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Take Charge

Process Evaluation

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

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.
• 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.

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Modified: Thursday November 17 2005

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