For 2022, priorities for women’s health were to reduce and eliminate barriers to ensure equitable and optimal health for women and reduce disparities in infant and maternal morbidity and mortality. All activities under each priority have been categorized using Levels of Public Participation (Inform, Consult, Involve, Collaborate, Empower) and can be found in Appendix H. Levels of Public Participation under the Women/Maternal Health section. The Women/Maternal health population domain continued their work in Health Equity and Family Engagement. The Health Equity activities are identified in italics throughout this section of the report and information about Family Engagement can be found in the Family Partnership narrative.

The 2020 ADHS Maternal Mortalities and Severe Maternal Morbidity Arizona report identified that each year in Arizona, approximately 70 women die within 365 days of pregnancy, of which 15-20 deaths are pregnancy-related cases (i.e., would not have died if they had not been pregnant). Additionally, approximately 900 women experience severe maternal morbidity (SMM) during labor and delivery in an Arizona hospital (i.e., a severe and unexpected complication). NPM 1: Well-Woman Visit was selected to address maternal health outcomes for all women of reproductive age in the state, improving the provision and quality of family planning services. ADHS supported the 2022 Title V Family Planning Program, funding 9 of the 15 Arizona county health departments through the MCH HAF IGA and 1 federally qualified health center, Valleywise Health, in Maricopa County. Funding is used to provide family planning and reproductive health services to improve the health of women before, during, and after pregnancy; to promote safe sexual behavior, decrease the teen pregnancy rate, and ensure access to quality health care, particularly for low-income or uninsured individuals living in rural and other underserved areas.

During 2022, the family planning programs provided 3,129 visits compared to 3,030 in 2021, serving 1,765 unique clients compared to 1,789 unique clients in 2021. Of the total unique clients, 1,127 were conducted in rural communities, with 638 in the one urban County of Maricopa. Due to ongoing pandemic disruptions, the unique clients served in 2022 were slightly lower than the previous year. A majority of the clinics reported that their nursing staff were pulled from normal clinic activities to actively participate in COVID-19 relief efforts, including vaccine administration and testing. Staff shortages were also a common challenge, with staff being out sick due to COVID-19 or clinical staff leaving for employment elsewhere. As a result, clinics were forced to reduce the number of available appointments. Once clinics were able to reopen, COVID-19 precautions caused longer appointment visits and turnaround times, limiting the number of participants served; appointment no-shows, patient recruitment, and retention were additional challenges faced. All clinics who identified staffing as an issue stated that they had plans to overcome these challenges by posting for and hiring additional staff to fill vacancies.

Arizona’s Title V Program continued to work on reducing severe maternal morbidity (SMM) and maternal mortality (MM) throughout the year through a multi-pronged approach that included coordination between the federally funded Maternal Health Innovation Program (MHIP), Maternal Mortality Review Program (MMRP), and Alliance for Innovation on Maternal Health (AIM) and through the state lottery and federally-funded home visiting programs - Health Start and Maternal Infant Early Childhood Home Visiting (MIECHV). Maternal Mortality continues to be an area of focus for the Governor’s Goal Council, and ADHS’ maternal health work is structured around the five goals outlined in the plan: 1) Improving Knowledge and Education for Pregnant and Postpartum Women; 2) Improving Access to Care; 3) Supporting Workforce & Workforce Capacity; 4) Improving Surveillance, and 5) Supporting Systems of Care.

The Maternal Mortality Review Program (MMRP) published a new report and infographic on maternal mental health and substance use-related deaths in Arizona that occurred between 2016 and 2018. The report found that 203 persons died within 365 days of pregnancy, and almost half (48%) of these deaths were related to a maternal mental health condition or substance use disorder. Nearly two-thirds (59.6%) of these deaths occurred between 42 and 365 days postpartum. The report identified disparities, where Native American/Indigenous women accounted for 11.1% of maternal deaths, despite Native Americans representing only 5.9% of the births in the state. The Maternal Mortality Review Committee determined 98% of these pregnancy-associated deaths were preventable.

This data helped to develop the theme and objectives for the 2022 Maternal and Infant Mortality Summit. The theme was See Me Differently: How Mental Health and Substance Use Impact Maternal and Infant Mortality. The objectives were to describe the impacts of mental health and substance use on maternal and infant health outcomes; discuss community, hospital, and post-hospital-based approaches to support women and families impacted by trauma; share innovations in community-based, social, and cultural supports for families; and participate in facilitated training to reduce health-related bias to deliver the best care for pregnant people, newborns, and their families. The audience primarily consisted of working professionals in the field of nursing (35%), social work (15%), and public health (15%).

