February 19, :00-4:00p ET , ext # ASTHO LARC Learning Community Virtual Learning Session Training

Agenda 2:00Welcome and Introductions 2:10State Team Updates 2:40State Presentation: Georgia 3:10State Presentation: South Carolina 3:40Abstract Proposal on LARC Evaluation 3:55Next Steps, Homework 4:00Adjourn

Webinar Objectives Discuss learning community state team progress in the three months since the last learning session. Learn about provider training for LARC immediately postpartum and resources and relationships that have enhanced Georgia’s work. Learn about provider training for LARC immediately postpartum and leadership and strategies that have moved South Carolina’s work forward. Discuss proposed abstract on inserting LARC immediately postpartum.

Welcome and Introductions Welcome from ASTHO  Dr. Lisa Waddell Chief of Community Health and Prevention

Training Framework Policy  Are there any supporting/hindering policies for providing training? Provider  What does successful training for providers look like? Pharmacy  How do you design training and content for pharmacists? Billing and Coding  What does successful billing/coder training for providers look like?  How can we successfully use pilot sites to take information back to the ones setting up the coding? Cross Cutting Issues:  where does leadership for training come from?  What roles do key stakeholders or professional organizations have?  What success stories can translate to other states

State Team Introductions LARC Learning Community State

Team Updates: “Round Robin” Each state will present for 3-5 minutes Alphabetical order Following state updates, time will be allotted for questions or reactions.

State Team : “Round Robin” Colorado GeorgiaIowa Massachusetts New Mexico South Carolina

 Provider Training Immediate Postpartum LARC Placement—Georgia’s experience

Collaborative experiences  Department of Community Health  Department of Public Health  Georgia Ob/Gyn Society  Georgia Perinatal Quality Committee  Regional Perinatal Centers  Local, regional and national agencies

Training approach  Peach State grant to Georgia Ob/Gyn Society  Train providers at six regional perinatal centers  Residency Programs  Areas of population density  Referral areas

Key components  Information about the Medicaid policy  Why this policy is good for Georgia  What is good about LARC devices  Why immediately postpartum is a great time for placement  Billing and reimbursement  From CMO Medical Director

Key components (continued)  Discussion of FAQ  Breastfeeding  Expulsion  Strings  Demonstration  Hands on with pelvic models  Setting the stage for next steps and additional stakeholders

Inspiration 

Additional training efforts  Similar trainings in non-RPC settings  Georgia Ob/Gyn  Newsletter  Webinar  Annual meeting talk  Annual meeting simulation lab  Georgia Perinatal Quality Committee  Maternal focus initiative  Department of Public Health  Incorporating contraceptive counseling at initial prenatal visit

Some findings  Developing institutional champions  State-level learning and problem-solving

Provider Training: Immediate Postpartum LARC Insertion (Georgia) Questions?

Inpatient Nexplanon Experience Amy H. Picklesimer, MD, MSPH Associate Professor Department of Obstetrics and Gynecology University of South Carolina - Greenville

WHY LARC?

WHY NOW?

Given the efficacy, safety, and ease of use, LARC methods should be considered first-line contraceptive choices for adolescents.

Inpatient LARC UB-04 must have following: HCPCS code for device ICD-9 Surgical Code ICD-9 Diagnosis Code August 2013 to Present Reimbursement Policy

Instructions for Medicaid Claims Codes must be included on the UB-04 or Institutional Claim so that a gross level credit adjustment can be generated The claim will adjudicate and the DRG portion will be paid in the weekly claims payment cycle. The LARC reimbursement will process as a gross level credit adjustment and will appear on a future remittance advice. HCPS: J7300 Intrauterine (IU) copper IUD (Paraguard) J7302 Levonorgestrel releasing IUD 52 mg (Mirena) J7303 Etonorgestrel (contraceptive) implant system (Nexplanon) ICD-9 Surgical Code: 69.7 Insertion Contraceptive Device ICD-9 Diagnosis Code: V25.02 Initiate Contraceptive NEC V25.1 Insertion of IUD

LARC Cost Update *Note that all rates are the same for both in-patient and out-patient. In-patient payment is in addition to the DRG for delivery Updated October 2012 Code Previous Reimbursement Rate Current Reimbursement Rate Insertion Code Rate A4264 Essure $1,164.00$1, $ J7300 Paragard $588.43$ $67.00 J7307 Impl/Nex $648.87$ $95.58 J7302 Mirena $691.80$ $67.00 J7301 Skyla n/a$ $67.00

GREENVILLE HEALTH SYSTEM

Nexplanon Insertion Request in-person training by calling Merck or online at

Supplies Hospital Pyxis Nexplanon device and local anesthetic

Supplies Tackle Box Sterile gloves Sterile towels Betadine swabs Sterile marking pen 20 cc syringe 18 and 23 gauge needles Band-aid Dressing pads and wrap

Order sets and patient consent

What about breastfeeding? The implant can be inserted at any time following delivery. The advantages generally outweigh real or theoretical risks if placed 1 month post- partum Observational studies of progestin-only contraceptives suggest they have no effect either on a woman’s ability to successfully initiate and continue breastfeeding, or an infant’s growth and development. CDC MMWR June 21, 2013 ACOG Practice Bulletin #121, July 2011

The advantage of Nexplanon over Depo Provera is that the implant can be removed in women who are struggling with lactation An additional advantage of Nexplanon over Depo Provera is that it has a lower peak serum concentration. –After Depo Provera injection, medroxyprogesterone acetate plasma concentrations peak at 7 ng/ml 3 weeks after injection –After Nexplanon insertion, etonorgestrel plasma concentrations peak at 0.8 ng/ml 4 days after insertion The risks of unintended pregnancy are much greater than the real or theoretic risks of progestin exposure in the post-partum period

Do women (and doctors) like it?

