TAKE CHARGE Process Evaluation A4 @3 A4@3 A4 @3 @3 A4 A4 IFS Sites @3 Control Sites @3 Washington State Department of Social and Health Services Research and Data Analysis Division Medical Assistance Administration TAKE CHARGE Process Evaluation Amy R. Ritualo, M.A. Laurie Cawthon, M.D., M.P.H. Trisha Keenan-Wilkie, M.A. Linda Weaver, M.A. December 2003 Research and Data Analysis Division Department of Social and Health Services Olympia, Washington 98504-5204 DEPARTMENT OF SOCIAL AND HEALTH SERVICES Dennis Braddock, Secretary MANAGEMENT SERVICES Kathleen Brockman, Chief Administrative Officer RESEARCH AND DATA ANALYSIS DIVISION Elizabeth Kohlenberg, Ph.D., Director In Collaboration with MEDICAL ASSISTANCE ADMINISTRATION Diana Larsen-Mills, Section Manager, Family Services When ordering, please refer to REPORT 9.69 ii ACKNOWLEDGMENTS This report was prepared for and funded by the Medical Assistance Administration, Department of Social and Health Services. This study represents a collaborative effort between the Medical Assistance Administration and Research and Data Analysis Division. We are deeply grateful to all research participants for sharing their personal information with us. We also appreciate the efforts of all of the TAKE CHARGE research providers for collecting the survey information and participating in the provider surveys and in- depth interviews. Without their contributions this report could not have been written. Thanks to Elizabeth Kohlenberg, Ph.D., Director of Research and Data Analysis Division, DSHS, for oversight and overall project management. Special thanks go to the members of the First Steps Database team who contributed to this report, including the previous project director, Barbara Baker. Michelle Coleman developed and maintained the client tracking database and entered survey data. Peter Woodcox assisted with the unduplication and matching of enrollment records with services data and provided SAS expertise. Dorothy Lyons unduplicated and matched data from the providers to enrollment records and provided comments on earlier drafts. Nella Lee provided comments on earlier drafts and entered client survey data. Nora Ellsworth provided valuable assistance and advice with formatting and printing. Jason Fry, Greg Kirkpatrick, and Francia Reynolds have our sincere appreciation for maintaining the Research and Data Analysis Division computer network, a system that meets the diverse demands of the agency’s managers, researchers, analysts, programmers, and talented support staff. iii TABLE OF CONTENTS EXECUTIVE SUMMARY vii INTRODUCTION 1 Background 1 Conceptual Model 3 Program Components 3 Program Administration 5 Program Participation 5 METHODS 7 Site Selection 7 Data Sources 7 Analysis 10 Limitations 11 RESEARCH SITES 13 Site Descriptions 13 Intensive Follow-Up Services 29 FINDINGS 33 Reaching the Target Population 33 Increasing Clinic Capacity 34 Feeling at Ease at Clinics 36 Providing More Client-Centered Practice 38 Utilizing Family Planning Methods and Services 40 DISCUSSION 45 CONCLUSION 49 BIBLIOGRAPHY 51 v EXECUTIVE SUMMARY Washington State’s TAKE CHARGE program, which began July 2001, expands Medicaid coverage for family planning services to men and women with family incomes up to and including 200% of the federal poverty level (FPL). Program goals are to improve the health of women, children and families in Washington State by reducing unintended pregnancies and lengthening intervals between births and to reduce state and federal Medicaid expenditures for unintended births and their associated costs (refer to WAC 388-532-700). TAKE CHARGE represents a change in state Medicaid policy by providing family planning services prior to pregnancy for low-income women not otherwise Medicaid eligible and includes low-income men in its target population. The Medical Assistance Administration (MAA) of the Department of Social and Health Services (DSHS) administers this program. Conceptual Model Client-centered provider behavior →↑ Client self-efficacy → Successful use of FP method →↓ Unintended pregnancies Increasing client-centered practice among TAKE CHARGE providers is predicted to result in enhanced client contraceptive self-efficacy leading to the successful use of family planning (FP) methods. To increase providers’ client-centered family planning behavior, two interventions were implemented: training in education, counseling and risk reduction (ECRR) for all sites and intensive follow-up services (IFS) for selected research sites. Both interventions represent the first time providers have been reimbursed for these services. The expected outcome for clients whose family planning services are provided by client-centered practices and whose contraceptive self-efficacy is enhanced is