Summary of the Delaware
Contraceptive Access Now (DelCAN) Initiative

The Delaware Contraceptive Access Now (DelCAN) initiative is a statewide program and set of policy changes focusing on reducing unintended pregnancies and improving access to and delivery of family planning services and contraceptives, including long-acting reversible contraceptives (LARCs). The goal is to ensure all women of reproductive age in Delaware, regardless of insurance or ability to pay, have same-day access to the full range of contraceptive methods at low or no cost. The DelCAN initiative is a public-private partnership between the state of Delaware and Upstream USA (Upstream USA, 2019a). The initiative is designed to remove barriers related to cost, education, and access by implementing policy changes, providing trainings and technical assistance to clinical sites, and developing a statewide public awareness campaign. The initiative began in January 2015. Upstream’s DelCAN activities ended in early April 2020 with their provision of telehealth guidance to clinics in the context of the coronavirus pandemic. (See timeline figure.) An independent evaluation of DelCAN by the University of Maryland and University of Delaware began in June 2016 and is expected to be completed by mid-2022.

Medicaid Reimbursement Policies for LARC

In January 2015, the Delaware Division of Medicaid and Medical Assistance (DMMA) began allowing separate reimbursement for LARC devices via the Medicaid pharmacy benefit when occurring concurrently with childbirth-related services (DMMA, 2019). This enables hospitals to provide LARC placement and be paid for the device for Medicaid patients immediately postpartum (IPP), meaning after childbirth but before hospital discharge. Prior to this reimbursement policy, like most states (Moniz et al 2016), Delaware’s Medicaid program and affiliated managed care plans reimbursed providers and hospitals using an all-inclusive fee for childbirth-related services. DMMA released a special bulletin asking clinic sites to “consider ways that [the] practice can open access to LARCs or increase awareness for…patients who are at risk for repeat unintended pregnancies,” (DMMA, 2015). Beginning in March 2015, at Christiana Care Health System (CCHS) maternity unit, where approximately half of all deliveries in Delaware occur, Medicaid patients with no contra-indications have been offered IPP LARC (IUDs and contraceptive implants). This includes pre-delivery counseling on all postpartum contraceptive options, and is an ongoing program at CCHS. Other Delaware hospitals began IPP LARC programs following Upstream trainings that were conducted beginning in 2016.

On June 26, 2017, a Delaware Medicaid State Plan Amendment (17-003) was approved and made retroactively effective from January 2, 2017 to provide a mechanism for federally qualified health centers (FQHCs) in Delaware to obtain compensation for LARCs that were not included in the FQHC prospective payment system visit rates from Medicaid. This allows FQHCs to maintain adequate stock of LARCs, and partially replaces the need for direct state purchase of devices (DHHS, 2017).

Funding for LARC devices in Title X clinics

Starting in May 2015, the Delaware Division of Public Health (DPH) made available funding to purchase LARC devices. Some funding was given directly to Title X agencies to purchase LARCs while the rest was used to purchase LARC stock for the State Pharmacy. On January 21, 2016, former Delaware Governor Jack Markell formally announced the launch of DelCAN (Markell, 2018), which included private funding from individual philanthropists and foundations, as well as funding from the Delaware DPH. In June 2016, DPH provided additional funding to purchase more LARC stock for the State Pharmacy. As a result of this funding, Title X sites were able to obtain LARCs at no cost from the State Pharmacy. DPH provided additional financial support to purchase LARCs in fiscal years 2017, 2018, and 2019 by Title X providers. The goal is to allow Title X clinics to provide same-day access to patients for LARC services. Title X clinics continued to use DPH funding for LARC devices through early 2019. Upstream also provided LARC devices directly to clinics.

Upstream Training

From February 2016 until March 2019, Upstream USA provided training sessions for clinicians and support staff (e.g. medical assistants, front desk staff, accounting and billing, and other administrative staff) to increase their clinical, counseling, and administrative capacity for providing the full range of contraceptive methods to patients (Upstream USA, 2019a). The clinic sites included all publicly funded Title X clinics, the largest private outpatient clinics and medical groups, and five of the six major inpatient hospitals in the state. Maternity hospital and outpatient providers were trained. Clinicians received training on the provision of the full range of contraceptive methods including the insertion, removal and medical management of both IUDs and implants in addition to information on effectiveness of LARC and other contraceptive methods and shared decision-making (Upstream USA, 2019b). Clinicians were permitted to deliver all methods of contraception except for IUDs after completing the training session. In order to provide IUDs, after the training, clinicians new to IUD provision had to complete preceptor supervised insertions, either by the clinic or through an Upstream-provided preceptor, to comply with manufacturer and clinic site requirements. The support staff received training focused on patient-centered contraceptive counseling, pregnancy intention screening, shared decision-making, and effective questioning. The model of contraceptive counseling includes the use of patient education materials that display a hierarchical list of methods from most to least effective, such as the materials developed by Bedsider and the University of California, San Francisco’s Bixby Center (UCSF, 2018). A separate set of trainings focused on non-medical providers at community organizations that serve women in foster care, domestic violence programs, substance use treatment centers, corrections, and other social services. These community organizations received training and assistance related to counseling, referrals, and navigation through the healthcare system.

