Strong Start for Mothers and Newborns Frequently Asked Questions

What is the Strong Start initiative?  

The Strong Start for Mothers and Newborns initiative is a U.S. Department of Health and Human Services (HHS) effort to improve birth outcomes for mothers and infants across the country, and in particular for those enrolled in Medicaid. The Strong Start initiative has two components:

1. A test of a nationwide public-private partnership and awareness campaign to spread the adoption of best practices that can reduce the rate of early elective deliveries prior to 39 weeks for all populations; and
2. An initiative to reduce the rate of preterm births for women who are at-risk of pre-term birth and covered by Medicaid through testing enhanced prenatal care models.

I.  Reducing the rate of early elective deliveries

How will this initiative seek to reduce early elective deliveries?  

To help achieve these aims, HHS will employ the following specific strategies:

1. Implementing a quality improvement platform through the Partnership for Patients to share best practices, provide technical assistance to hospitals in implementing and adapting the practices and reporting data.  
2. Creating support for change with a broad-based campaign to engage and educate providers, patients, and the public, working with organizations such as the March of Dimes and the American College of Obstetrics and Gynecology.  

Why is the Strong Start campaign utilizing the existing Partnership for Patients infrastructure to promote reductions in early elective deliveries?  

In addition to engaging expectant mothers and providers of obstetrical services, the Strong Start campaign also focuses on hospitals that provide obstetrical services. Improving maternal and fetal outcomes in hospitals is one of the areas the Partnership for Patients focuses on. Recently, the Partnership for Patients announced 26 Hospital Engagement Networks that will help identify solutions already working to improve birth outcomes at participating hospitals, and support their broad dissemination to other hospitals and health care providers.

Why are HHS and the Centers for Medicare & Medicaid Services working with the March of Dimes, the American College of Obstetrics and Gynecology, and other stakeholders on this campaign to promote reductions in early elective deliveries?  

The March of Dimes and the American College of Obstetrics and Gynecology both have extensive experience advocating for the benefits to mothers and infants of reductions in early elective deliveries prior to 39 weeks. Despite their best efforts, elective deliveries prior to 39 weeks continue to account for 10 to 15 percent of all deliveries. The Strong Start campaign is intended to build on and amplify existing efforts by the March of Dimes, the American College of Obstetrics and Gynecology and others advocacy organizations and professional association.

II. Reducing the rate of preterm births among Medicaid beneficiaries

Regarding the data on gestational age and birthweight from a baseline period that spans at least 2 years prior to the start of the intervention, who should be represented?

The expectation is that the baseline data will represent the applicant’s own Medicaid and/or CHIP population for a period that spans at least 2 years prior to the start of the intervention. If an organization does not have two years of their own baseline data, the applicant may propose an alternative baseline data source.

What should an applicant do if they do not have baseline data on pregnant women they have served who were enrolled in Medicaid and/ or CHIP?

Applicants will be expected to state their commitment and demonstrate their ability to collect individual level gestational age and birthweight data for the applicant’s own Medicaid and/or CHIP population for a baseline period that spans at least two years prior to the start of the intervention.

If an applicant does not have two years of their own baseline data on the population that they will serve under the Strong Start initiative because the applicant is a start up, has been in operation for less than two years, or already provides intervention services but to non-Medicaid and/or non-CHIP patients only, the applicant may propose an alternative data source that may include aggregate information. Under these circumstances, applicants must demonstrate that these alternative data represent a population that is socio-demographically similar to the population that will be served under Strong Start. The Center for Medicare and Medicaid Innovation (Innovation Center) expects applicants to propose the best quality baseline available to the applicant. Individual level data will be considered higher quality than aggregated data. Upon award, CMS or the CMS contractor will work with awardees to collect an appropriate baseline for the awardee’s specific circumstance.

Other than gestational age and birthweight, what additional data will Strong Start Awardees be expected to report?

