Illinois Family Planning Provider Needs Assessment - Ci3

Illinois Family Planning Provider Needs Assessment

Needs Assessment Outline • Introduction • Objectives • Phase I: Key Informant Interviews

• Methods • Findings + Novel Tech Approaches to Care

• Phase II: Statewide Survey • Methods • Findings

• Summary and Recommendations

Person Centered Contraceptive Care Framework

Person-Centered Reproductive Health Program

Provider Needs Assessment Overview • What is the landscape of contraceptive care in Illinois?

• How can Illinois improve health care provider capacity and increase access to comprehensive, high-quality contraceptive care?

• • • •

Contraceptive method availability LARC comfort and knowledge Comfort serving adolescents and LGBTQ+ patients Training needs (self-reported and based on knowledge, attitudes and practices)

• Two Phase Process

• Phase I: key informant interviews with Illinois reproductive health leaders • Phase II: statewide survey of family planning providers

Phase I: Key Informant Interviews

Key Informant Interview Methods • 25 phone interviews with reproductive health leaders across the state • Questions focused on practical needs of providers and priority areas to improve capacity and expand contraceptive access • Sample included:

• 11 OBGYNs, 3 family medicine physicians, 6 nurses/midwives, 6 administrators or other relevant stakeholders • 10 community health centers, 8 health systems, 7 public health agencies, 1 other • 10 Title X clinics • 14 Cook County, 6 statewide, 8 outside Cook County

Key Informant Perspectives • Training opportunities for contraceptive counseling and provision, including • • • • •

hands-on experience implicit bias training shared-decision making models mentorship financial support for clinics and providers

• Improved Medicaid reimbursement, expanded Title X funding, billing resources • Greater engagement with primary care providers, rural providers and clinics, and community stakeholders

Key Informant Perspectives—Training “Providers may not be offering all the methods because maybe they themselves don't have the skill set or the healthcare entity they work with doesn't support them to do it. Of course time is always the issue when we talk about how do we do full contraceptive counseling in a 15 minute slot. I think there's creative ways around that. I think most providers would say it's hard to do full education.”

“I think you're gonna need to find a way where people need the training, say it's the rural practitioners, need to be able to go somewhere and have high volume training for a certain period of time or we send someone to them, pay a provider to go there and be there onsite and do X number of procedures supervised. That's how we're gonna get people trained adequately.”

Key Informant Perspectives—Finances “Barriers to billing. A lot of times, what I have learned in my many years of working with providers and billing, it is more of a perception that there's problems. Then when we do a deep dive, look at this patient, look at the code, look at the reimbursement, everything went fine. So much of it seems daunting. I don't know. I don't think it's billed correctly because they're just confused.”

“Title X is truly the perfect model from a financial standpoint and from a confidentiality standpoint. If we could replicate that or create that somehow through other funding, that would be fantastic or Medicaid could make their services more confidential ... They already are fairly confidential, which is nice, but maybe even if there's a way for those that aren't on Medicaid to get that same benefit, that's where Title X really comes in. Or expanding that Title X model somehow.”

Key Informant Perspectives—Centering Patients “It just has to be your clinic's standing practice that you always see every patient alone. And our age is 12. We don't always do it for a completely acute visit like for an earache or pneumonia.

But if it is an annual exam visit or a wellchild visit after age 12, they are absolutely always seen alone during that visit. Because [if] it's not standardized and universal, then you're gonna get push back and it's not gonna happen.”

“From the standpoint of their economic status, racial status, I think patients may sometimes feel like that they historically had potentially negative interactions with their healthcare providers or if there's biases from their healthcare providers, and [so it’s important to make] sure we have as open and honest conversations as possible.”

Special Focus on Novel Tech Approaches to Care

Potential for Novel Tech Approaches to Care • Tailored, theory-based, computerized interventions have been used to support a number of preventive health behaviors.

• Providers observed:

• Tech approaches must be adequately reimbursed and valued • Consider quality & comprehensiveness of care, scope of practice and liability • Consider appropriateness of setting (e.g. apps could be used for education ahead of an appointment or to allow pharmacists to conduct counseling and dispense contraception)

Potential for Novel Tech Approaches to Care • “Someone may think [telemedicine] is a great idea but it takes a lot of work. Also, reimbursement for non-in-person visits, virtually nonexistent.

So it has to be basically telemedicine or apps medicine, it has to be a selfpay service because currently insurance is also very much caught up in brick and mortar. To be able to implement an app, which we have just recently, and as often is the case because [our organization] is a national organization, and has more resources, we have a program for it but if you're just a private group or even at [a university], where you don't necessarily have an entire tech team or multiple examples of people in your own situation doing it, I think it's pretty hard.�

Phase II: Family Planning Provider Survey

Survey Sample • Between October 2019 and March 2020, Ci3 conducted a mailed a survey to Illinois clinician specialties who provide the bulk of family planning services:

• Obstetrician/gynecologists (OB/GYNs) • Pediatricians • Family and internal medicine specialists • Federally qualified health centers • School-based health centers • Clinics who received Title X funding prior to 2019

*Scholle SH et al. Sources of Family Planning Services. 2002.

