range of reproductive health services, including contraceptive counseling, reproductive life planning, and same-day LARC. CompDrug provides research-based addiction treatment and prevention services operating one of the largest outpatient opioid treatment programs in Ohio. The clinic is held every Wednesday and accepts appointments and walk-ins for all services which are either no cost or low cost.

Since opening, 49 visits have been completed with a Nurse Practitioner specializing in women's health at which 33 obtained a same-day method with 18 being a LARC method (IUD & Implant); this represents a 67% overall contraceptive uptake and 55% LARC ratio. In addition to contraception, full-scope reproductive health services were provided including well woman care, cancer screening, testing and treatment of STIs, reproductive life planning, immunizations, and management of gynecologic concerns.

Specific factors that led to this project's success include:

  • the partnership between Columbus Public Health and CompDrug
  • support and facilitation from Ohio Better Birth Outcomes
  • integration of reproductive health services into the existing medical care
  • marketing and promotion with assistance from counselors and group leaders
  • location adjacent to daily treatment dosing
  • ease and convenience of walk-in services
  • contraception and other medications provided at visit
  • contraceptive counseling training for treatment staff
  • feedback from focus groups and surveys

The potential public health impacts are reduction of unintended pregnancy, neonatal abstinence syndrome (NAS), and infant mortality through promotion of safe birth spacing and overall improved maternal wellness. Projects that integrate reproductive health services into substance abuse treatment also support a person's recovery program and other life goals.

https://www.columbus.gov/publichealth/programs/Women-s-Health,-Family-Planning/

Infant mortality and opioid abuse are negatively impacting the health and well-being of Ohioans. One of the most preventable causes of infant mortality is prevention of unplanned pregnancy; it is estimated that almost 90% of pregnancies in opiate users are unintended. At the same time, the incidence of neonatal abstinence syndrome (NAS) continues to grow. The aim of this project was to address both public health crises through an innovative approach by linking reproductive health and wellness services in the same facility in which addicted women receive daily treatment. This approach reduces barriers such as transportation, time, and cost. Our target population is women of child-bearing age with substance abuse disorder currently in treatment at CompDrug in Columbus, Ohio.

At CompDrug in Ohio, there is nearly 700 women in treatment. Through surveys and a series of focus groups, we found the majority of women in treatment for substance abuse reported no routine women's health preventative services such as pap smears, nor are they using consistent contraception. For many women there is stigma associated with addiction and treatment by the medical providers outside the addiction practice, which greatly reduced their desire and opportunity to receive routine medical care. Most of the women desire reproductive health and wellness services and contraception yet are unable or willing to obtain services for a variety of reasons.

A recent article by Terplan, Lowental, Connah and Martin conducted a study of patients of substance abuse treatment centers to evaluate needs and assess the acceptability of family planning service delivery within a treatment center. The study found that although more than 90% of participants had access to health care services in the past 3 years, 25% of women and 33% of men reported difficulty accessing health care providers. The majority of respondents said they would likely use family planning services if available at their treatment center (83% of women and 58% of men).

In the past, reproductive health and wellness services for women in treatment could be obtained through referral or appointment at another location which may include barrier such as transportation, stigma, or high costs for the patient. Traditional treatment staff is not trained on reproductive health or reproductive life planning, nor was pregnancy intention routinely assessed during intake. In the first seven months of this project, the clinic completed 49 visits with a high level of contraceptive uptake of  67%. As important, many women received critical wellness services that some had gone decades without, including cervical cancer screening and breast mass evaluation. It should be noted that approximately 75% of the appointments seen are on a walk-in basis.

The practice of providing on-site health services to women at their treatment facility reduces barriers to receiving reproductive healthcare for women that are at risk of an unintended pregnancy and other risk factors for poor infant and maternal outcomes. Additionally, co-location of services provides a safe space for women, many of whom have previously experienced trauma, to seek critical healthcare services. This is especially important as many of the focus group participants verbalized negative experiences with medical providers related to the stigma of being an addict. Participants spoke of missed appointments as a result, being judged, denied pain mediation during delivery and dismissed as drug seeking during an ER visit. Several participants expressed relief in the ability to seek services without having to divulge their diagnosis of substance abuse disorder to another medical provider.

Integration of reproductive health services with substance abuse treatment is a new and innovative practice in the field of public health. Guidance from the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA) recommending that women at-risk for a substance-exposed pregnancy be provided with the full menu of contraceptive options, including LARC free of barriers informed this project.

