Domain: Cross-Cutting/Systems Building

Reporting for October 2021-September 2022

Objective

By 2025, reduce the percentage of Minnesotans that did not receive routine medical care they needed because of cost by 35%.

State Performance Measure

(SPM 1) Percent of Minnesotans that did not get routine medical care that they needed because of cost.

Minnesota’s Title V program has chosen to focus priority goals on Minnesotans accessing needed care rather than insurance coverage alone. Therefore, measurement for this priority area is focused on the proportion of Minnesotans reporting an unmet need for medical care due to cost.

The 2021 Minnesota Health Access Survey (FY2022 annual indicator) found that 5.4% of all Minnesotans did not get the routine medical care that they needed because of cost. This is a decrease from the 2019 Minnesota Health Access Survey (FY2021 annual indicator) which showed 7.8% of Minnesotans had forgone routine medical care because of cost.

Community-Identified Priority Need: Accessible and Affordable Health Care

Comprehensive, quality health care services are important for promoting and maintaining health throughout the lifespan. Access to health care is impacted by household finances, insurance coverage, geographic availability, timeliness of entry into services and many more factors. Poor access to health care services can result in unmet health needs, lack of preventive services, hospitalization, and increased financial burden. Equally as important as access is the alarming rising costs of health care.

Approximately 4% of Minnesotans lacked health insurance coverage in 2021, according to the most recent Minnesota Health Access Survey. The maintained high rates of coverage in 2021 were consistent with levels experienced after the full implementation of the Affordable Care Act in Minnesota in 2014 – 95.3% of Minnesotans had health insurance coverage that year. Compared to 2017, coverage in the state was significantly higher, likely because of Minnesota’s strong economy and job market, as well as by provisions enacted by the Minnesota Legislature to help stabilize the individual health insurance market. Despite relatively high levels of insurance coverage historical disparities in coverage experienced by certain groups persisted in 2021. 

The highest proportion of Minnesotans without insurance live in rural areas in the northern regions of the state. Minnesotans living in rural areas experience more barriers to accessing health care because of decreased geographic access and health provider shortages. By the most recent estimates, there were 121 Health Professional Shortage Areas in Minnesota and 97 Medically Underserved Areas. Rural residents are especially disadvantaged in terms of access to dental care with very few dental providers practicing in greater Minnesota counties. Additionally, providers within a community may still not be accessible if they are not considered “in network” for insurance companies.

Structural racism is pervasive within health care and has led to inequities in access to and affordability of health care by race/ethnicity across the state. It shows up in our health care system in many ways that impact BIPOC communities’ access to safe, affordable, and dignified health care. For example, structural racism within systems and policies shape things like who has access and ability to take opportunities for well-paying jobs that offer health benefits. BIPOC Minnesotans are less likely to have access and ability to take opportunities like these, and experience significantly higher uninsurance rates than among white Minnesotans. Specifically, BIPOC Minnesotans are around two times more likely to be uninsured than white people living in Minnesota.

The 2021 Minnesota Health Access Survey found that uninsurance rates among Black and Latinx Minnesotans substantially increased compared to 2019. In 2021, there were 7.9% of Black Minnesotans who were uninsured compared to 4.4% in 2019, while uninsured rates for American Indian Minnesotans was at 13%. Additionally, there was a statistically significant increase of uninsurance rates among Latinx Minnesotans in 2021 (21.6%) compared to 15.5% in 2019.[1] Additionally, systemic racism has a detrimental effect on the quality of care that communities of color receive. Data from the 2020-2021 National Survey of Children’s Health (NSCH) reveals how structural racism has affected whether children of color have access to and receive family-centered care – while 94.1% of white children received family-centered care in the last year, only 77.8% of Hispanic children and 76.9% of Black children did.

Disparities in access to health care are felt acutely among families of children and youth with special health needs (CYSHN). The cost of health care adversely affects families of CYSHN, with 17.4% of these families struggling to pay for a child’s medical bills, compared to 5.8% of families without CYSHN.[2] Taken into consideration with the increased likelihood of parents of CYSHN to have to cut back their work hours or stop working altogether to provide care for their child particularly during the pandemic, the disparities in access to and cost of health care can have a significant impact on families and their household income.

Strategies and Activities

A.  Strategy A: Recognize and Reduce Systemic Racism, Discrimination, and Marginalization in Health Care

1. State Level Activities
   1. Promote and Provide Training on Accessibility in Health Care and Other Community Settings for Children and Adults with Disabilities

Persons with disabilities, including children, experience a great deal of discrimination in our health care system and community – which can lead to increased disparities in health and well-being. The COVID pandemic resulted in major disruptions and challenges to the lives of persons with disabilities in areas such as transportation, technology, education, medical care, caregiver support and stress, mental health, accessibility to essential services, supports, testing and vaccinations, masking, housing, employment, and basic rights.

In FY2022, Title V staff worked diligently to bring forward the needs of the community and create change where possible, including promotion, guidance development, and training to improve accessibility in healthcare and other community settings.  For example, Title V staff working within the COVID-19 response set up an accessibility workgroup of external and internal experts.  From this group as well as other efforts, Title V staff created a Disability checklist for COVID-19 vaccination sites, assembled a Disability Etiquette resource and training that was routinely utilized, and began to include more persons with disabilities into the development of programs and resources within MDH.

2. Partner with Minnesota’s State Medicaid Program to Identify Populations Most Likely to Experience Inequities in Health Settings

Due to staff turnover and transition of staff from COVID-19 response back into their normal duties, this activity was mostly put on hold in FFY2022. However, relationship building between Minnesota’s Title V and State Medicaid programs continued with the goal to work more closely together in FFY2023, beyond, to identify gaps and opportunities for improvement related to the Title V/Medicaid MOU.