National Sources of Family Planning Services*

Public Clinics 25% Obstetrics / Gynecology 50%

Internal Medicine 8%

Family Medicine 16%

Provider Eligibility • Sampled physicians from American Medical Association Physician Masterfile and one provider from each clinic • Eligible providers offer family planning services to women of reproductive age at least twice per week • Family planning service defined as related to postponing or preventing conception •

Medical examination, contraceptive counseling, method prescription, supply visit

• Survey topics included

• provider & patient demographics • practice characteristics • contraceptive knowledge, attitudes, and practices

Survey Implementation and Sample Initial Survey Mailing October 2019 n = 1,678 • • • •

Reminder postcard to non-responders (2 weeks) Second survey mailing to non-responders (2 weeks) Phone calls to non-responders Internet searches to verify eligibility Undeliverable n = 102 Ineligible n = 161

Final n = 251 / 1,678 Response Rate = 17.7%

Weighted n = 2,030

Geographic Distribution of Providers Sampled Providers

Enrolled Providers

Our sample reflects the distribution of providers who offer the bulk of family planning services Illinois Sample Clinical Specialty

Mid-level providers 17%

Pediatrics 16%

Family Medicine 30%

Illinois Sample Provider Role

Ob/Gyn 54%

*We categorized mid-level providers according to their specialty

Physicians 83%

Sampled Provider Characteristics Characteristic

%

Race/Ethnicity Non-Hispanic White Non-Hispanic Black Asian Hispanic Other

70% 10% 11% 6% 3%

Gender Cisgender woman Cisgender man Transgender

72% 27% 1%

Years Since Completion of Medical Training < 4 years 5-14 years 15-24 years â&#x2030;Ľ 25 years

9% 26% 32% 32%

Practice Characteristics for Sampled Providers Practice Characteristics

%

Urbanicity Urban Suburban Rural

40% 45% 15%

Proportion of Patients Eligible for Family Planning Services 0-24% of patients 25-49% of patients 50-74% of patients â&#x2030;Ľ75% of patients

23% 18% 23% 36%

Setting Private Public

65% 35%

Private=solo/group practice, university or hospital setting P u b l i c = c o m m u n i t y h e a l t h c e n t e r, f a m i l y p l a n n i n g c l i n i c , h e a l t h d e p a r t m e n t , s c h o o l b a s e d h e a l t h c e n t e r s

Contraceptive Method Availability

Importance of On Site Contraceptive Method Availability â&#x20AC;˘ Same-day contraceptive provision has been shown to increase contraceptive method uptake and long-term use. â&#x20AC;˘ The on site availability of all contraceptive methods supports sameday provision through patient access to quick start etc.

Most providers offer at least one contraceptive method on site 100% 90%

94%

94%

89%

82%

80%

72%

70%

85%

76%

75%

63%

60% 50% 40% 30% 20% 10% 0%

Total

Ob/Gyn

Family Pediatrics Medicine

Private

Public

On-site availability of any method

Urban

Rural

Suburban

Depo and LARC methods were most commonly available on site 100% 90% 80% 70% 60%

61%

60%

58%

54%

50% 40%

31%

30%

26%

22% 16%

20%

14%

10%

9%

0%

DMPA

Lng-IUD

Implant

Cu-IUD

Male Condoms

Pills

Ring

On-site availability of any method

Patch

Female Condom

Diaphragm

Nearly half of all providers noted barriers to on site availability of Depo, IUDs and contraceptive implants • Barriers to on site availability included: • • • • •

cost/reimbursement clinic flow/staffing provider training confidence interest

• A number of respondents noted religious restrictions as barriers to providing care

Provider-related barriers to on site availability of IUDs and Implants differed by specialty 100% 90%

83%

80% 70% 60%

63% 53%

50% 40%

34%

30% 20% 10%

11%

8%

0%

Provider-related IUD barriers Family medicine

Provider-related implant barriers Pediatrics

OBGYN

Provider-related barriers to on-site availability of IUDs and Implants differed by specialty 100% 90% 80% 70% 60% 50% 40% 30%

More than one83%quarter of respondents cited cost and training as barriers to offering depo, IUDs and the implant on site.

63% â&#x20AC;˘ Cost often cited by OBGYN providers 53% â&#x20AC;˘ Training often cited by Family Medicine and Pediatric 34% providers

20% 10%

11%

8%

0%

Provider-related IUD barriers Family medicine

Provider-related implant barriers Pediatrics

OBGYN

Summary: Contraceptive Method Availability • Most Illinois family planning providers offer at least one contraceptive method on site.