fewer unintended pregnancies. FINDINGS • TAKE CHARGE has been reaching the target population Nearly 170,000 women and men enrolled in TAKE CHARGE in the first two years. More than 94% of women who enrolled in TAKE CHARGE wanted to prevent pregnancy. Over two-thirds (67.5% or 113,446) of clients enrolled in the first two years were women between eighteen and twenty-nine years of age, the same age group that accounted for 73.0% of all Medicaid-paid births in 2002. • Provider behavior included more client-centered practice Nearly three times as many providers felt totally confident at follow-up that they discuss clients’ living situations compared to baseline. While only 52.3% of providers at baseline felt mostly or totally confident that they could recognize when a client was experiencing risk factors affecting successful use of family planning, such as living in an abusive environment or relationship, by follow-up 66.67% felt that way (an increase of 27.3%). Over one year after implementation, 80% of IFS providers reported always or most of the time finding out about underlying concerns, compared to roughly 60% of control site providers. vii By year two, providers at IFS sites were more likely than those at control sites to check with clients to see if their birth control plan had been put into practice: 70% of IFS providers, compared to 48% of control site providers. • Clients used more effective birth control methods About three-quarters of women in the first and second years of TAKE CHARGE received more effective birth control methods, such as oral contraceptives, injections, or implants. Clients’ reported use of a less effective method of birth control decreased from 31% at enrollment to 14% a year later; decreases were similar for IFS and control sites. Of the 6.9% of women who reported using no method at their last intercourse, 34% reported that they wanted to become pregnant in the next 12 months. • Greater patient volumes required increases in clinic capacity Nearly 41% of providers felt their clinics were not adequately staffed to meet TAKE CHARGE clients’ needs at baseline; by year two, this had decreased to 17%. Significant differences existed between the providers at IFS sites and those at control sites in their perception of their ability to handle the volume of their TAKE CHARGE population. At implementation 73.2% of IFS providers felt that their clinic was adequately staffed compared to 39.3% of control site providers. At follow-up the proportion of control sites that felt adequately staffed increased by 135% to 92.3%. At follow-up, the majority of providers felt mostly or totally confident that their clients were able to schedule appointments in a timely and convenient manner. To meet the needs of the unanticipated large population of TAKE CHARGE clients, the State of Washington and provider agencies have invested in building capacity by streamlining the application and billing processes, expanding physical workspace, increasing staff, and providing extensive trainings. Our findings support what other national health organizations are calling for in public health policy: that these family planning services continue as a regular part of the scope of Medicaid services. viii INTRODUCTION Washington State’s TAKE CHARGE program, which began in July 2001, expands Medicaid coverage for family planning services to men and women with family incomes up to and including 200% of the federal poverty level (FPL). Program goals are to improve the health of women, children and families in Washington State by reducing unintended pregnancies and lengthening the interval between births, and to reduce State and Federal Medicaid expenditures for unintended births and their associated costs (refer to WAC 388-532-700). TAKE CHARGE represents a change in Medicaid policy in that TAKE CHARGE provides family planning services prior to pregnancy for low-income women not otherwise Medicaid eligible and includes low-income men in its target population. The Medical Assistance Administration (MAA) of the Department of Social and Health Services (DSHS) administers this program. TAKE CHARGE is based on the concept that increasing the level of client-centered practice among providers will result in increased client contraceptive self-efficacy, leading to more successful users of family planning methods and a decrease in unintended pregnancies. In addition to expanding eligibility for Medicaid coverage for family planning services, TAKE CHARGE covers services not previously reimbursable: education, counseling, and risk reduction (ECRR) and intensive follow-up services (IFS).1 This report focuses on the design, structure, organization, and implementation of the TAKE CHARGE program. The process evaluation covers approximately the