3. Address Disparities in Data Available on Minnesotans with Disabilities

In FY2022, Title V staff assembled an extensive report called the After Action Summary of Minnesota’s COVID-19 Response by the Disabilities Unit. The purpose of the report was to provide an in-depth analysis and share the data that was collected during the pandemic response, including sections dedicated to the children and youth with special health needs population and associated disparities in health and health support services.

B.  Strategy B: Expand Access to Health Care by Increasing Availability of Community-Based and Remote services

1. State Level Activities
   1. Provide Road Map/Technical Assistance to Expand Opportunities for Collaboration Between the Health Care System and Schools

Title V staff collaborated with the Center for Emergency Preparedness and Response and received Centers for Disease Control (CDC) CDC Crisis Response Cooperative Agreement: COVID-19 Public Workforce Supplemental Funding (CDC-RFA-TP18-1802). The primary goal of the funding was to establish, expand and sustain a public health workforce to fill the gap left behind by the pandemic. 

School nurses are an identified workforce gap in Minnesota. Minnesota is one of the largest geographical states in the nation serving child and adolescent in-person education, across 2,000 public schools, accounting for over 350 school district jurisdictions where policies and budget are uniquely determined.  MDH administered $6,000,000 to establish regional licensed school nurses to provide active coordination, training and technical assistance across school districts in each region, via the  Minnesota Education Service Cooperatives .

Additionally, MDH administered $2,493,508 to serve 26 school-based health centers (SBHC) via seven grantees, one statewide organization that provides capacity building, MN School Based Health Center Alliance . SBHCs provide primary care health services to children and adolescents, essential for Covid-19 recovery, including mental health care, immunizations, and comprehensive health check-ups. School-Based Health Centers in Minnesota - MN Dept. of Health (state.mn.us) SBHCs will turn no child away for their ability to pay, medical insurance coverage, or immigration status. SBHCs serve all members of their student population including medically underserved populations most impacted by social determinants of health, located within the top quadrant of CDC’s social vulnerability index, used by MDH in Covid-19 equity effort. Specific activities during FFY2022 included:

• Convened a Regional school nurse coordinator monthly community of practice (CoP) - Regional school nurse coordinators, funded by the Workforce Grant, organized 14 CoP meetings across the state, covering all 9 Minnesota Service Cooperative regions. The meetings addressed planning tools, school-based vaccinations, immunizations, and other critical health services related to COVID-19 recovery efforts for children in schools. In addition, these CoP meetings also supported COVID-19 recovery efforts by helping to establish professional networks and a community of support for new school nurses, particularly those in Greater Minnesota where attrition has been high during the pandemic. During this reporting period, 86% of school nurses who attended their newly established regional CoP reported the meetings were “highly valuable” or “valuable” for their professional needs, including their morale.
• Developed a Technical Package for School Nurses – A new technical package of critical school nurse practice tools, state and federal statutes, as well as related credible, up-to-date resources was developed for use statewide by school nurses and school health staff. This was developed by the newly established statewide coalition entitled, the Minnesota School Nurse Collaborative, which was convened by MDH.
• Established a Training Cadre for Mental Health in School – Workforce Grant funding supported hiring 6 mental health regional coordinators, out of 9 total regions, across the state of Minnesota. The regional coordinators will make up a cadre to provide trainings to school staff on trauma-informed school practices, a COVID-19 recovery effort to support the relational needs of children while in school.
• Increased K-12 Workforce Retention Efforts – In response to the need for K-12 staff mental health support, the Metro Educational Service Co-op developed a 20-video curriculum to be shared statewide. Entitled “Emotional Wellness and Resiliency for School Staff,” the on-demand curriculum addresses simple skills to build resiliency, increase wellness and manage stress. K-12 staff report high levels of anxiety and burn-out, evidenced by staff attrition. School mental health professionals developed the on-demand, video-based curriculum to support COVID-19 recovery efforts.
  2. Assess and Promote Accessible and Barrier-Free Access to Telehealth and Other Remote Methods of Health Care for MCH Populations

The 2021 Minnesota Legislature passed the Minnesota Telehealth Act, which expands telehealth in Minnesota and extends payment parity to include telephone-only visits through June 30, 2023. As a part of this legislation, MDH was directed to conduct a study of the impact of Minnesota’s telehealth policies under private sector health insurance. An additional component of the study is to be led by MN DHS to focus on the impact of Minnesota’s telehealth policies on Minnesota Health Care Programs. The study is set to produce two reports: the first by January 15th, 2023, and the second by January 15th, 2024.

During FFY2022, MDH convened the Minnesota Study of Telehealth Expansion and Payment Parity: Technical Advisory Group. This group of subject matter experts will “provide strategic and technical advice to MDH as it studies the impact of telehealth policies on Minnesotans through a lens of quality, access, and affordability, with special attention to the impacts on Minnesota’s communities of color, the disabled community, and on rural residents.”[3] Additionally, MDH worked to assess the use of telehealth for MCH populations noting situations of most positive impact and where barriers exist. Title V staff expanded their understanding of the landscape of telehealth in MDH and other state agency structures (including policies around use of telehealth) and have begun to identify areas for partnership.  