• Barriers to availability include cost and provider training

• cost was a more common concern among OBGYNs • training was a higher concern among family medicine and pediatric providers.

LARC Comfort + Training Needs

Importance of provider comfort with LARC â&#x20AC;˘ A person-centered contraceptive care framework includes access to the full range of contraceptive methods, including long-acting reversible contraception (LARC). â&#x20AC;˘ While provider training and comfort providing LARC has increased, less is known about provider subgroups.

Most providers reported comfort with IUD provision, with differences across specialty 99%

100% 90% 80%

75%

74%

79% 72% 66%

70% 60%

71%

54%

50% 40% 30% 20%

12%

10% 0%

Total

ObGyn

Family Medicine

Pediatrics

Private

Comfort with IUD provision

Public

Urban

Rural

Suburban

Provider comfort was similar for Implants 100%

89%

90% 80% 70%

Provider comfort was similar for Implants.

74%

70%

68%

70%

73% 67%

60%

60% 50% 40% 30% 20%

16%

10% 0%

Total

ObGyn

Family Medicine

Pediatrics

Private

Public

On-site availability of any method

Urban

Rural

Suburban

Nearly half of providers are interested in LARC training, but interest didnâ&#x20AC;&#x2122;t always correspond with comfort.

100% 90% 80% 70%

70% 60%

60% 50%

48%

60% 47%

44%

40%

40%

38%

36%

30% 20% 10% 0% Total

ObGyn

Family Pediatrics Medicine

Public

Interest in LARC training

Private

Urban

Rural

Suburban

Nearly half of providers are interested in LARC training, but interest didnâ&#x20AC;&#x2122;t always correspond with comfort.

100% 90% 80% 70%

Providers were most interested in online resources, 70% interactive, and in-person trainings.

60%

60% 50%

48%

47%

44%

40%

40%

60%

38%

36%

30% 20% 10% 0% Total

ObGyn

Family Pediatrics Medicine

Public

Private

Urban

Rural

Suburban

Summary: LARC Provision â&#x20AC;˘ Most providers were comfortable providing LARC methods. â&#x20AC;˘ While there was demonstrated interest in training, interest was lower than expected given the high percentage of providers who cited training as a barrier to providing LARC methods â&#x20AC;˘ Providers were most interested in online resources, interactive and in-person training.

Serving Adolescent Patients

Adolescent family planning concerns and needs • Adolescents experience unique barriers to the receipt of personcentered healthcare, including: • confidentiality concerns • limited time alone with their providers • provider misperceptions about the safety and appropriateness of LARC methods • knowledge consent laws

Proportion of Patient Population <20 Years of Age Sample description

<25%

25-49%

>50%

Specialty Family medicine OBGYN Pediatricians

80% 10% 1%

10% 15% 6%

10% 2% 92%

Setting Public Private

55% 76%

24% 6%

21% 18%

62% 70% 73%

16% 22% 6%

22% 22% 21%

Urbanicity Urban Rural Suburban

P r i va te = s o l o /g ro u p p ra c t i c e , u n i ve rs i t y o r h o s p i ta l s e tt i n g P u b l i c = c o m m u n i t y h e a l t h c e nte r, fa m i l y p l a n n i n g c l i n i c , h e a l t h d e p a r t m e nt , s c h o o l b a s e d h e a l t h c e nte rs

Nearly all providers are comfortable providing contraceptive care to adolescent patients 100%

96%

97%

98%

96%

99%

97%

98%

95%

Private

Public

Urban

Rural

Suburban

89%

90% 80% 70% 60% 50% 40% 30% 20% 10% 0%

Total

ObGyn

Family Medicine

Pediatrics

Comfort providing contraceptive care to adolescents

Knowledge of parental consent laws was high for all groups.

97%

100% 90%

89%

93%

87%

91%

87%

91%

95%

94% 87%

84%

85%

Rural

Suburban

80% 70% 60% 50% 40% 30% 20% 10% 0%

Total

<25%

25-49%

>50%

Family medicine

OBGYN

Pediatrics

Public

Knowledge of parental consent laws

Private

Urban

Provider comfort asking for time alone with adolescent patients was lower 100%

88%

90% 80%

77%

82%

82%

88%

84% 76%

74%

70%

79%

78% 72%

64%

60% 50% 40% 30% 20% 10% 0% Total

<25%

25-49%

>50%

Family medicine

OBGYN Pediatrics

Public

Comfort with asking for time alone with patients

Private

Urban

Rural

Suburban

Only half of providers are comfortable providing LARC to adolescents without parental consent 100% 90% 80% 70% 60%

