Existing law declares the intent of the Legislature to maintain, to the extent resources are available, a permanent statewide community-based comprehensive perinatal system to provide care and services to low-income pregnant women and their infants who are considered underserved in terms of comprehensive perinatal care. Existing law requires the State Department of Public Health Health, which is within the California Health and Human Services Agency, to develop and maintain a statewide community-based comprehensive perinatal services program to, among other program objectives, ensure the appropriate level of maternal, newborn, and pediatric care services necessary to provide the healthiest outcome for mother and infant. Existing law authorizes the department to maintain a mental health service that shall advise and assist local departments of health and education in the establishment of mental health services.

Existing law declares the intent of the Legislature to maintain, to the extent resources are available, a permanent statewide community-based comprehensive perinatal system to provide care and services to low-income pregnant women and their infants who are considered underserved in terms of comprehensive perinatal care. Existing law requires the State Department of Public Health to develop and maintain a statewide community-based comprehensive perinatal services program to, among other program objectives, ensure the appropriate level of maternal, newborn, and pediatric care services necessary to provide the healthiest outcome for mother and infant.

This bill would declare the intent of the Legislature to enact legislation to address the shortage of treatment options for women suffering from maternal mental health disorders, including postpartum depression and anxiety disorders, and to encourage the implementation of a single county telepsychiatry referral pilot program that would help build the capacity of health providers serving pregnant and postpartum women up to one year after delivery to effectively prevent, identify, and manage depression and other mental health conditions.

Date of Hearing: April 18, 2017

ASSEMBLY COMMITTEE ON HEALTH

Jim Wood, Chair

ABPCA Bill Id:AB 244

Author:(Cervantes) – As Amended Ver:March 21, 2017

SUBJECT: Maternal mental health.

SUMMARY: Creates a pilot program in counties that elect to participate, including Riverside County, to increase the capacity of health providers that serve pregnant and postpartum women to prevent, identify, and manage postpartum depression and other mental health conditions. Specifically, this bill:

1. Allows the program to be coordinated by the California Task Force on the Status of Maternal Mental Health (MMH taskforce); requires it to be privately funded; and, authorizes it to include a provider-to-provider or patient-to-provider consultation program and utilize telehealth or e-consult technologies.
2. Authorizes the program to include the following elements: a) Training and toolkits on screening, assessment, and the range of treatment options; b) Coordination of care to link women with individual services in their communities; and, c) Access to perinatal psychiatric consultation.
3. Requires, within six months after the results of the pilot program are reported, the California Health and Human Services Agency, in consultation with the MMH taskforce and state entities, as necessary, to submit a report to the Legislature which does all of the following:
   1. Documents the impact of the pilot program on increasing the number of women who were screened, assessed, and treated for maternal mental health (MMH) disorders;
   2. Identify methods to expand the pilot program to additional counties or statewide; and,
   3. Identify funding opportunities to support the expansion of the pilot program including federal funding, state funding, and surcharges.

EXISTING LAW:

1. Establishes within the Department of Public Health, the Maternal, Child and Adolescent Health Division to work with statewide and local partners to develop systems that protect and improve the health of California's reproductive-aged and pregnant women, infants, children, adolescents, and their families.
2. Defines telehealth as the mode of delivering health care services and public health via information and communication technologies to facilitate the diagnosis, consultation, treatment, education, care management, and self-management of a patient's health care while the patient is at the originating site and the health care provider is at a distant site. Telehealth facilitates patient self-management and caregiver support for patients and includes synchronous interactions and asynchronous store and forward transfers.
3. Requires prior to the delivery of telehealth, the health care provider initiating the use of telehealth to inform the patient about the use of telehealth and obtain verbal or written consent from the patient for the use of telehealth as an acceptable mode of delivering health care services and public health. Requires the consent to be documented in the patient’s medical record, and states that all laws regarding the confidentiality of health care information and a patient's rights to his or her medical information apply to telehealth interactions.
   

FISCAL EFFECT: This bill has not yet been analyzed by a fiscal committee.

COMMENTS:

1. PURPOSE OF THIS BILL. According to the author, this bill will address the key issues of improving access to treatment for MMH. The author states that creating the pilot program, and allowing a provider-to-provider psychiatry teleconsult, virtual mentoring services, and a provider training capacity program in Riverside County, among other counties will help build the capacity of health providers serving pregnant and postpartum women up to one year after delivery. The author notes that MMH issues, if untreated, have serious health, societal, and economic detrimental effects that causes adverse birth outcomes, negative bonding between infants and mothers, impacts an infant’s cognitive and behavioral development, and affects family stability. The author concludes that one in five women in California experience depressive symptoms during or after pregnancy, and the highest prevalence of these symptoms were found among Black and Hispanic women, women of lower educational attainment, women utilizing Medi-Cal, and women in poverty.
2. BACKGROUND. The California MMH Collaborative was established in 2011 as a result of the passage of ACR 105 (Nava), Resolution Chapter 9, Statutes of 2010, which declared May as Perinatal Depression Awareness month in California. ACR 105 also urged private and public stakeholders to form a volunteer task force to address opportunities for increasing awareness of and screening for MMH disorders. The stated mission of the California MMH Collaborative is to bring stakeholders together to exchange ideas, identify barriers and opportunities and form collaborative relationships to increase and improve MMH awareness, diagnosis and treatment in California and beyond. In 2013 the organization launched with its partner, Postpartum Support International, a Web-based training in MMH to address the shortage of trained providers, and its national campaign, called the 2020 Mom Project, which sets forth tactical steps that hospitals, insurers and providers can take to improve awareness and outcomes.
   