C.  Strategy C: Improve the Quality of Health Care by Promoting Person and Family-Centered Practices

1. State Level Activities
   1. Increase the Availability and Use of Community Health Workers and Other Cultural Brokers

Community Health Workers (CHWs) are trusted, knowledgeable, frontline health personnel who typically come from the communities they serve. CHWs bridge cultural and linguistic barriers, expand access to coverage and care, and improve health outcomes. MDH staff within the Health Promotion Chronic Disease section (HPCD) at MDH have partnered with the Minnesota Community Health Worker Alliance to expand CHW initiatives and promote the profession. Additionally, HPCD staff have been working closely with the CHW Alliance on grant proposals such as HRSA’s CHW Training Program and supplemental budget proposals.

Other cultural brokers who identify and provide ethnic and culturally specific perinatal care for women and families within their communities are doulas and midwives. Although doulas do not provide medical care, they do offer evidence-based information to women and their families that support the informed decision-making process. Minnesota led several activities related to doula and midwifery services in FFY2022, including the following activities.

Request for Proposals for a Community of Assessment of Strengths and Barriers to Accessing Midwife and Doula Services

MDH recognizes the community-informed solutions are needed to identify opportunities and gaps connecting individuals to birthing services and resources that support optimal health outcomes. In FFY2022 MDH released a request for proposals seeking a community assessment of strengths and barriers to accessing midwife and doula services in Minnesota with a requirement that the awardee engage the communities experiencing the greatest disparities in maternal and infant pregnancy outcomes, to ensure the voices and input of the communities are aligned with recommendations and future work. The overall goal of the community assessment was to improve maternal and infant health outcomes in groups with the most significant disparities, including Black, Indigenous and other communities of color, new immigrants, families with lower incomes, and/or rural communities by increasing the availability of midwife and doula services. The contract, and related activities, was set to occur February 1 - June 30, 2023, with a potential option to extend the project for an additional one year.

Maternal Care Access Coordinator

The Dignity in Pregnancy and Childbirth Act (144.1461) was passed by the Legislature in 2021 to address inequities in maternal health care, calls on the state to increase the availability of, and access to, doula and midwifery services by removing barriers to communities disproportionately affected by maternal and infant morbidity and mortality. To help improve health equity in pregnancy and postpartum outcomes, MDH hired a Maternal Care Access Coordinator to develop a strategic plan and to develop and implement policies, activities, and programs, with community input, aimed at expanding access to prenatal care, doula, and midwifery services by working with internal and external partners and stakeholders. The work of the Maternal Care Access Coordinator will inform cross-sector collaborations with internal and external stakeholders working to advance policies and systems changes to remove barriers to access for doula and midwife services such as trainings, certification, and reimbursement.

2. Increase Access to Family Planning with Special Attention to Youth, Rural Areas, and Communities of Color and American Indians

Established by the Minnesota Legislature in 1978, the Family Planning Special Projects (FPSP) grants program provides low-income, high risk individuals pre-pregnancy family planning services. Funding is focused on individuals who would have difficulty accessing services because of barriers such as poverty, lack of insurance, or transportation. Grants are awarded to county, local public health and nonprofit organizations to provide family planning services in communities throughout the state. In FY2022, there were 25 grantees located throughout the state including one county health care system,   one university-operated clinic, five local public health agencies, and 18 nonprofit organizations. 

Minnesota’s Sexually Transmitted Infections (STIs) remained at near historic high levels with 33,706 STI cases reported in 2021. Due to the COVID-19 pandemic, clinics (including clinics funded by FPSP) observed a sharp decline in appointments for STI screening, access to long-acting reversible contraceptives (LARCs), and hormonal contraception obtained from pharmacies. Declines in the utilization were even greater in ZIP codes with lower average income levels, for non-white residents, and among nonproficient English speaker’s communities which already experienced disparities in care before the pandemic. 

To address the limited resources, MCH staff provided training to FPSP grantees about the 340B program, a federal drug discount program administered by the Health Resources and Services Administration. The program requires drug manufacturers to offer discounts to certain safety net providers. The outcome of this collaboration resulted in six new Minnesota clinics (FPSP grantees) becoming 340B providers, which ultimately allows clinics to stretch scarce financial resources and serve more clients. 

In the most recent State Fiscal Year (July 1, 2021 – June 30, 2022), FPSP grantees reached 69,261 individuals through outreach activities such as small groups and health fairs; counseled 20,000 individuals on reproductive life planning and contraceptive options; and provided 15,485 people with a range of family planning method services. The FPSP Statistical Report provides additional details Family Planning Special Projects Program Statistical Report for Fiscal Year 2022 (state.mn.us)). Of these individuals served, 51% of people had incomes below 100 percent of the federal poverty guidelines, and 76% were below 200 percent.  Ninety percent of people receiving method services were 18 or older, with 58 % between the ages of 18 and 29. 

D.  Additional Related Activities

1. State Level Activities
   1. Establish a Center for Health Equity at the Minnesota Department of Health

MDH has established a Center for Health Equity (CHE), which is an active part of strategy, education, and programming for the department. More information on the CHE can be found in the Overview of the State. Additionally, MDH formed the Health Equity Advisory and Leadership (HEAL) Council to address Minnesota’s disparities in health status – particularly those persistent disparities across various ethnic, racial, and regional groups. The HEAL Council represents the voices of many communities most severely impacted by health inequities across the state, including racial and ethnic minority groups, rural Minnesotans, Minnesotans with disabilities, American Indians, LGBTQ community members, and refugees and immigrants. The council assists MDH in carrying out the efforts outlined in the department’s strategic plan and its Advancing Health Equity report, including advising on specific MDH policies and programs. The council also assists MDH in developing strong performance measures related to advancing health equity. The CFH Division and Title V Program remain engaged with the HEAL Council and work of the CHE, including the MCH Director who sits on an internal advisory body to the CHE.