The MMRP partnered with the University of Arizona’s Mel and Enid Zuckerman College of Public Health to conduct a Title V Supplementary Maternal Health Assessment as an extension of the 2020 Title V Needs Assessment to further explore the maternity care experiences of women residing in rural areas and African American women. The findings of the supplementary analysis highlight mothers’ perceptions of perinatal care, information services, and specialist care. It provides qualitative data from participants on the facilitators and barriers of mental health care, oral health care, COVID-19, telemedicine for perinatal care, health insurance, employment, transportation, and childcare. It summarizes the services, resources, and policies needed to improve maternal health outcomes in Arizona. Some things learned from this analysis included:

• Participants residing in rural areas have limited options for maternity care providers and would often have to travel 2-3 hours for specialist services.
• Participants who were African American avoided some services due to experience of or anticipation of disrespectful care.
• Several participants experienced postpartum depression but did not access services or receive a referral for mental health care.
• Some participants reported that lack of coverage was a reason for not accessing services such as specialist perinatal care, mental health care, oral health, doula services, and postpartum care.

The Maternal Health Innovation Program’s (MHIP) initiatives and priorities are informed by the data published by the MMRP and in alignment with Title V women and maternal health priorities. The MHIP has successfully funded and implemented programming, and through the branches of the MHIP-led Maternal Health Task Force, partners have made advancements in advocacy and policy.

Throughout 2022, collaboration, partnerships, and leadership created an impressive synergy working towards improving outcomes of maternal mental health and substance use disorders in Arizona. As reported in the MMRC portion of this section, almost half (48%) of all pregnancy deaths were related to a maternal mental health condition or substance use disorder. American Indian and Alaska Native (AI/AN) Arizonans experience the greatest disparity in pregnancy-associated deaths related to mental health conditions or substance use disorder.

The Maternal Mental Health Task Force provided reviews and recommendations for the newly published MMRP report on maternal mental health and substance use related deaths in Arizona. The Task Force also explored whether or not the state had the capacity to implement a perinatal psychiatric access line (modeled after MCPAP for Moms). The program was able to convene two key partners to assist in bringing this project to fruition. The state medicaid program (AHCCCS) had funding available to support these efforts and the University of Arizona Medical Center’s Perinatal Psychiatry Program had the capacity to implement it. A contract was established between the 2 organizations, and the Arizona Perinatal Access Line (A-PAL) will fully launch in June 2023.

The perinatal mental health training series funded by MHIP and facilitated by Postpartum Support International (PSI) enrolled 456 maternal health providers (mental health providers, physicians, nurses, midwives, doulas, pharmacists, home visitors/community health workers, public health, and more) in 3 tracks - Advanced Psychotherapy, Advanced Psychopharmacology, and Perinatal Mood Disorders: Components of Care. Providers from 14 of Arizona’s 15 counties participated in the training. Throughout the year, MHIP offered scholarships to pay for exam fees for any qualifying provider interested in receiving a Certification in Perinatal Mental Health, significantly increasing the number of statewide Perinatal Mental Health Certified (PMH-C) professionals. PSI-Arizona reported increased interest in the completion of the training because of MHIP’s support. The Components of Care training previously averaged 25 participants per year and increased to 429; Advanced Psychotherapy averaged 11 per year and increased to 221; Advanced Psychopharmacology averaged 3 participants per year and increased to 60. The certification scholarships also resulted in a great impact. Prior to the scholarships, Arizona had a total of 21 PMH-C’s; with the scholarships, that number increased to 82. Arizona’s most populated counties saw a vast increase in PMH-C’s, with Maricopa County quadrupling their numbers and Pima County tripling theirs. Five rural counties (Coconino, Navajo, Pinal, Yavapai, and Yuma) added their first PMH-C provider. The successful partnership with PSI will continue into 2023. With the support of the MHI Program, PSI Arizona will be hosting a historic event in May 2023, the first-ever training series for professionals that identify as a person of color, and all of the training staff will be people of color. This will allow participants to not only receive quality training but the opportunities to dig deeper into unique needs, challenges, and opportunities in serving communities of color in Arizona.

The Maternal Mental Health Task Force also identified the need for Perinatal Mental Health certified providers to be seen as a specialty within mental health classifications in the state medicaid system and private insurers. Advocacy through Task Force members resulted in the state medicaid program agreeing to this request. AHCCCS is working through its approval process to implement the changes. Once this happens, Arizona will be the first state to recognize perinatal mental health as a specialty.

