TX’s Draft Postpartum Depression Plan is a Good Start. More Work is Needed.

Update: We submitted these comments to HHSC regarding the draft Strategic Plan.

As more state leaders recognize that a child’s health is inextricably linked to the health of his or her mother, there has been growing interest in the Texas Legislature in maternal health, including maternal mental health. Maternal mental health challenges — sometimes called postpartum depression or maternal depression — are among the most common complications of pregnancy, affecting 1 in 7 Texas women.

To address these challenges, the Texas Health and Human Services Commission (HHSC) recently released its Draft 5-Year Postpartum Depression Strategic Plan, a plan the Legislature required through HB 253 in 2019.

We’re glad to see that the state’s draft plan includes a number of recommendations that we provided to HHSC after our team conducted a survey, community engagement efforts, and other research on the subject earlier this year.* For example, the plan includes increasing awareness of maternal mental health challenges by training more professionals serving moms and families; adding mental health counseling as a covered benefit in Healthy Texas Women’s postpartum package; and leveraging formal and informal peer supports to help more moms, including certified mental health peer specialists, community health workers, promotoras, and group prenatal care like Centering Pregnancy.

As of now, the draft Strategic Plan does not include other important state steps, such as Medicaid coverage for a full year postpartum rather than 60 days. Texans surveyed said that the inability to afford services because of lack of insurance was the greatest challenge women face in receiving treatment or support for maternal mental health challenges — and respondents’ top recommendation for Texas is to extend Medicaid for a full year postpartum. Last year, the Texas House passed HB 744 to implement this policy, as recommended by the state’s Maternal Mortality and Morbidity Review Committee, but it fell short in the Senate. The draft Strategic Plan also currently excludes strategies to incentivize and build capacity among pediatric providers and NICU staff to screen moms for maternal mental health challenges. Additionally, it omits strategies to promote use of tele-mental health despite the acceleration of telehealth we are seeing during the coronavirus pandemic.

If you would like to submit comments on the draft Strategic Plan to HHSC, you can email HDISPublicComments@hhsc.state.tx.us by 5 p.m. CT on July 24, 2020.

The coming months, and the next legislative session, are a critical time for state policymakers to support maternal mental health. The coronavirus pandemic and recession exacerbate some of the challenges facing new mothers and babies. Prior to the pandemic, 1 in 4 Texas women of reproductive age were uninsured. An estimated 659,000 Texas adults became uninsured between February and May as unemployment soared amid the COVID pandemic. Now, 3 in 10 Texas adults are uninsured, the worst rate in the nation. Added stressors, isolation, and lack of available help from friends and family due to social distancing leave many new parents on an island like never before, increasing risks of maternal mental health challenges among new mothers. While all women are at risk of maternal mental health challenges, research shows Black moms in Texas are more likely to experience them and less likely to receive treatment compared to other moms.

In the space below, we have outlined in greater detail a few strategies currently included in the draft Strategic Plan and which strategies should be added. Under those strategies, we have also summarized relevant findings from our survey and other research.

We look forward to working with HHSC, the Legislature, our partners, and other Texans to pursue all of the strategies explained below.

WE ARE GLAD TO SEE THE FOLLOWING GOALS AND STRATEGIES INCLUDED IN THE DRAFT STRATEGIC PLAN.