Domain: Cross-Cutting/Systems Building

Reporting for October 2021-September 2022

Objective

By 2025, at least 9 of the 11 federally recognized tribes will participate in developing technical assistance plans.

State Performance Measure

(SPM 2) Percent of tribes that participate in collaborating with Minnesota Department of Health (MDH) to develop technical assistance plans to provide culturally relevant services.

Tribal leaders across the state have told us they are concerned that the structures and policies within MDH do not address the cultural context of providing services in American Indian communities. To identify and overcome barriers to authentic engagement, MDH has developed personalized technical assistance plans with each participating tribe to provide meaningful services that meet their needs in a culturally relevant way. We have also engaged leadership at the agency to work towards addressing policies that are barriers for tribal communities. As such, the only performance measure tracked was the percent of tribes agreeing to collaborate with MDH in developing technical plans.

As of FY 2022, 9 out of 11 (81.0%) federally recognized tribes in Minnesota are participating in the collaboration with MDH to develop technical assistance plans.

Due to meeting our goal we are retiring this SPM for FFY2023 and thereafter.

Community-Identified Priority Need: American Indian Family Health

Structural and systemic racism plays an integral role in perpetuating poor health outcomes among American Indian women, children, and families, who experience the greatest health disparities in Minnesota. These disparities are caused by historical trauma, racism, and continued colonial practices and policies that create barriers to opportunity and thriving. Oppressive systems have denied American Indians access to adequate health care, employment, and food and nutrition. This has led to greater child poverty rates, a larger number of children growing up in single-parent households, greater rates of placement in out-of-home care, and lower high school graduation rates. In 2021, the American Indian child poverty rate was 44% compared to 9.3% of all Minnesota children living in poverty.[4] Approximately 45.6% of American Indian children are growing up in single parent families.[5] Less than 61.3% of American Indian youth graduated from high school in 2022, compared to the overall state graduation rate of 83.6%.[6] Compared to white children, American Indian children in Minnesota are 16.4 times more likely to be placed in out-of-home care.[7]

Families are central to the healthy physical, social, and emotional development of infants and young children. However, American Indian families in Minnesota face challenges that impact the development of their children and family unit during the critical early years of life. Stressors, such as poverty and adverse experiences, disproportionately affect children and families in economically, socially, and environmentally disadvantaged communities. Frequent exposure to these stressors and adverse experiences increases the likelihood of people facing health disparities later in life.

Minnesota acknowledges that American Indian people carry cultural knowledge and wisdom that has sustained their communities and nations for generations, and that only through authentic engagement and partnership will we see change. We recognize that approaches need to be guided by the communities most affected, and we need to support their efforts and give them enough time and resources to see change. It will take dedication to understanding culture and history, community health board engagement, and state and federal partnerships with American Indians to make change.

Strategies and Activities

A.  Strategy A: Increase Access to Culturally Specific Health Services

1. State Level Activities
   1.            Collaborate with Partners to Support Training of American Indian Doulas and Community Health Workers

Doula care is an important yet underused resource in improving maternal health equity. Doulas are non-clinical health care personnel who provide physical, emotional, and informational support not only during labor and delivery, but also to expectant and postpartum mothers. Doulas provide support in the form of offering breathing techniques during labor, empowering mothers to advocate for their health care preferences, facilitating communication with providers, sharing guidance with mothers’ loved ones, and providing breastfeeding assistance. 

American Indian focus groups shared that the return to traditional pregnancy, birthing, postpartum, and breastfeeding care is one of the most effective measures that can be instituted in their communities to reduce maternal and infant mortality. American Indian doulas and doulas well-versed in American Indian culture understand that birth in the post-colonial United States has never been equal and take medical racism as a given. These doulas do not question American Indian women about the validity of their concerns and experiences because they are “those women”. American Indian women traditionally have always worked with non-medical birth supporters throughout the pregnancy and postpartum period. This can mitigate the challenges these women face in receiving standard prenatal care in the first trimester and connect them to providers earlier. 

Robust evidence demonstrates the benefits of doula care for mothers and infants. For mothers, doula care is associated with increased maternal engagement in and higher satisfaction with care. Additionally, babies whose mothers received doula services are less likely to have low five-minute Apgar scores of their health at birth. Given the data—including a finding that doula care is one of the most effective evidence-based practices for labor and delivery—the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine back the use and expansion of health insurance coverage of doula care. However, doulas do not generally comprise part of the traditional maternity care team, and insurance coverage is variable.

While Indigenous doula training is available, the major roadblock continues to be the inability of doulas to be equitably and appropriately reimbursed by Minnesota’s Medicaid system and private insurers. Community Health Workers (CHW) can bill for some services if strict guidelines around medical orders are adhered to; this is often a barrier for Indigenous communities to be able to successfully seek reimbursement.   