In 2021, the Arizona State Legislature passed Senate Bill 1011, which established a Maternal Mental Health Advisory Committee with the purpose of producing a report of recommendations for screening and treating maternal mental health disorders in the state. In 2022, AHCCCS, which was the lead agency for these efforts, convened the Maternal Mental Health Advisory Committee. To leverage the work already established through MHIP and MMRC, the Advisory Committee drew from the ADHS Maternal Mental Health Task Force recommendations already established to address maternal mental health and substance use. The Committee also included the Chief from the Office of Women’s Health as the ADHS representative and MHIP and Maternal Mental Health Task Force participation in workgroups. The Report of Recommendations was issued to the legislature in December 2022, outlining 10 recommendations for preventing maternal morbidity and mortality resulting from perinatal mental health and substance use disorders.

During 2022, the MHIP also funded the development of a perinatal mental health awareness campaign, Know The Signs, which launched at the beginning of 2023. The campaign aims to increase awareness and connect individuals and their support systems to perinatal mental health professionals through resources such as the National Maternal Mental Health Hotline. The campaign includes a landing page with a social media toolkit and local and national resources. The campaign ads were posted on social media and aired on the radio in rural communities and tribal lands.

The MHIP and MMRC continued funding the Arizona Hospital and Healthcare Association (AzHHA) to manage the AIM Collaborative and implement the Severe Hypertension in Pregnancy Safety Bundle. AzHHA enrolled 35 of the 42 birthing hospitals in the state to participate, accounting for almost 92% of all births in Arizona, per preliminary 2022 birth data. Arizona is home to only 2 tribal and 2 IHS hospitals that offer labor and delivery services. Currently, 1 tribal and 1 IHS hospital participate in the AIM Collaborative, and AzHHA is in the process of engaging with the 2 remaining facilities in an attempt to recruit them to join the project.

Technical assistance and ongoing support to provide an opportunity for participating hospitals to share lessons learned and challenges experienced is given through monthly calls, webinars/ training, and interpersonal education to improve implementation efforts and health outcomes. In September 2022, the Collaborative hosted its first in-person conference with participation from 33 hospitals across the state. Five of the hospitals in attendance were non-AIM participating hospitals that attended to gain the educational offerings, preview the AIM program, and better serve their patients. The conference focused on AIM’s maternal hypertension bundle, and attendees received information about the newest evidence and strategies for the timely treatment of hypertensive disorders of pregnancy; and the integration of health equity into patient care. The conference featured a diverse group of exhibitors and an opportunity for hospitals to network with expert speakers and colleagues from across the state. Post surveys from the conference were very positive, with respondents expressing their appreciation for receiving clinical guidelines and best practices and planning on sharing the information gained with the rest of their hospital staff.

Considering the disparities found among Native American/Indigenous women, MHIP’s funding included a strong focus on this population, including the funding of a Tribal Program Manager to work with communities. The MHIP continued to support the Tribal Maternal Health Task Force, which focused on initiatives specific to improving maternal outcomes for the indigenous population. An American Indian facilitator facilitates the Task Force to ensure an understanding of and relatability to participants and communities. In 2022, the Tribal Maternal Health Task Force identified 4 priority areas - Access to and early participation in prenatal care, Awareness of Chronic Disease and Associated Perinatal Risks, Access to Behavioral Health Resources, Substance Use Treatment, Breastfeeding Support, and Oral Health, and improving American Indian/Alaskan Native Surveillance data with Tribes, IHS, State Registries, and Tribal Epidemiology Centers.

The MHIP continued to fund Diné College and the Inter-Tribal Council of Arizona to improve maternal health outcomes among American Indians. Diné College works with the Navajo Nation to convene the 60-person Navajo MCH Committee made up of tribal providers, home visitors, and other tribal community partners working on initiatives and activities to improve maternal and infant health outcomes in all parts of the Navajo Nation. Diné also continued to produce the Healthy Navajo K’é (families) podcast, which provides information and resources on Navajo infant, child, maternal, and overall family health. The podcast has over 50 subscribers and, in 2022, produced 16 episodes. Additionally, they provided a Navajo Maternal Health Webinar with presentations focused on Navajo midwives, Indigenous Doulas, and Indigenous Breastfeeding Counselors and a panel discussion that focused on sharing birthing experiences. The Navajo Maternal Health Webinar was attended by upwards of 100 people.

To reach the other 21 federally qualified tribal communities in the state, MHIP funded the Inter-Tribal Council of Arizona (ITCA), which focused its 2022 efforts on engaging, recruiting, and convening tribal stakeholders to assist with the development of a tribal maternal health strategic plan. This strategic plan is a call to action to reduce the disparities among AI/AN mothers. The plan includes recommended actions for 7 priority areas for mitigating and preventing severe maternal morbidity and mortality in Tribal communities.