   ACR 148 (Lowenthal) Resolution Chapter 96, Statutes of 2014, sponsored by the California Legislative Women's Caucus, requested the formation of a MMH task force to study, review, and identify: a) current barriers to screening and diagnosis; b) current treatment options for both those who are privately insured and those who receive care through the public health system; and, c) evidence based data on emerging treatment options that are scalable in public and private health settings. The MMH task force Implementation Steering Committee was asked to identify the needs of both providers and patients in order to improve diagnosis and treatment. On March 1, 2017, the MMH task force released a white paper that identified gaps in the current effort to identify and treat MMH disorders and provides recommendations that address physician capacity, treatment shortages, screening and referral, an awareness campaign, and action steps for stakeholder groups. This bill addresses the treatment shortage recommendation, specifically the recommendation that California adopt a statewide provider-to-provider expert psychiatric access program by 2021.
   
   1. MMH. According to the March 2017 report from the MMH taskforce, MMH disorders, including depression, anxiety, and the much more rare but serious, postpartum psychosis, affect one in five women (20%), during pregnancy or the first year following childbirth. Among those living in poverty, up to 50% may be affected. Maternal depression is the most common complication of pregnancy in the United States, surpassing gestational diabetes and preeclampsia combined. Maternal depression presents a significant early risk to proper child development, the mother-infant bond, and the family. Maternal depression screening and treatment is an important tool to protect the child from the potential adverse physical and developmental effects of maternal depression. According to the American Academy of Pediatrics (AAP), screening mothers for maternal depression is a best practice for primary care pediatricians and can be integrated into the well-child care schedule, as well as included in the prenatal visit.
      
   2. Clinical recommendations for screening. In May of 2015, the American Congress of Obstetricians and Gynecologists published Committee Opinion Number 630, recommending that clinicians screen patients at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool. In January 2016, the U.S. Preventive Services Task Force (USPSTF) released a revised recommendation for depression screening of all adults, including pregnant and postpartum women. The USPSTF noted that screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow up. In February 2016, the National Council on Patient Safety in Women's Health Care issued the Maternal Mental Health Bundle, providing high-level direction to health care providers in office and hospital settings on how to implement maternal mental health screening and treatment, and the most recent AAP Bright Futures Guidelines recommends postpartum depression screening from the one-month through the six-month well-child visit.
      
   3. Telehealth. Access to providers and health care services is an ongoing concern among stakeholders and policymakers throughout the state. In an effort to ensure quality services are accessible to patients, health reform policies have focused on innovative methods, such as telehealth, to deliver care. Telehealth uses telecommunication tools and technologies to connect providers to patients who may otherwise have limited access to care. In doing so, it provides a means of delivering care and services, including diagnosis, treatment, and patient education. The California HealthCare Foundation reports that health plans, providers, and information technology vendors are currently using telehealth applications to increase quality of care, reduce costs, and increase access for the underserved, and that studies have demonstrated telehealth services have improved outcomes and continuity of care for patients, particularly in rural settings. AB 415 (Logue), Chapter 547, Statutes of 2011, established the Telehealth Advancement Act to revise and update existing law to facilitate the advancement of telehealth as a service delivery mode in managed care and the Medi-Cal program.
      
   4. Other states. In 2015, Minnesota's Department of Human Services received an Adult Medicaid Quality grant from the Centers for Medicare and Medicaid Services which facilitated a quality improvement program (QIP) on postpartum depression screening. Minnesota focused on addressing screening implementation issues during well-child checks because more mothers attend a two-month well-child visit (92% in Minnesota's Medicaid population in 2012) compared to postpartum visits. As of December 2015, providers participating in the project had completed 2,885 screens, with 203 out of the 341 positive screens referred. Even though the grant has concluded, Minnesota continues to run the postpartum depression QIP.
      
      Massachusetts Child Psychiatry Access Program (MCPAP) for Moms incorporates care coordination to link women to services in their community and telephonic access to perinatal psychiatric consultation. MCPAP for Moms successfully increased provider capacity to address MMH disorders and served more than 1,100 women in its' first 18 months. The pilot program proposed by this bill would incorporate elements from MCPAP for Moms.
3. SUPPORT. The March of Dimes (MoD) in California and 2020 Mom are the co-sponsors of this bill and note that DPH's Maternal and Infant Health Assessment (MIHA) documents the prevalence of postpartum depression and other MMH disorders. MoD notes that while these conditions are common, only about 15% of women with postpartum depression receive treatment, even though about 90% can be successfully treated. MoD concludes that more work is needed to ensure that women are successfully screened, referred and treated for MMH disorders. The California Council of Community Behavioral Health Agencies and the California ACCESS Coalition state that current data shows that nationally women in their child-bearing years are much more likely to suffer from mental health disorders, particularly depression, than other populations segments. Both organizations note the need to direct more resources toward treating this especially vulnerable population.
4. SUGGESTED AMENDMENT. As currently drafted this bill requires a report to the Legislature within six months after the results of the pilot program are reported, however there is no specified end date for the pilot program. The Committee may wish to sunset the pilot program in three years to evaluate its effectiveness.

REGISTERED SUPPORT / OPPOSITION:

Support

March of Dimes, California (cosponsor)
2020 Mom (cosponsor)
California Access Coalition
California Council of Community Behavioral Health Agencies
Los Angeles Trust for Children’s Health

National Association of Social Workers
Physicians for Social Responsibility

Opposition

None on file.

Analysis Prepared by: Lara Flynn / HEALTH / (916) 319-2097