Some activities Minnesota implemented during this reporting period to address the barrier around reimbursement and address the need for more culturally informed doula care included: 

• Minnesota’s Family Home Visiting (FHV) program provided funding for three home visitors to complete Indigenous doula training to augment their services for families in Fall 2021. These doulas also provide Family Spirit home visiting services to families – an evidence-based and Indigenous specific FHV model – and their services are grant funded to be able to eliminate the need to bill Medicaid or private insurance. 
• FHV staff participated in discussions with MN Department of Human Services (DHS) – Minnesota’s state Medicaid agency – on six occasions during FFY2021 and FFY2022 regarding the Families First Preservations Services Act to advocate for culturally informed interventions to serve Minnesota’s American Indian communities. There is more work to be done on how this will be implemented. 
• FHV staff held discussions on two occasions during FFY2022 with DHS leadership on doula and CHW reimbursement rates. 
• FHV staff worked with Northwest Indian Community Development Center and the MN State Colleges and Universities system to reinstate the culturally normed CHW program once offered. Ongoing efforts are needed to be able to return this valuable program to the community.  
• An amendment to the statute for the doula registry opened up the possibility of adding Indigenous doula training organizations to the list of recognized certifying organizations for doulas. Title V staff continue to work with MDH’s Health Regulation Division on implementing this change.
  2.            Support Family-Centered Evidence-Based Programs and Practices that are Normed in the American Indian Community

Focus groups with members of American Indian communities in MN noted the fractured framework of birthing, postpartum, and family care in their communities. The lack of consistent, culturally centered care is viewed as “at the heart of” Minnesota’s dire American Indian maternal and infant mortality data. It also helps to perpetuate the lack of access to resources for substance use disorders, intimate partner violence and programs that help reduce family poverty. 

The FHV program continues to provide funding for nine of MN’s eleven tribal communities to provide a range of services from Temporary Assistance for Needy Families (TANF) universal home visiting to targeted evidence-based models. Some of these funding sources provide flexibility for communities to utilize funding in ways that make the most sense for them; however, most funding sources continue to have restrictions that make it difficult for American Indian communities to implement FHV services in a culturally specific way.  In addition to funding, Minnesota provided the following additional services:

• Technical assistance during the pandemic for staff reassigned to COVID work to remain engaged in FHV services as much as possible. 
• Funding for a FHV Community of Practice co-developed and presented by Johns Hopkins Center for Indigenous Health and MDH FHV staff. The year-long event was held virtually because of COVID. Nine of the eleven tribal communities participated in some or all the sessions. Lt. Governor Peggy Flanagan gave both the opening and closing remarks at the event. As a member of the White Earth Nation, the Lt. Governor’s remarks on the importance of culture in care and parenting education were affirming to home visitors who have not often had this value supported. 
• Extensive training on “Building Resilience:  A Trauma Informed Approach to Home Visiting” with assistance from Johns Hopkins Center for Indigenous Health. Staff from eight of the eleven tribal communities, as well as five nonprofit organizations serving the urban American Indian population, attended the training. The training events utilized cultural healers from around the area to speak, and feedback from participants was incredibly positive.
  2. Local Public Health and Community Spotlight
     1.            Implement Family-Centered Evidence-Based Programs and Practices that are Normed in the American Indian Community

A majority of Minnesota’s eleven Tribal Nations implemented a variety of services that were culturally-responsive to and led by engagement within their community, as able; however, all Tribal Nations in Minnesota reported challenges related to rural living; inaccessibility to basic needs such as food, shelter, transportation; and staff working over capacity due to having to take on many roles for their Tribe.

• White Earth’s Nurse Family Partnership (NFP) program is Minnesota’s only Tribally Maternal, Infant, and Early Childhood Home Visiting (MIECHV)-funded site. They work with MIECHV for technical assistance support and report data to NFP and MIECHV, but not to MDH other than minimum reporting requirements for state funding. Their NFP program staff share that they are maintaining enrollment numbers. White Earth also has several wrap-around programs to serve families experiencing substance use, including housing and both in-patient and out-patient treatment programs. Most of their home visitors (HVs) are non-American Indian registered nurses (RNs) or public health nurses (PHNs) from outside the community. Intensive cultural training is required for community members and non-community members working for the tribe. The community has developed a robust transportation system and billing infrastructure is good.
• Fond du Lac also offers the NFP program. Their assessment of their pregnant and parenting population shows a significant number of families who are not eligible to enroll in NFP. In addition, they are finding more young parents who express a desire to include traditional practices. They continue to look for a program that can be delivered by nurses and has a cultural component. They have a very robust billing infrastructure, though some challenges persist. In addition to billing, the program is also funded through some state funding as well as tribal dollars.
• Bois Forte partnered with Grand Portage as our first tribal sites receiving the Family Spirit family home visiting training in 2013. They have had consistent staff to utilize the curriculum throughout the years but identified low fidelity as a challenge due to HV staff having to balance many roles. With evidence-based FHV funding, Bois Forte hired a home visitor who attended training in August of 2019, and since are successfully implementing the Family Spirit program with positive response from their community and leadership. According to staff, transportation and access to resources for food, medical care, and social support are limited due to their rural location.
• Grand Portage was the very first active Family Spirit site in Minnesota, enrolling their first participant in 2013. They, along with Bois Forte, were part of a pilot project and still employ one of the nurses trained in that pilot program. They have continuously utilized the program and maintain an average caseload of 5 or fewer clients. Their birthrate is 5-10 a year. Substance use disorder among pregnant/parenting women is very low. Their participants are very isolated and must often travel two or more hours each way for any specialty medical care. There is little unemployment, tribal businesses employ most band members. There are two RNs staffing the health office and they address ‘womb to tomb’ healthcare issues in their community.
• Red Lake has had staff trained in Family Spirit since 2014. They have not been able to maintain a broadly-integrated Family Spirit program, though one PHN utilizes the curriculum independent of model enrollment for all MCH home visits made in the home and at WIC clinics. Red Lake secured EBHV funding and are planning for an ambitious launch with four full-time community health workers (CHWs), a Health Educator, and a supervising PHN with a target caseload of 100. Comprehensive Health includes both tribal and Indian Health Service (IHS) services through clinic and in-patient facilities. Clients are seen prenatally to seven months at Comprehensive Health and then transferred to a local community clinic/hospital for final care and delivery. This tribe is in a very isolated region of the state with limited transportation options. Many traditional health practices are resurging, and the community felt Family Spirit was a good fit for their population.
• Leech Lake is currently an EBFHV funded program as part of a group of counties in northwest Minnesota. This partnership has greatly improved the overall relationships between the counties and tribe. It has also provided reflective practice – a recommended but not required facet of the Family Spirit program. They utilize paraprofessionals under the supervision of an elder/LPN respected in the community. Staff turnover has been a challenge. Tribal leadership is supportive of FHV delivered through the Family Spirit model. More work is needed to develop reporting capabilities and complete quality improvement projects and data.
• Mille Lacs is a currently funded EBFHV site partnering with Mille Lacs and Pine Counties. They have had significant staff turnover since the program began in 2015 at this site and quit offering the program until receiving EBHV funding in 2018. Relationships with their partnering counties seems to have improved. They are involved with continuous quality improvement (CQI) projects; the paraprofessional home visitors are requesting more training and have been encouraged to utilize Achieve on Demand and The Institute for the Advancement of Family Support Professionals to start.
• Lower Sioux has had Family Spirit staff trained in the past but have not widely implemented it. They currently work with a Tribal Early Head Start program that utilizes it. In 2017, Southwest Health and Human Services (a six-county community health board) along with Lower Sioux received a DHS grant to have staff from a multitude of their agencies serving the American Indian population trained in Family Spirit. They continue to use the program in those areas but have not worked closely with Johns Hopkins or MDH in reporting enrollment and staffing numbers.
• Upper Sioux has not had staff trained in Family Spirit or implemented other structured long-term family home visiting programs. In the past, they worked more closely with counties to provide services for their members but are now working on building their own infrastructure and services. They are working on addressing teen pregnancy prevention and early childhood developmental and social emotional screening programs.
• Prairie Island does not have FHV services, nor do they receive TANF funding. We have had little connection with their small health office.
• Shakopee provides clinic services to members and employees alike. They had expressed an interest in the Family Spirit curriculum several years ago, but to date have not followed up.