The Maternal Health and Family Wellness from an Indigenous Perspective training is still very popular among our AI/AN community. The MHI Program continues to partner with tribal communities and identify community-driven and culturally appropriate sessions to improve maternal health outcomes for Indigenous families. Since 2021 there have been over 200 sessions offered statewide in tribal nations and urban indigenous communities, with over 4,000 community members who have attended these sessions. The training is created by and for indigenous communities, and the sessions are community driven with cultural approaches to maternal health & traditional birth education. Training topics include Indigenous Doula and Advance Indigenous Doulas, culturally competent approaches to mental health, traditional birth education, Indigenous Foods to eat to decrease inflammation afterbirth, and Indigenous Foods that increase milk production, to name a few. The Indigenous Doula Trainings are very popular, and each class has about 30 participants; however, facilitators have expressed that they receive over 200 applications.

The MHIP team was invited to participate on a panel at the HRSA Advisory Committee for Infant and Maternal Mortality (ACIMM) meeting. The panel focused on the challenges and approaches to improving birth outcomes from a tribal, state, and local perspective. Because of ADHS’ robust work focusing on Tribal maternal health, the team was invited to share their experiences working on a statewide effort to reduce maternal mortality to provide a sense of the issues facing Indigenous women and infants and the agencies that serve them. The purpose of the meeting was to inform the development of recommendations that were made to the Secretary of Health and Human Services on how to reduce infant and maternal mortality among Indigenous populations. The report Making Amends: Recommended Strategies and Actions to Improve the Health and Safety to American Indian and Alaskan Native Mothers and Infants was submitted in December 2022.

In Arizona, there is currently a statewide outbreak of syphilis, a bacterial infection that is usually spread by sexual contact. Medical providers are seeing the largest increase of syphilis cases in women and newborns. A pregnant woman can pass syphilis to her unborn child, also known as congenital syphilis. In 2022, BWCH partnered with the ADHS Office of STI Control, Bureau of Infectious Disease and Services to provide a presentation to MCH staff. In addition, a presentation was provided to home visitors to share information and awareness about syphilis cases in women and newborns and available STD testing sites. ADHS Office of STI Control created a dashboard to monitor and track real-time data as well as a Find a Clinic webpage with testing sites by county.

As a joint research project between ADHS and the Centers for Disease Control and Prevention (CDC), Arizona Pregnancy Risk Assessment Monitoring System (PRAMS) collects monthly survey data on the health and experiences of moms before, during, and after pregnancy. The objective is to obtain data of high scientific quality on maternal behaviors to monitor health status and allow ADHS to more effectively tailor preconception, pregnancy, and postpartum services and programs to Arizona’s diverse population.

In 2022, AZ PRAMS added three full-time staff to provide programmatic and operational support and conduct bilingual interviews. Expanding the team allowed for an increase in evening and weekend calls to participants. The team performs interviewer training twice a year. AZ PRAMS added a 12-question Social Determinants of Health supplement to the core questionnaire and interview questions. The supplement explores mental health, discrimination, and economic barriers to healthcare access. These questions allow for a more nuanced understanding of social challenges that face mothers and families in Arizona and how these social determinants of health may impact pregnancy and postpartum outcomes. For outreach purposes, AZ PRAMS attended several conferences, including Arizona Perinatal Trust Conference, Alliance for Innovation on Maternal Health, and Healthy Families. AZ PRAMS connected with healthcare providers and public health advocates throughout Arizona.

AZ PRAMS stratifies our sample by Medicaid (AHCCCS) and non-Medicaid to assess the needs and health disparities among these populations. Given that African American mothers have the lowest participation rate (response rate), AZ PRAMS will increase outreach efforts to this community. AZ PRAMS has an ongoing partnership with leaders and collaborators at Diné College and Navajo Nation. AZ PRAMS representatives regularly participate in the Navajo Maternal and Child Health Committee and provide data to support their initiatives. Navajo Nation partners provided feedback on Phase 9 (launching May 2023) of the AZ PRAMS survey.

Informed by findings from AZ PRAMS data, the Preconception Alliance led by Dr. Dean Coonrad is promoting folic acid use among pregnant women in Arizona. Planned presentations will help inform providers – Maricopa Integrated Health System, AHCCCS Medical and Health Plan Directors, AHCCCS MCH Coordinators, and others. The Navajo Maternal and Child Health Committee uses PRAMS data to strategize actions related to diabetes among mothers in Navajo Nation. Immediate outcomes include the designation of pre-pregnancy and gestational diabetes as a key priority for maternal health advocates in the Navajo Nation and the presentation of AZ PRAMS data to community and tribal leaders.