1. Increase awareness of maternal mental health challenges by training a range of professionals serving mothers and families. Specifically, under the draft Strategic Plan, DSHS Grand Rounds will host a series of continuing education presentations on maternal mental health challenges in 2021 with information on the signs, symptoms, diagnosis, and treatment options. And as DSHS implements the Maternal Care Coordination Pilot Program (under SB 748), it will include maternal mental health as a component of training for promotoras and community health workers.Through our statewide community engagement and online survey, we found a widely recognized need for increased training. Professionals working with families want to know the signs and symptoms of maternal health challenges, but also want to feel more comfortable screening for maternal mental health challenges, discussing results with their clients, and finding a reliable referral option. Eighty-nine percent of surveyed health professionals said they wanted to increase their ability to screen for maternal mental health challenges. According to the survey, the top-reported challenges in screening were: (1) not knowing how to screen, (2) lack of confidence that referral options are effective or accessible, and (3) not knowing how or where to refer.
2. Improve access to mental health care by adding mental health services and counseling as a covered benefit in the new postpartum package in Healthy Texas Women+. As we explained in this issue brief, when Medicaid for Pregnant Women cuts off 60 days after childbirth, a new mom can receive limited benefits in the Healthy Texas Women program, such as well-woman exams, family planning, and maternal depression screening in the primary care setting. Under SB 750, which passed the Legislature in 2019, HHSC is creating a postpartum care package within HTW. The draft Strategic Plan says “behavioral health services and counseling for women diagnosed with postpartum depression and other mood disorders” will be a covered benefit in the new postpartum package under “Healthy Texas Women+.” However, coverage is just the first step. Texas must work closely with provider groups and have a strong provider recruitment strategy so mental health professionals participate in the HTW+ network to deliver mental health services. Access to mental health care for new mothers, especially those who are uninsured or have a low income, is sorely needed. Nearly three-quarters of survey respondents in Texas said that the top barrier keeping mothers from treatment to address maternal mental health challenges is that treatment is not affordable. And when asked what steps would increase the number of moms receiving needed mental health treatment, the top recommendation was to add mental health therapy as a covered benefit in Healthy Texas Women.
3. Leverage informal and formal peer support services, including certified peer specialists, community health workers, and group prenatal care such as CenteringPregnancy. The type of support a mother needs to address her maternal mental health challenge may vary. HB 253 directs HHSC to develop strategies to increase “access to certified peer specialists who have received additional training related to postpartum depression.” Certified through the state, peer specialists use formal training and their lived experience of recovery from mental health or substance use conditions to help guide individuals through recovery from their condition(s). The draft Strategic Plan states that HHSC will review utilization of the new Medicaid peer support benefit and consider policy changes needed to increase access to the benefit. This is a good first step since there’s mounting evidence that the Medicaid peer benefit is underutilized, primarily because of low reimbursement rates. To truly leverage the expertise of peer support specialists, Texas should take further action: 
   • Increase Medicaid rates to cover the costs of peer specialists;
   • Encourage more health settings to add mental health peer specialists to their teams, especially settings where moms already go for their or their baby’s care, such as FQHCs, women’s health practices, and pediatric practices; and
   • Work with HHSC’s contractors offering training to peer specialists to develop continuing education focused on maternal mental health, ultimately enhancing the network of professionals with training to serve moms with maternal mental health challenges.
   Further, group prenatal care, such as CenteringPregnancy, offers a unique opportunity to discuss maternal mental health and treatment options in a trusted setting with other women and health providers. The draft Strategic Plan says HHSC will add information in the Obstetrics Handbook to increase awareness of the Medicaid group prenatal care benefit. This is a good first step since awareness of the Medicaid group care benefit is low. Yet, more is needed to address policy and operational challenges that prevent health centers from doing group prenatal care. One step is to update the Medicaid group prenatal care benefit so more provider types, including FQHCs and facility-based providers, can get reimbursed for the enhanced prenatal group rate.Our community engagement and online survey reinforce a need for both formal and informal peer supports to help new mothers. Over 44 percent of Texans surveyed recommend peer support specialists with lived experience and specialized training. When asked what steps would increase the number of moms receiving needed mental health treatment, one of the top recommendations was to “have more home visiting options, including nurses, mental health peer specialists, and postpartum doulas.”
4. Build off of Texas’s new Child Psychiatry Access Network (CPAN) as a foundation for establishing a perinatal psychiatric teleconsultation program. Implemented in 14 other states, Perinatal Psychiatric Access Programs help health professionals — including OB/GYNs and family practice physicians — feel more comfortable assessing and managing clients with maternal mental health challenges. Trained perinatal psychiatrists are available in real time, via teleconsultation to help answer provider questions about medications, complications, how to find a referral, etc. Some states used their child psychiatric access program as a launching pad to create perinatal psychiatric access programs. While the draft Strategic Plan does not say Texas will establish a psychiatric access program, it notes that Texas CPAN (created by SB 11 in the 86th Legislature) lays the foundation for future implementation of a Texas perinatal psychiatric access program. We urge HHSC to expand CPAN to include perinatal psychiatric access in future years.  