B.  Strategy B: Mandate Cultural Proficiency, as Defined by Community

1. State Level Activities
   1.            Review State Employee Tribal State Relations Training Accessibility and Impact

Minnesota acknowledges the sovereignty of the eleven federally recognized American Indian tribes within Minnesota’s geographic borders, and supports their absolute right to existence, self-governance and self-determination. Recognizing the importance and benefits of communication, consultation and informed decision-making among Minnesota state agencies and elected tribal government officials on matters that have tribal implications, Minnesota enacted Minnesota Statute 10.65 Government-to-Government Relationship with Tribal Governments during the 2021 legislative session. One of the requirements under M.S. 10.65 is that state employees whose work has tribal implications attend Tribal-State Relations Training (TSRT), a course designed to educate state agency staff about American Indian tribal governments, histories, cultures, and traditions and to empower state employees to work effectively with American Indians and Tribal Governments. Participants learn that each Tribal Nation in our state is unique and that it is important to become knowledgeable about the history, culture, and governance of the Tribe as well as the role of agency’s Tribal liaison(s) in order to authentically and effectively partner with tribes.

Measurement of the percent of Child and Family Health Division staff who complete the TSRT will become our new objective and SPM for the Cross-Cutting/Systems Building: American Indian Family Health Domain in FFY2023 and 2024. Additionally, like all numerical data, there is a story behind these percentages that Title V staff aim to understand more deeply in order to assess accessibility to and impact of completing the TSRT. For example, getting into the training has been challenging due to the high demand for and rapidly reaching capacity of enrollment. Title V staff will be working to develop a more comprehensive understanding of enrollment, accessibility, and impact of the TSRT in FFY2024. 

C.  Strategy C: Shift Power and Policies to Address Structural Racism

1. State Level Activities
   1.            Develop Opportunities for Grantees to Deliver Grant Reports Via Oral and In-Person Methodology

Since September 2019, MDH piloted a program adaptation that allows for more flexibility in grant reporting and accommodates cultural differences. Numerous aspects of MDH’s funding and reporting processes are based in Westernized administrative practices. One notable example of this is the requirement that program updates are to be delivered in the form of written reports. While American Indian FHV staff are more than capable of meeting this requirement, multiple American Indian grantees have communicated they appreciate having the option to provide updates through oral reports. American Indian culture is rooted in oral communication more so than written communication; this is a small gesture Minnesota can make to honor cultural differences and preferences for the grantees working so hard to serve Minnesota’s families. When grantees are given the option to provide updates orally, they can share stories of participants’ progress and challenges within the program rather than answering prescribed questions. They are also able to engage in a conversation with grant managers that allows for more nuance and detail. These conversations are best held in-person, which provides vital opportunities to build trust and relationships and improve technical assistance strategies.

2.            Develop Request for Proposal Processes that Demonstrate a Knowledge of American Indian Communities, their Norms, and Values

In April 2022, MDH released one of the largest grant applications in its history. The roughly $150 million, five-year grant will continue to fund Tribal Nations to provide evidence-based and promising practice family home visiting services. FHV and Title V staff have worked closely with the Director of American Indian Health and our Center for Health Equity at MDH to get input to assure the RFP provides a culturally informed framework. For sites currently funded and in good standing, the grant will be non-competitive and will allow for cultural adaptations as long as they align with the model chosen by the community.