AZ PRAMS challenges impacting response rates include:

• USPS mail delays - undelivered mail among mailed surveys and incentive rewards.
• Participant contact - incorrect or incomplete contact information for participants negatively impacts response rates, data quality, and AZ PRAMS credibility. AZ PRAMS is continually working on improving contact databases (i.e., Whitepages and other paid resources).
• Language barriers - eleven moms reached out by phone requesting that the survey be translated into Farsi, Swahili, Kinyarwanda, Vietnamese, Portuguese, Bosnian, and Chuukese. Survey translation (other than Spanish) is prohibited per CDC protocol.

AZ PRAMS accomplishments include:

• AZ PRAMS response rates have risen from 36.14% in January 2022 to 50.65% to date (March 2023), an increase of 14.42%.
• The AZ PRAMS Steering Committee has increased by 15% since January 2022 due to outreach efforts and conference exhibits.
• An AZ PRAMS interactive dashboard is now available. The dashboard contains data from the 2020 PRAMS survey on various topics, including COVID-19, Demographics, Health Behaviors, Postpartum Care, and Preconception/ Perinatal Health. Within each topic dashboard, users can explore infographics to break down the data by several demographic characteristics such as maternal age, race, Medicaid status, household income, marital status, county region or residence, and others. Various stakeholders can use this dashboard, and it is an exciting opportunity to interact with and utilize AZ PRAMS data.

As noted in the Maternal Mental Health and Substance Use Related Death in Arizona report, 41.4% of pregnancy-associated deaths and 19.6% of pregnancy-related deaths are related to substance use disorder. Pregnancy-associated deaths related to Mental Health Conditions or Substance Use Disorder involved opiates (MMRC Reviewed deaths in Arizona of Women 15-49 years of age with a pregnancy in the previous 365 days) and accounted for 61.9% of deaths. As part of the ongoing response to the opioid epidemic, state lottery and Title V funding was used to continue the work on the stigma reduction media campaign, Hope Heals. The campaign aimed to reduce stigmas against mothers with substance use disorders and change the narrative so they are treated with dignity. The campaign was directed toward women of reproductive age to promote behaviors that prevent and/or reduce prenatal exposure to opioids and to reduce the stigma that pregnant and parenting women feel when interacting with healthcare providers and support services.

The Arizona Health Start Program is an evidence-informed, promising approach home visiting program for at-risk pregnant and/or postpartum women with children under the age of 2 that is funded through the state lottery (as part of the Title V match), the Maternal Health Innovation Program and the Maternal Infant Early Childhood Home Visiting Program. In 2022, the Health Start Program provided services to 3,005 children providing prenatal, postpartum, and child visits. At the end of 2022, the Health Start Program was transferred to the Office of Children’s Health to better align the home visiting programs.

Alongside the Women/Maternal Health activities and work headed by the Office of Women’s Health team and collaborators, the Office of Oral Health (OOH) and Primary Care Office (PCO), housed within BWCH, continued their cross-cutting activities relating to Women/Maternal Health.

The OOH implements several oral health programs and initiatives to improve the oral health of Arizona's pregnant women and other high-risk populations. The fundamental principles for OOH strategies include equity-focused, evidence-empowered, data-driven, integration-centered, stakeholder engagement, and innovation-focused. Key programs and initiatives include the Fluoride Varnish Program, the Community-based Oral Health Program for Pregnant Women, and the Mission of Mercy. Each of these programs receives partial funding from Title V.

The OOH implements a Fluoride Varnish Program for pregnant women. This is in partnership with Arizona’s early childhood agency, First Things First (FTF), through the Arizona Early Childhood Development and Health Board. The program is offered at Women, Infants, and Children (WIC) Program offices, immunization clinics, obstetricians' offices, and prenatal classes throughout the state. The application of fluoride varnish, an extremely effective cavity-prevention agent, in combination with dental screenings, referrals, and other educational services, is the core of the primary prevention program. During the 2022 state fiscal year (July 1, 2021–June 30, 2022), the Fluoride Varnish Program served 1,475 women of childbearing age in five counties, including screenings, oral hygiene education, referrals, and case management as needed.

The OOH continued working in partnership with the Arizona Health Care Cost Containment System (AHCCCS; Arizona's Medicaid program) by collaborating on connecting pregnant women to oral health care. Accessing affordable oral health care for pregnant women continues to be a challenge as the only dental benefit for Medicaid-eligible adults includes emergency dental services for the extraction of teeth. OOH continued its partnerships with a wide range of policymakers, advocates, and other stakeholders to respond to the need for improvements in the provision of oral health services to women during pregnancy.