Also starting in February 2016, clinic sites received technical assistance from Upstream USA’s team of quality improvement officers to monitor progress among trained providers and staff and to assess and provide assistance in overcoming site-specific barriers to contraception provision. These assistance components include billing and coding, revenue cycle, electronic medical records, quality and performance improvement, patient education materials, and stocking of contraceptive devices. This technical assistance ended March 2020.

Public Awareness Campaign

The public awareness campaign “Be Your Own Baby” was launched in late May 2017 and ended October 2018. The campaign was directed by Upstream USA in partnership with a national advertising firm. Campaign messages and the choice of media channels were informed by focus groups from Delaware, North Carolina and an online survey. Messaging focused on access to “free” birth control (no specific method was highlighted). Messages were designed to be “fun” and “empowering.” The central message formats were professionally produced music video (hosted on YouTube), online streaming music advertisements, social media posts and online advertising. The call to action for all messaging was to visit the Be Your Own Baby webpage (beyourownbaby.org) where visitors were steered towards a nearby clinic (via a ZIP code look-up tool) that could provide free same-day contraceptive services. Three sites from a large family planning outpatient clinic enabled online scheduling through the website. Website visitors could also submit reimbursement for transportation to a clinic or for any out-of-pocket contraceptive costs. The website also provided information about different contraceptive method types and linked to Bedsider.org for more information. The media channels included paid search and website banner advertising, paid social advertising, and organic social media traffic. Platforms included Instagram, Facebook, Google Adwords, Pandora, Spotify, and YouTube. The target demographic for ad purchasing was women age 18-29 in Delaware.

References

Delaware Division of Medicaid & Medical Assistance (DMMA). (2015). Medicaid Special Bulletin: Third Quarter 2015. Retrieved May 1, 2019, from https://medicaidpublications.dhss.delaware.gov/dotnetnuke/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=436&language=en-US&PortalId=0&TabId=94

Delaware Division of Medicaid & Medical Assistance (DMMA). (2019). Inpatient Hospital Provider Policy Manual. Retrieved February 9, 2019, from https://medicaidpublications.dhss.delaware.gov/dotnetnuke/DesktopModules/Bring2mind/DMX/Download.aspx?Command=Core_Download&EntryId=895&language=en-US&PortalId=0&TabId=94

Department of Health & Human Services (DHHS). (2017). Delaware State Plan Amendment 17-003. Retrieved February 9, 2019, from www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/DE/DE-17-003.pdf

Markell, J. (2018, May 17). This local health initiative has expanded birth control access (Opinion). Retrieved March 7, 2019, from CNN website: https://www.cnn.com/2018/05/16/opinions/delaware-birth-control-initiative-opinion-markell/index.html

Moniz, M. H., Chang, T., Davis, M. M., Forman, J., Landgraf, J., & Dalton, V. K. (2016). Medicaid Administrator Experiences with the Implementation of Immediate Postpartum Long-Acting Reversible Contraception. Women’s Health Issues 26(3):313–320.

University of California, San Francisco (UCSF). (2018). Beyond the Pill: Educational Materials for Patients and Students. Retrieved March 7, 2019, from https://beyondthepill.ucsf.edu/educational-materials

Upstream USA. (2019a). Delaware CAN: Increasing birth control access. Retrieved March 14, 2019, from https://www.upstream.org/campaigns/delaware-can/

Upstream USA. (2019b). Approach to Patient-Centered Counseling. Retrieved April 21, 2019, from https://www.upstream.org/2019/01/23/upstreams-approach-to-patient-centered-counseling/

 

 

Suggested Citation:
Choi, Y.S., Rendall, M.S., Boudreaux, M, and Roby, D.H. (2020). Summary of the Delaware Contraceptive Access Now (DelCAN) Initiative. June 4, 2020. https://popcenter.umd.edu/delcaneval/summary-init