D.  Additional Related Activities

1. State Level Activities
   1.            Collaborate with the Office of American Indian Health

Title V staff met monthly with the Director of American Indian Health at MDH to review MCH and evidence-based services that serve our American Indian population. We have also discussed the needs we have noted in our strategy to measure how our Tribal communities engage with MDH and what the barriers are to providing more helpful TA. Since this strategy was developed, MDH has received CDC funding that allowed for the Director of American Indian Health to set up an Office of American Indian Health within the Health Equity Bureau at MDH. Our work and discussions helped to inform the work of that office and hire a State-Tribal Policy Specialist/Planner. We will continue to work closely with the Office of American Indian Health to increase our expertise at providing meaningful and supportive services and developing personalized TA plans for each of our Tribal Nations.

Domain: Cross-Cutting/Systems Building

Reporting for October 2021-September 2022

Objective

By 2025, decrease the proportion of Minnesota adolescents who report staying in a shelter, somewhere not intended as a place to live, or someone else’s home because you had no other place to stay in the past 12 months by 15%.

State Performance Measure

(SPM 3) Proportion of Minnesota adolescents who report staying in a shelter, somewhere not intended as a place to live, or someone else’s home because you had no other place to stay in the past 12 months.

Nearly half of the state’s homeless population is comprised of homeless children and youth aged 24 and younger, with approximately one third being children aged 17 or younger (with their parents). There is no one reason for why youth experience homelessness - some are homeless because despite family employment, they cannot afford rent and end up living on the street. Youth experiencing homelessness have a higher risk of being in a gang, using substances, feeling depressed, attempting suicide, or experiencing trauma and violence than their housed counterparts.

To measure progress in the housing priority area, Minnesota is tracking the proportion of Minnesota adolescents who report staying in a shelter, somewhere not intended as a place to live, or someone else’s home because you had no other place to stay in the past 12 months, collected every three years in the Minnesota Student Survey (MSS). Data from 2022 MSS showed that 2.9% of 8th, 9th, and 11th grade students reported staying in a shelter, somewhere not intended as a place to live, or someone else’s home because you had no other place to stay in the past 12 months.

Community-Identified Priority Need: Housing

Access to safe and affordable housing is connected to every aspect of people’s lives and is a critical factor in financial security, academic success, and the health and wellbeing of children, women, and families. Research shows that kids are more likely to do well in school if they aren’t worrying about where they will sleep, and adults are more likely to get and keep jobs, achieve financial security, and have good health and well-being when they have a secure home. Every person living in Minnesota should have a safe, affordable place to live in a thriving community but not all do.

Housing was consistently one of the most reported needs of children, women, and families throughout our needs assessment process. It was mentioned 752 times in the Discovery Survey, making it the second most stated need from respondent’s overall. Additionally, people that identified as African American/Black, American Indian, and Hispanic identified housing as the number one need in their communities with housing safety, affordability, and stability the three most mentioned themes related to housing.

Systemic racism has had and continues to have a significant impact on housing and homelessness across the state of Minnesota. Strategies to reduce housing disparities need to focus on addressing the deeply rooted structural barriers surrounding housing policy and access that result from systemic racism. Indigenous peoples in Minnesota continue to be affected by land theft and land treaties that were broken by the U.S. government. MDH, for example, occupies land stolen from the Dakhóta people. Multiple generations of Twin Cities residents were and are affected by discriminatory federal housing policies, zoning regulations, and lending practices that aimed to keep certain people in certain areas in specific types of housing. Redlining from early in the 20th century left a lasting effect on neighborhoods, with the zoning map for much of the city remaining largely unchanged from the era of overt racial segregation.

Since the year 2000, white and Asian households in Minneapolis have seen an increase in household income, while Black households have experienced an approximately 40% decrease in income during the same period.[8] Rising housing costs in the face of decreased income means that for many residents of Minneapolis, particularly people of color, few, if any, have access to affordable housing. North Minneapolis has seen a rise in single-family rentals owned by investors with at least three properties, according to the Urban Institute. While these examples are specific to Minneapolis, similar practices have impacted other communities in Minnesota, and housing disparities adversely impact much of the state.

Minnesota has one of the highest rates of owner-occupied home ownership in the nation at 75.6%.[9] However, when this statistic is stratified by race, a different picture emerges. In 2019, the home ownership rate for non-Hispanic white Minnesotans was 3.3 times greater than that of Black/African American Minnesotans. Minnesota has one of the largest gaps in homeownership between white and BIPOC residents – more progress is needed on housing and future efforts must focus on the disparities in home ownership that are created and maintained by systems of power and oppression.

As the cost of owning a home increases in Minnesota, there are less affordable rental homes and apartments every year. Minnesota has seen dramatic rent increases over the past few years with rents rising hundreds of dollars a month, sometimes doubling, leaving renters unable to afford their homes. This often leads to displacement, with people needing to double up with family and friends, seek temporary shelter, live in their cars, or live on the streets until they can find a new apartment. Homelessness can cause interruptions in employment, education issues for kids, and poorer health outcomes. If families do secure housing, over half of the lowest-income families in Minnesota spend more than 50% of their income on housing costs.

On a single night in January 2022, the annual nationwide point-in-time count of people experiencing homelessness identified 2,960 people in families and 7,917 individuals in Minnesota.[10] These numbers are unchanged from the 209 and 2020 point in time counts. Homelessness has a disproportionate impact on marginalized groups in Minnesota. Compared to the white, non-Hispanic population:

• Indigenous people are 30 times as likely to experience homelessness.
• Black people are 12 times as likely to experience homelessness.
• People of mixed race are 7 times as likely to experience homelessness.
• Hispanic people are 3 times as likely to experience homelessness.