Based on the Oral Health Care During Pregnancy: A National Consensus Statement, was designed to help health professionals, program administrators and staff, policymakers, advocates, and other stakeholders respond to the need for improvements in the provision of oral health services to women during pregnancy. OOH developed training materials and resources for multiple audiences, including home visitors, childcare providers, health providers, pregnant women, and new mothers, to enhance their knowledge and skills in improving oral health for women and young children. These resources include e-learning modules on oral health best practices. In 2022, 62 home visitors completed the oral health best practice e-learning modules, as well as motivational interviewing modules. The oral health training resources reside on the home visitor portal, Strong Families AZ, and are available to home visitors and partners statewide. As part of the training in 2022, OOH distributed nearly 350 oral hygiene kits to participating home visitors to provide to their clients during oral health conversations.

In addition, OOH developed three in-person training sessions to train oral health providers on oral health best practices for pregnant women, infants, and toddlers. In partnership with First Things First, Arizona’s early childhood agency, OOH trained nearly 96 oral health providers across Arizona. The training was provided throughout the calendar year and located geographically and virtually to accommodate broad participation from all counties and to address ongoing pandemic issues.

During 2022, OOH worked with a broad array of national, state, and local public and private partners to educate decision-makers on dental public health issues and concerns of state oral health programs that impact and reach women. One such partnership included statewide and regional oral health coalitions that were instrumental in addressing access to care issues for our most vulnerable populations. In 2022, Arizona worked on providing technical assistance to partners regarding the recently signed Dental Therapy bill, which created a new class of dental care providers in Arizona who will be able to provide primary dental care for children and underserved individuals. While employment of this provider type is still in the rules stage of development, partners are eager to move forward with implementation.

Arizona also looks at ways to reach and serve the oral health needs of the disenfranchised and underserved. As a result, the OOH partnered with the Arizona Mission of Mercy in 2012. This event is hosted annually and provides free dental care to those in most need. It is partly made possible through the work of hundreds of volunteers. A startling 42% of Arizona adults over 65 years have lost six or more teeth due to decay or gum disease, are less likely to visit the dentist compared to other states, and suffer from health disparities related to race, income, and chronic disease status. We know that nationally about half of people do not have dental insurance and pay for dental care out-of-pocket, and in Arizona, Medicaid recipients are covered for emergency dental care, which is capped at $1,000 per year. In 2022, the 10th Annual Mission of Mercy event held at the Arizona Fairgrounds was once again implemented. The event addressed the severe dental needs of women that resulted during the pandemic. More than 1,500 volunteers provided dental care to more than 1,160 patients, with a total of $1,702,607 in free dental care provided.

Here are some of the results from the December 2022 event that spanned over 3 days:

• 1,160 patients treated
• $104,400 in free medical screening services
• 8,454 patient procedures completed
• $275,000 in free vision screening and glasses
• $485,000 in life-changing procedures: dentures, partial dentures, & crowns

The Mission of Mercy was made possible through the efforts and commitment of the following volunteers:

• 250 Dentists
• 300 Dental Assistants
• 30 Laboratory Technicians
• 5 Pharmacists
• 12 X-ray Technicians
• 10 Registered Nurses
• 150 Dental Hygienists
• 435 Students
• 8 Nurse Practitioners
• 10 Physician Assistants
• 20 Translators
• 275 General Volunteers

The Primary Care Office (PCO) within BWCH leads statewide efforts to improve access to care to all health services in Arizona’s rural and underserved communities. The PCO continues to lead the data evaluation and coordination of submitting for Health Professional Shortage Areas (HPSA) or Medically Underserved Areas or Populations (MUA/P) to HRSA to inform where resources can be leveraged to create the greatest impact for improving access to health care. Throughout 2022, the PCO continued the ongoing HPSA data review and as of March 2023, Arizona had 661 HPSAs: 248 primary care, 249 dental, and 236 mental health. These include facility HPSAs for Federally Qualified Health Centers and Indian Health Service sites. Arizona needs 667 primary care physicians, 485 dentists, and 227 psychiatrists to eliminate these HPSA-designated areas, which is a higher need when compared to earlier in 2022. There were also 37 MUAs and 10 MUPs in the State. Residents residing in these underserved areas are less likely to receive preventative health services. Title V funding also supported the changes and additional data collection needed for the new Maternity Care Target Areas (MCTAs), which are areas within existing Primary Care HPSAs that are experiencing a shortage of maternity healthcare professionals. MCTAs are supplementary scores given to Primary Care HPSAs.

The work conducted through the PCO is primarily funded through the State Primary Care Office Grant (federal), State Loan Repayment Program funds (includes federal funding and state match), Arizona State General Funds, and private donations. Title V provides supplemental funding to support the development of infrastructure to support the workforce programs, access to care activities, and professional development of health professional staff throughout the state.