Evidence that supports this practice:

U.S. Substance Abuse and Mental Health Services Administration (2017). Protecting Our Infants Act: Final Strategy. Retrieved from https://www.samhsa.gov/sites/default/files/topics/specific_populations/final-strategy-protect-our-infants.pdf

Centers for Disease Control and Prevention (2017). Addressing the Unique Challenges of Opioid Use Disorder in Women. Retrieved from https://www.cdc.gov/grand-rounds/pp/2017/20170117-presentation-opioid-overdose-H.pdf

Gavin, L. (2014). Providing quality family planning services: recommendations of CDC and the US Office of Population Affairs, MMWR, 2014, 63 (4): 1–54. Retrieved from https://www.cdc.gov/mmwr/pdf/rr/rr6304.pdf

The U.S. Department of Health & Human Services Substance Abuse and Mental Health Services Administration (SAMHSA) provides evidence-based guidelines for the treatment of substance abuse disorder and developed a resource center with specific guidance.

https://www.samhsa.gov/ebp-resource-center

The Centers for Disease Control and Prevention (CDC) provide evidence-based guidelines for safe contraceptive use with U.S. Medical Eligibility Criteria and Select Practice Recommendations.

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


The mission of Columbus Public Health (CPH) 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. Strategic priorities for the department include both infant mortality and mental health and addiction services. CPH houses the Women's Health & Wellness Center and Alcohol and Drug programs. In 2018, CPH announced a new division, Addiction Services, combining the existing Alcohol and Drug program with the Franklin County Opiate Action Plan.

The practice of integrating reproductive health services with a community treatment facility supports the agency's strategic priorities.

Goals and objectives:

  • Initiate and integrate reproductive health and wellness services on-site at a community treatment facility
  • Increase access to services for females of reproductive age including same-day provision of contraceptives

The project achieved the goals and objectives through:

  • Sharing a clear vision and mission from both organizations with leadership buy-in
  • Aligning this work with existing infant mortality, opioid abuse, and NAS strategies
  • Strong support and vision from the Ohio Better Birth Outcomes, including assistance with project management, marketing, and focus group facilitation
  • Regular planning sessions leading up to a kick-off date (2/21/18)
  • Marketing and media coverage of the clinic to promote awareness and interest
  • Transformation of a private clinic area adjacent to the daily dosing facility
  • Female staff experienced in working with women with substance abuse disorder
  • Treatment staff completed contraceptive counseling training
  • Development of education materials
  • Emphasis on evidence-based guidelines
  • Ensuring efficient visits so that women can return to their support groups or transportation
  • Consistent hours of operation and staff to build trust
  • Utilizing a full menu of reproductive health services and stocking medications on-site
  • Using a sliding fee scale for services to remove cost as a barrier
  • Reviewing customer satisfaction surveys to guide interventions
  • Collaborating with CompDrug perinatal program to expedite referrals to the clinic post-partum
  • Working with nursing and counseling leadership to encourage visits to the clinic

This is a long-term project for both Columbus Public Health and CompDrug. As the clinic continues to build and volume increases, the partners will consider adding additional clinic days and hours (currently the clinic operates one 4 hour day per week). There are future plans to incorporate One Key Question® into the treatment plan and electronic health record at the treatment facility and to develop a women's health education group to meet routinely.

A fundamental factor leading to success for this project is the collaboration and partnership of multiple community stakeholders:

CompDrug: CompDrug provides research-based addiction treatment and prevention services and operates one of the largest outpatient opioid treatment programs in Ohio. The facility is licensed by the Ohio Department of Mental Health and Addiction Services (OMHAS) and is nationally accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF).

http://www.compdrug.com/

Ohio Better Birth Outcomes (OBBO) collaborative: 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 board and CPH staff serve on multiple OBBO work groups including that which addresses reproductive health and access to LARC.

https://ohiobetterbirthoutcomes.org/

Ohio Department of Health (ODH): 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 for vulnerable populations including men, women, and teens in substance abuse treatment and in the justice system; ODH granted approval of this project.

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The program also received recognition from the Franklin County Neonatal Abstinence Syndrome (NAS) Reduction committee.

There were few start-up costs associated with this project (less than $2,000). These costs (flooring renovation, exam table, and purchase of disposable medical supplies) were shared by partners. Ongoing costs associated with operation of the clinic are funded by the Ohio Department of Health's Reproductive Health & Wellness program (Title X) and Columbus Public Health.