South Carolina Inpatient Nexplanon Experience: Training Questions?

Evaluating the Implementation of a State Medicaid Policy Initiative to Promote Long- Acting Reversible Contraception (LARC) Access during the Delivery Hospitalization Kristin Rankin, PhD Assistant Professor, Division of Epidemiology University of Illinois at Chicago School of Public Health

Purpose of Presentation Introduce proposal to apply the methodology of implementation science to study the roll-out of IPP LARC in early adopting states Solicit feedback, questions and support of project from ASTHO Learning Community Teams Ultimate Goals of Study: – Highlight work in learning community states – Systematically study implementation activities – Disseminate findings to other states embarking on similar policy initiatives

Implementation Science (IS) IS focuses on facilitators and barriers to the wide scale implementation of evidence-based practices This study’s specific focus is on success of implementation strategies to capitalize on facilitators or overcome barriers in different contexts Outcomes related to uptake of IPP LARC include: – Adoption – Reach – Penetration – Equity – Acceptability

Specific Aims: IPP LARC Study 1.To describe variation and similarities across state- and birthing facility-level implementation strategies currently being adopted to increase access to immediate postpartum long-acting reversible contraception (IPP LARC) 2.To measure the effect of implementation strategies, alone and in combination, on outcomes at the facility, provider and patient levels, such as adoption, reach, equity, penetration and patient acceptability of IPP LARC 3.To identify whether each implementation strategy, alone and in combination with other strategies, is differentially effective according to state- and facility-level context

Conceptual Model Multiple Levels State Birthing Facility Provider Patient Behavior Change Wheel (Michie et al 2011)

Methods Mixed Methods Design – Qualitative: Key Informant Interviews for exploration of state and facility-level context and implementation strategies – Quantitative: Delivery Facility Survey – Qualitative: Key Informant Interviews for elaboration of findings Outcome: IPP LARC rates for eligible women over time at different levels (state, facility, provider) – Ascertained through Medicaid claims for codes associated with devices and procedures during delivery hospitalization

Research Team Team MemberAffiliationExpertise Kristin Rankin, PhD (PI)UIC-SPHMCH Epidemiology, Medicaid Claims, Postpartum Health Melissa Kottke, MD, MPH, MBAEmory, GA ASTHO Team Family Planning, IPP LARC provider champion, Adolescent Health Nadine Peacock, PhDUIC-SPHQualitative Methods, Family Planning Arden Handler, PhDUIC-SPHMCH, Medicaid Policy Sadia Haider, MD, MPHUIC-COMFamily Planning, Adolescent Health Rachel Caskey, MD, MS,UIC-COMPediatrics, Internal Medicine, Health Services Research

Timeline 3-year study Submission to NIH: October 2015 Earliest possible start date: July 2016 Key Informant Interviews: Facility Survey: Outcome Ascertainment: Dissemination:

Partnership with Learning Community Teams: Requests Now… 1.Feedback about relevance and feasibility of proposed research and how it can help you (anytime) 2.Letters of Support from members of ASTHO Learning Community Teams (March 2015) When project is funded… 1.Participate in Key Informant Interviews and identify other state partners to be recruited 2.Facilitate access to outcome data from state Medicaid Management Information System 3.Suggest and connect us with partners for birthing facility survey (e.g. state hospital association)

Related Activities of PI PI Pilot Grant (Feb 2015-Feb 2016) – Examine women’s experiences in Georgia (barriers and facilitators to IPP LARC, informed choice) – Funder: UIC School of Public Health IL Medicaid Claims Project (Apr 2014 – present) – Examine factors associated with Postpartum Visit and Contraception among IL Medicaid women – Funder: HRSA Maternal and Child Health Bureau Co-I Postpartum Choices Study (PI: Handler, Funder: IL Medicaid) RCT of co-located family planning services at WBV (PI: Haider, Funder: Society for Family Planning)

QUESTIONS? SUGGESTIONS? Contact Information: Kristin Rankin, PhD Assistant Professor, Division of Epidemiology University of Illinois at Chicago School of Public Health Phone:

Next Steps Learning Community Sessions:  Mar. 17, 2015, 3:00-5:00p ET: Consent  Apr. 23, 2015, 2:00-4:00p ET: Stocking, Supply  May 12, 2015, 2:00-4:00p ET: Pay streams, Sustainability  TBD Aug. 2015: In Person Learning Community?, Outreach Materials and recordings will be available on the ASTHO LARC page: Child-Health/Long-Acting-Reversible- Contraception-LARC/ Child-Health/Long-Acting-Reversible- Contraception-LARC/

Homework Next Call: March 17, 3:00-5:00p  Present what your state is doing around training (provider, pharmacy, coding, etc.)  How your state is progressing on your LARC priorities from the in-person meeting  ASTHO will send a template and priorities reminder next week Review state team participants list

Closing and Goodbyes Closing from CDC  Charlan D. Kroelinger, PhD Team Leader Maternal and Child Health Epidemiology Program Field Support Branch Division of Reproductive Health Centers for Disease Control and Prevention

Framework for Future Calls Future Learning Session Topics: Consent, Stocking/Supply, Pay Streams/Sustainability, Outreach Are there supporting/hindering policies? What does successful _______ for providers/pharmacists/clients look like? What does successful _____ for Medicaid look like? How can we successfully use pilot sites to take information back to Medicaid? Cross Cutting Issues:  Where does leadership for ____ come from?  What roles do key stakeholders or professional organizations have?  What success stories can translate to other states

Evaluation Please take our evaluation survey so we can improve for the next call: VPzHC3fT