The State Loan Repayment Program (SLRP) and the National Health Service Corps Loan Repayment Program (NHSC) help to recruit and retain healthcare professionals into HPSAs by providing loan repayment incentives to providers in exchange for an initial two-year commitment to practice medicine in the underserved areas.

In 2022, 133 providers were obligated through the SLRP. Of those providers who were awarded, 14 focused on Women's Health or specialized in Obstetrics and Gynecology, this included 9 Physicians, 4 Nurse Practitioners, and 1 Licensed Clinical Social Worker. The SLRP also awarded additional primary care providers that comprised 17 Pharmacists, 11 Dentists, 26 Physicians, 47 Nurse Practitioners, 10 Physician Assistants, and 8 additional mental health providers (4 Licensed Professional Counselors, 3 Licensed Clinical Social Workers, and 1 Licensed Marriage and Family Therapist).

In 2022, NHSC supported approximately 767 health professionals who worked in areas of Arizona identified as having a workforce shortage. Of the 767 professionals, 25 were Physicians who specialized in Obstetrics and Gynecology, 18 were Certified Nurse Midwives, and 25 additional providers specialized in Women’s Health (16 Nurse Practitioners and 9 Physician Assistants). The remaining NHSC medical providers were focused on primary care in the following disciplines: 276 Nurse Practitioners, 108 Physicians, and 64 Physician Assistants. NHSC also supported Mental Health Care Providers which included: 67 Substance Use Disorder Counselors, 63 Licensed Professional Counselors, 48 Licensed Clinical Social Workers, 12 Health Service Psychologists, 5 Marriage and Family Therapists, and 3 Psychiatric Nurse Specialists. In addition, NHSC supported 47 Dentists and 6 Registered Dental Hygienists who are serving in dental HPSAs across Arizona.

The Primary Care Office manages the Conrad 30 Waiver Program, also known as the J-1 Visa Waiver Program. The J-1 visa waivers allow foreign physicians to practice in medically-underserved communities without returning to their home residence, thus, allowing them to receive nonimmigrant, H1B status for three years. Arizona currently supports 124 Physicians, with 1 specializing in Obstetrics and Gynecology. Arizona also supported other J-1 Physicians who specialized in Allergy & Immunology, Anesthesiology, Cardiology, Endocrinology, Family Medicine, Forensic Pathology, Gastroenterology, Headache Specialist, Internal Medicine, Medical Genetics, Nephrology, Neurology, Oncology/Hematology, Pathology/Anatomy, Pediatrics, Psychiatry, Pulmonary, Radiology, and Surgery.

The PCO partnered with the Arizona Alliance for Community Health Centers (AACHC), Arizona’s Primary Care Association (PCA), to implement activities that educate communities about programs and resources that can help recruit healthcare professionals in areas with significant challenges with recruitment. The partnership aims to support the development of health professionals from diverse backgrounds and expose them to service in rural and underserved communities.

The PCO partnered with the AACHC on the health professional and student engagement activities above to aim to build partnerships with academic training programs, employers, local and state partners, tribal entities, and providers to collectively address workforce shortages in Arizona. Examples of activities implemented in 2022 included education and technical assistance to students and residents attending medical, dental, or behavioral health training; local and national presentations; partnering with the PCA to help students receive rotation placements in community health centers; assisting providers with finding job placements; and working on improving the coordination efforts between the PCO, PCA, and the State Office of Rural Health to recruit providers in underserved rural areas of the state. In 2022, the PCO provided 16 presentations to various stakeholder meetings, outreach events, or educational opportunities, and estimates approximately 898 people were reached during these events.

In late 2021, the Health Professional Shortage Areas Designations were updated. Stakeholders from rural areas which experienced growth in their communities were concerned about the effects on their HPSA scores. Therefore, in August 2022, we partnered with the Arizona Hospital and Healthcare Association, Az Center for Rural Health, the Arizona Rural Health Association, the Regional Center for Border Health, and the Arizona Telemedicine Program to provide an educational webinar that was widely attended, 96 attendees live and 164 registered.

As part of the mission of the Primary Care Office (PCO) to expand services in rural and underserved areas, PCO is the lead in the AzHIP Rural and Urban Underserved Health Priority. Within this capacity, the office supports four diverse initiatives to expand access to care.

The PCO staff oversees a contract with the University of Arizona’s Arizona Telemedicine Program (ATP), which is focused on tribal areas and increasing broadband and access to telemedicine given the health care shortages in those areas. Broadband, billing, and funding resources were identified as major concerns. ATP is active on the state broadband committees bringing a voice for all, especially tribal and rural communities. ATP contracted with a national billing expert to offer open office hours and provide educational reimbursement events and hosted an “Intro to Funding” webinar with a Tribal Grant Module.