69%

64% 53%

56%

58%

56%

56% 50%

50%

44%

40%

46%

42% 33%

30% 20% 10% 0% Total

<25%

25-49%

>50%

Family OBGYN Pediatrics medicine

Public

Private

Comfort providing adolescents LARC without parental consent

Urban

Rural

Suburban

Summary: Adolescent Care • Knowledge of and comfort with best practices for adolescent care are generally high • OBGYNs and urban providers exhibit the most knowledge • OGBYNs and rural providers exhibit the most comfort

• However, training opportunities remain

• Asking for time alone with patients for all providers, especially family medicine and urban providers • Comfort around LARC provision without parental consent for all providers

Serving LGBTQ Patients

Importance of LGBTQ+ Friendly Practices â&#x20AC;˘ Lesbian, Gay, Bisexual, Transgender, and Queer (LGBTQ) individuals make up a growing proportion of family planning patients. â&#x20AC;˘ Scant data exist on provider comfort and practices serving LGBTQ populations.

Providers reported relatively high levels of comfort serving LGBTQ+ patients 100% 90% 80%

90%

85% 77%

75%

70%

70%

79%

77%

72%

63%

60% 50% 40% 30% 20% 10% 0%

Total

ObGyn

Family Medicine

Pediatrics

Public

Private

Urban

Rural

Suburban

Few providers include sexual orientation and gender identity in patient charts 100% 90% 80% 70% 60% 50%

44%

44%

48%

39%

36%

40%

52%

51% 44%

40%

30% 20% 10% 0% Total

Family medicine

OBGYN

Pediatrics

Public

Private

Urban

Rural

Suburban

Providers report moderate comfort providing care to transgender patients, with room for subgroups.

100%

90%

86%

85% 79%

80%

70%

68%

70%

70% 63%

58%

60%

50%

39%

40%

30%

20%

10%

0%

Total

Family medicine

OBGYN

Pediatrics

Public

Private

Provider comfort serving transgender patients

Urban

Rural

Suburban

Summary: LGBTQ+ Services • All provider subgroups reported comfort serving LGBTQ populations • With the exception of family medicine and rural providers, few incorporate LGBTQ+ behaviors into their practices • Comfort serving transgender patients differed across urbanicity and public/private status • Lowest comfort among private providers

Training Needs

Providers expressed interest in a variety of topics mentioned in prior sections.

100% 90% 80%

79%

78%

76%

74%

74%

74%

70%

56%

60%

48%

50% 40% 30% 20% 10% 0%

Patientcentered counseling

LGBTQ

Disabilities

Adolescents

Traumainformed care

Implicit bias training

Medication abortion

LARC

Providers expressed interest in topics such as patientcentered counseling and trauma-informed care 100% 90% 80% 70% 60%

Urban and rural providers, and providers in private settings expressed greatest interest in training across topics 79%

78%

76%

74%

74%

74%

56%

48%

50% 40% 30% 20% 10% 0%

Patientcentered counseling

LGBTQ

Disabilities

Adolescents

Traumainformed care

Implicit bias training

Medication abortion

LARC

Summary and Recommendations

Summary • Overall, providers in Illinois are doing well with respect to:

• availability of at least one contraceptive method on site • comfort with LARC methods among OBGYNs • comfort with serving adolescent patients and knowledge of laws regarding consent and confidentiality • willingness to participate in trainings to support their provision of family planning services

• There’s room for improvement around: • • • • •

Availability of a range of contraceptive methods on-site LARC training for family medicine physicians General knowledge and provision of LARC for adolescents Implementing time alone for adolescent patients Comfort with and inclusive practices surrounding LGBTQ patients

Recommendations • Contraceptive Availability

• Efforts to improve education around reimbursement strategies, increased reimbursement rates and reimbursement for time with patients, and provider training may increase on-site method availability.

• Many key informants cited the value of the Title X program both for offering affordable methods but also training and support for clinics

• LARC Provision

• Targeted training and engagement efforts should focus on family medicine providers, publicly-funded, and urban providers who reported lower knowledge and higher interest in training.

Recommendations • Adolescent Care

• Training on adolescent-specific laws may most benefit pediatrician, family medicine and suburban providers who are uncomfortable offering LARC to adolescents • Training would also benefit family medicine providers who are uncomfortable asking for time alone with adolescent patients.

• LGBTQ+ Services • Additional training may be needed to increase provider comfort and use of inclusive practices when serving LGBTQ populations, specifically among pediatricians and clinicians in private practice.

Recommendations • General provider training interests

• Increased training on patient-centered contraceptive counseling for all family planning providers • Strong provider interest in trainings on: • Disabilities • Trauma informed care • Implicit bias

• Training incentives needed, with emphasis on CME credits

@UChicagoCi3

@UChicagoCi3

Ci3 at The University of Chicago