In addition to collecting gestational age and birthweight for intervention infants and a baseline period, CMS expects all awardees to engage in continuous quality improvement and report on maternal and infant outcomes, utilizing and reporting both quality metrics and process of care metrics. CMS expects applicants to describe the metrics most appropriate to the applicant’s proposed enhanced prenatal care approach within the application. These metrics should take into account clinical guidelines and standards for obstetrical care, health outcomes, continuous provider quality improvement and the entity’s operations and utilization information specific to the proposed enhanced prenatal care approach.

CMS will ultimately require certain standard metrics to be reported by all awardees for monitoring and evaluation purposes. The format and details of this data reporting on standard metrics, as well as metrics specific to an awardee, will be determined at the start of the project in collaboration with CMS and the CMS evaluation contractor.

For planning purposes, applicants should budget for the administrative activities related to collecting and reporting the proposed monitoring, evaluation, and continuous quality improvement metrics. Content requirements of progress and quarterly reports will be outlined in the Standard and Special Terms and Conditions to be provided to candidate awardees at a later point in the process. Applicants will have an opportunity to discuss and negotiate these metrics with CMS prior to award.

Can funds for the Strong Start Cooperative Agreement be used to pay for home visiting?

The Strong Start initiative will pay for the following three (3) approaches to enhanced prenatal care: (1) Centering/Group Visits, (2) Birth Centers, (3) Maternity Care Homes. Strong Start funds may not be used to pay for home visiting as an approach to enhanced prenatal care. For the three enhanced prenatal care approaches described, the Innovation Center may consider home visits as an allowable cost only if visits to the home serve as an ancillary activity that enables the provision of one of the three Strong Start approved enhanced prenatal care approaches. Ultimately, it is the applicant’s responsibility to describe their enhanced prenatal care approach and demonstrate how their approach is consistent with the three enhanced prenatal care approaches being funded by Strong Start.

What happens to women who are midway through their pregnancy, and have not delivered, at the end of the third intervention year?

Awardees should report to CMS all women enrolled in a Strong Start Approach prior to the end of the third intervention year. During the fourth year, CMS or the CMS evaluation contractor will collect monitoring, evaluation, continuous quality improvement, and utilization data on all women enrolled prior to the end of the third intervention year. CMS expects that the proposed budget will include administrative and other costs for collecting and reporting the required data on the women enrolled in an enhanced prenatal care model prior to the end of the third intervention year.

Budget-related questions

What costs can be included in an applicant’s budget proposal?

Strong Start applications should include all direct and indirect costs for providing enhanced prenatal care services.  Applicants should justify the requested funding designated for each activity through 2016.

Allowable costs may include, but are not limited to,

• Providing enhanced prenatal care services in the three approved approaches;
• Collecting and reporting quality improvement, evaluation, and monitoring data on intervention services and intervention mothers and infants;
• Start up costs;
• Supplies;
• Education materials;
• Limited staff training; and
• Minor renovations to a facility or building.

While it is not possible to provide an exhaustive list of allowable expenses, a particular cost item will not automatically disqualify an application. If a particular cost item is deemed not unallowable during the review process, there will be an opportunity for budget discussions and negotiations prior to the final selection of awardees.

Can an applicant include incentive payments in a budget proposal?

Incentive payments to providers of enhanced prenatal care services are outside the scope of the Strong Start funding opportunity. Therefore, incentive payments for providers are not an allowable cost that may be reported in an applicant’s budget.

Incentive payments to individual volunteers or patients to motivate them to take advantage of federally supported health care or other services are allowable if they are within the scope of an approved project. The applicant must justify the use of funds and explain the role of such incentives in the overall proposal.

What is the expected cost per beneficiary?

The Strong Start FOA was developed to target a minimum of 90,000 Medicaid and/or CHIP beneficiaries, with $41.4 million made available for awardee costs to deliver enhanced prenatal care services. The Innovation Center arrived at this total as result of a literature review and consultations with experts in the three approved enhanced prenatal care approaches. This amounts to an estimated average of $460 per beneficiary, however, we stress that this is an average amount, not a limit for budget proposals. All applicants should provide sound justification for all budget items, especially when the proposed budget differs significantly from the estimates developed by the Innovation Center for this funding opportunity.