This project set out to address two of Ohio's most prevalent health problems: infant mortality and opioid addiction. Through community collaboration and partnership, this project achieved co-location of reproductive health and wellness services with a local substance abuse treatment facility. Since the project kicked off in February, almost 50 visits were completed with a 67% contraceptive uptake. Women also opted for well woman and preventative care including cervical cancer screening and immunizations.

Additionally, feedback from participants revealed a desire for reproductive health services on-site and a high level of satisfaction for those seen in the clinic.

For this project, there are multiple sources of sources of data:

Customer Satisfaction Surveys

Every women seen in the clinic is asked to complete a voluntary survey to provide feedback. Notable comments from surveys:

  • I was always scared to get an IUD, but you made it easy”
  •  I have a 2 and a 3 year old and can't afford to get pregnant so fast again”
  •  You guys are really special to do this”
  •  I can't believe I can get my birth control here today. I've been trying to get into my OB/GYN for months”
  •  Thank you, thank you. I'm focused on me right now and this helps”
  • I'm proud of myself today”
  • I'm happy I'm finally doing this”

Data collection (via electronic health record, data warehousing, and clinic logs)

Specific metrics tracked:

  • Age
  • # of women receiving any contraceptive method
  • # of women receiving a LARC
  • Post-Partum status
  • Payer/Insurance
  • Type of method
  • Zip code
  • If method provided same-day
  • Other reproductive health services provided
  • Appointment type (walk-in or prescheduled)

Survey results and data are analyzed through monthly reporting, quarterly dashboard metrics, and control chart comparing monthly and quarterly changes.

Focus Groups

Six months into the project, a series of 3 focus groups, 90 minutes in duration, were facilitated by Ohio Better Birth Outcomes. The purpose of the focus groups was to assess motivation to visit the clinic, examine messaging and marketing materials, and determine future steps. Key findings of the focus groups include:

  • Upon learning of the contraceptive clinic, nearly all participants thought it was a needed service and were supportive.
  • For those who had used the contraceptive clinic, 100% of the feedback was positive. It took like 15 minutes start to finish”- female patient who had received a Mirena IUD.
  • Providing medical services at a drug treatment site reduces stigma for the patient and increases probability of the patient attending appointments
  • A reproductive health clinic should be promoted as such and not as a birth control clinic. The narrow descriptor removes the possibility of patients making an appointment for routine reproductive health care or even preconception care as the impression is this is only for contraception.
  • Marketing materials must be widely and readily available and consistently visible. All materials must be vetted by patients prior to use and be created with the insight of a recovering addict.
  • Counselors and nurses can be trained to promote services and provide basic education about the contraceptive methods.
  • Women in treatment are on multiple medications such as Suboxone and methadone and there is concern and side effect issues when using one of these treatment medications with contraception. This needs to be addressed when working with this population.
  • When creating marketing materials for this population, it is important to seek the input of the population during the development of any marketing.
  • Providing services for recovering addicts at treatment centers is a welcome idea. Continuous education about the services as well as about contraceptives will help promote the services and integrate the clinic into the structure of CompDrug. Education should be extended to counselors, and nurses as well as the patients. All marketing and services must be created, developed and implemented with the recovering addict in mind and with their input.

Actions based on feedback in the focus groups:

  • A Refresh of marketing materials
  • Collaboration with intake, nursing, and counseling staff
  • Education within existing women's support groups

Through community partnerships, evidence-based care, and strategic planning, the Women's Health and Wellness Center at Columbus Public Health successfully opened a reproductive health and wellness clinic on-site at CompDrug, a leading community substance abuse treatment facility. This clinic increases access to health care services for women in treatment and is a replicable model. This project supports the agency's dedication to local infant mortality reduction work and drug and alcohol education and treatment. This project showed that women in recovery are in need of reproductive health services and welcome them co-located within their treatment facility.

The majority of women seen in the reproductive clinic are insured by public insurance and services are highly reimbursable. To support sustainability, future work is focused on increasing visit numbers, strengthening internal partnerships and referral sources, enrollment assistance for uninsured patients, revenue cycle work, improving marketing materials, and continued work on integration. In order to continue the program, funds from the ODH reproductive health and wellness grant/Title X are critical. Other funding sources will be explored to supplement current grant funding and 3rd party reimbursement.

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