In addition, the PCO manages a contract, as part of the AzHIP, with the University of Arizona to support the Arizona Area Health Education Centers (AzAHECs) to establish partnerships between academic institutions to develop pathway programs for underserved students and consider scholarships, tuition remission, and training in high-needs communities. It will also work to determine how to best support health professions students beyond the financial aspect and make recommendations to support these needs.

The third contract supported by the AzHIP is with the Arizona Advisory Council on Indian Health Care (AACHIC), which has been tasked with convening AzHIP advisory meetings beginning in 2023 dedicated to increasing collaboration and focus on strengthening infrastructure between Tribal communities and Arizona state agencies. The advisory group includes AACIHC and the Tribal Liaisons of ADHS, the Arizona Department of Economic Security (DES), the Arizona Health Care Cost Containment System (AHCCCS), and First Things First (FTF).

The fourth contract supported by AzHIP Rural and Urban Underserved Health tactic is with Arizona Community Health Workers Association (AzCHOW) to support the strategy of maximizing the utilization of community health workers (CHWs) and community health representatives (CHRs) in clinical settings.

The final contract that is overseen by the PCO staff for AzHIP is held by the Arizona Alliance of Community Health Centers. This contract supports the fast-tracked training for Medical Assistants in Federally Qualified Health Centers (FQHC). This supports entry-level staff in growing their skills and career development.

The PCO worked on the biennial Arizona Medically Underserved Areas (AzMUA) report, published in October of 2022. This report found that of Arizona's 126 PCAs, 82 are currently designated as AzMUAs. This is a decrease of seven AzMUAs from the last biennial report published in 2020. Only two PCAs designated as an AzMUA in this report (Flowing Wells and Tucson Foothills) are not currently designated as primary care HPSAs. Greenlee was the only county that did not have an obligated SLRP provider. Title V funding was used to support the creation of the AzMUA report.

During the 2022 legislative session and state budget allocation in 2022, the Primary Care Office was tasked with four new workforce programs. Two of the programs focused on expanding nursing and building the infrastructure at nursing schools. 1) The Accelerated Nursing Program provides scholarships for tuition and fees for students in programs that take 18 months or less to complete. After graduation, scholarship recipients are required to serve four years of full-time work in Arizona as a nurse. 2) Nurse Education Investment Pilot Program is targeted to support universities and community colleges with nursing programs to increase the number of faculty available and infrastructure to expand program capacity, thus, increasing the number of spots available for students to seek nursing careers.

The other two new workforce programs support multiple provider types. The Preceptorship Grant Program provides stipends to healthcare providers who precept a student within the same field for at least 4 weeks. Eligible providers include Osteopathic and Allopathic Physicians, Advanced Practice Registered Nurses, Physician Assistants, and Dentists. The annual stipend is geared to increase the availability of preceptors in the state, prioritizing primary care and rural area providers.

The PCO received funding to create the Behavioral Health Care Provider Loan Repayment Program, which provides funding to pay off portions of educational loans for behavioral health care providers and nurses, including Behavioral Health Technicians, Behavioral Health Nurse Practitioners, Psychiatric Nurse Practitioners and Licensed Practical Nurses, Physicians, Psychiatrists, and Psychologists who serve in behavioral health facilities, including the Arizona State Hospital, behavioral health residential facilities, and secure behavioral health residential facilities. The PCO established emergency rules to implement the program and begin receiving applications, and in December 2022, 23 applications were received.

In 2022, Title V funded the Arizona Workforce Recruitment and Retention Conference held on September 26 and September 27, 2022. The conference was attended by 72 participants from various entities including Federally Qualified Community Health Centers, NHSC sites, tribal entities, and other healthcare organizations in rural and underserved communities of Arizona. The meeting included various topics addressing recruitment and retention. Strategies discussed included how to develop diverse staff, methods for increasing flexibility, and how to provide incentives to promote retention. The conference also covered information about the Community Health Workers (CHWs) voluntary certification in Arizona and reimbursement updates for these providers.

In April of 2022, the PCO and the Primary Care Association held the Arizona Annual NHSC Scholars Conference. The conference was attended by multiple Primary Care Scholars that comprised of 4 Medical Students, 1 Medical Resident, 14 Physician Assistant Students, and 11 Dental Students. During the conference, the scholars got to hear from NHSC staff about PCO programs, HPSAs, and a panel Q&A session with NHSC Alumni, which included one Physician, one Dentist, and two Physician Assistants. NHSC Scholars also had the opportunity to speak to leaders from Federally Qualified Health Centers about opportunities to fulfill their scholarship obligations. Since the conference, we have learned that three scholars were connected to their current employers as a result of attending the 2022 conference.