THE FOLLOWING STRATEGIES SHOULD BE ADDED TO THE DRAFT STRATEGIC PLAN:

1. Recommend that the Legislature extend Medicaid coverage for eligible mothers from 60 days to 12 months postpartum, as recommended by the Texas Maternal Mortality and Morbidity Review Committee, so mental health conditions can be treated before getting worse. Other than limited benefits in HTW, if a woman does not receive insurance through her job or spouse’s job, she likely becomes uninsured after Medicaid cuts off 60 days postpartum, especially if she has a low income. The sudden plunge into uninsured status when a new baby is just two months old can mean mothers discontinue visits to the doctor, mental health treatment, or medications they need. In 2019, the Texas House passed a bill to take this important step to extend Medicaid for a year after childbirth, HB 744, but it stalled in the Senate. As part of its response to the pandemic, Texas temporarily suspended the removal of mothers from health insurance two months after childbirth. Texas should make that change permanent.Our community engagement and online survey reinforce the dire need for affordable health insurance. Survey respondents said their top recommendation to increase early detection of maternal mental health challenges is to extend Medicaid for eligible moms from 60 days to one year postpartum. And our survey also showed that the inability to afford services because of lack of insurance was the greatest challenge women face in receiving treatment or support for maternal mental health challenges.
2. Incentivize and build capacity for maternal mental health screenings in more settings, including pediatric care and neonatal intensive care units (NICU). The draft Strategic Plan includes strategies to promote screenings among providers serving women. Yet, pediatric providers are a critical touchpoint for identifying maternal mental health challenges and working with new parents. Mothers of infants in the NICU are more likely to experience maternal mental health challenges, and research shows the benefits of screenings in NICUs as a critical part of every family assessment. Strategies for Texas should include:
   • Reimbursing pediatric providers for screening done at 1, 2, 4, and 6-month well-baby visits, as recommended by AAP (not just reimbursing once per year);
   • Giving clearer guidance to pediatric providers on screening tools, reimbursement and billing practices when additional time is needed to discuss results with a new mom, and how to develop referral plans with parents;
   • Promoting maternal mental health screenings in NICU settings by reimbursing facilities for screenings under a baby’s Medicaid and CHIP insurance;
   • Disseminating information to Texas hospitals to better equip NICU staff on how to do effective, safe referrals or “warm hand-offs” with moms.
3. Create a website and provider toolkits with referral network resources focused on maternal mental health. Professionals serving families want to know how and where to refer mothers for mental health care or follow-up services. Providers — ranging from women’s health and pediatric providers to community health workers — have difficulty locating a mental health provider in their area that offers mental health services. In fact, according to our survey, the top-reported challenges in screening were: (1) not knowing how to screen, (2) lack of confidence that referral options are effective or accessible, and (3) not knowing how or where to refer. A list of Local Mental Health Authorities or making updates to Medicaid health plan directories is not sufficient. Referral network resources must be available to families and providers and should include community-based mental health providers, peer supports, local and online support groups, and home visiting programs. In creating a website, Texas can leverage existing referral network resources, such as Postpartum Support International provider directory, PSI Support Coordinators who are available in each region of Texas, and Pregnancy and Postpartum Health Alliance directory (“Kristi’s list”), among others.
4. Promote telehealth flexibilities in future years, including ensuring Medicaid, CHIP, and TDI-regulated private insurance cover and reimburse for behavioral health services delivered via telehealth and telemedicine, including audio-only services. The coronavirus pandemic accelerated the need for – and implementation of – telehealth, especially in terms of behavioral health. Providers have seen significant drops in ‘no-show rates’ through the use of telehealth. Even before COVID-19, tele-mental health was a critical need for pregnant women and new mothers, especially those without transportation or child care options. Mental health delivered by telephone/audio-only will continue to be critical for moms in rural areas where high speed Internet for simultaneous visual-audio capabilities is not possible. In our survey, the top-reported barriers keeping moms from mental health care were: (1) treatment is not affordable (73%), (2) child care issues (61%), (3) stigma (43%), (4) unable to find a provider (36%), (5) transportation issues (34%), and (6) location (18%). Tele-mental health has the incredible opportunity to address several of these barriers to treatment.

---

* With support from the St. David’s Foundation, Texans Care for Children engaged communities, providers, families, and others across Texas in early 2020 to learn more about challenges and opportunities in maternal mental health. After convening an advisory group of more than 20 Texas maternal health and mental health experts, disseminating an online survey across Texas, and hosting an online listening session, we submitted recommendations to HHSC with action steps to improve screening and treatment of maternal mental health challenges. More information on the findings from our online survey is available here.