Data from the new Minnesota Homeless Mortality Report, 2017-2021 released in 2023 found:

• The rate of death is 3 times higher among people who experience homelessness (PEH) in Minnesota than the general population.
• 20-year-olds experiencing homelessness in Minnesota have the same rate of death as 50-year-olds in the general population.
• Mortality across each racial and ethnic group is higher among PEH than in the general Minnesota population.
• American Indian PEH have 1.5 times higher rates of death than other PEH and 5 times higher rates of death than the general Minnesota population.
• Deaths from substance use are 10 times higher among PEH than the general Minnesota population.
• 1 in 10 substance use deaths in Minnesota are among PEH.
• 1 in 3 of all deaths among PEH are caused by substance use, especially opioids including fentanyl.

Strategies and Activities

A.  Strategy A: Expand Funding Opportunities

1.  State Level Activities

1. Promote Housing Support for Families through Homework Starts with Home

As one of Minnesota’s partners on the Governor’s Children’s Cabinet, Minnesota Housing and Finance Agency (MHFA) has a focus on providing housing support for families through Homework Starts with Home, a grant program focused on addressing homelessness and housing instability among students and their families. Outcomes of this grant program included reducing the number of students who become homeless for the first time, reducing the number of students and families who remain homeless, and reducing the number of students that experience homelessness at all. Grants were provided to housing programs that worked in collaboration with schools and early childhood programs. Additionally, programs needed to be responsive to specific community and cultural needs. The community-based grants could be used to provide temporary rental assistance, security deposits, rental application fees, housing inspection costs, and other undesignated costs, such as moving costs for families. MDH will continue to identify opportunities to support MHFA’s Homework Starts with Home grant program through the end of FFY2024 – when grant contracts are set to end.

1.2  Promote Continuum of Care Models to Focus on Homeless Prevention and Assistance

The Family Homeless Prevention and Assistance Program (FHPAP) is a MHFA program that provides supportive services and/or financial assistance to families with children and youth/unaccompanied youth who are homeless or at imminent risk of becoming homeless. Funds are intended for populations most disparately impacted and to ensure services are culturally specific to better reflect the needs of those being served. During FFY2022 these services were provided through 20 grantees that served all 87 counties in Minnesota.  The FHPAP is intended to complement a community’s Continuum of Care and provide funding for coordinated entry, street outreach, prevention, and rapid re-housing. Funds can be used for direct assistance (rent, utilities and other expenses to address housing crisis) or services (housing navigation, case management, outreach staff, coordinated entry assessment) to households who are at or below 200 percent of the Federal Poverty Guidelines and homeless or at imminent risk of homelessness.

2.  Local Public Health and Community Spotlight

1. Provide Prevention, Outreach, and Assessment through Continuums of Care

A Continuum of Care (CoC) is a community-based strategic plan that organizes and delivers housing and services to reduce the incidence of homelessness by assisting homeless youth and families with children to move into permanent housing. CoCs focus on prevention, outreach and assessment, emergency shelter, transitional housing, and permanent supportive housing. There are ten CoC regions within Minnesota that establish priorities for the household type of housing units needed within their region. During FFY2022, CoCs worked closely with state and local governmental agencies, homeless service providers, school districts and other community organizations to ensure that State and Federal funding reached individuals, families, and communities most at risk of experiencing homelessness from 2020-2022.

B.  Strategy B: Person-Centered Approach/Services

1. State Level Activities
   1. Increase Access to Safe and Affordable Housing for People who are Pregnant or Parenting Infants

Family Home Visiting (FHV)

In FFY2022, approximately 4% of families served were identified as homeless. Of the families identified as homeless, 4.5% were pregnant and 3.3% were parenting. Family home visitors are a resource for routinely screening for clients and families who are experiencing homelessness. Throughout this reporting period, family home visitors provided referral and support services to community resources to help find stable housing for families who were pregnant or parenting infants and/or young children. 

Positive Alternatives Grant Program

Established by the Minnesota State Legislature in 2005, the Positive Alternatives (PA) grant program provides funds to nonprofit organizations promoting healthy pregnancy outcomes by assisting low-income pregnant and parenting women in initiating and maintaining family stability and self-sufficiency. Twenty-seven PA grantees throughout Minnesota provide individual support services and work in collaboration with community resources to promote self-reliance and family stability. All services are provided at no cost to the client. 

Since inadequate housing is recognized as a barrier to healthy pregnancy and birth outcomes, all 27 PA grantees provided every client with a housing assessment along with housing assistance or community referrals for clients in need. Four PA grantees provided long-term residential housing including wrap around services for client support and self-sufficiency. In addition, 11 grantees provided rental assistance funds for clients needing stable and safe housing. In FFY2022 the total PA clients receiving residential housing support or financial/rental assistance totaled 447 participants. 

Also, in FFY2022 PA grantees served a total of 5,868 clients statewide. Of these individuals served 59% were from the BIPOC community, 20% were Hispanic, and 58% were between 18 and 29 years old. Forty percent of the PA grantees provide services in the Twin Cities area while the remaining 60% of grantee organizations are in rural communities throughout the state of Minnesota. In 2022 one grantee, through a network of 204 affiliate sites in Minnesota, provided 276 participants financial assistance for housing and related living expenses. 

1.2  Develop Cross-Sector Partnerships to Support Families Experiencing Homelessness

Calling All Sectors (CAS) is a Pew Charitable Trust and Robert Wood Johnson Foundation national collaborative intended to create lasting partnerships across state agencies and with community-based organizations to identify innovative solutions to public health issues – specifically, recognizing quality housing access and experiences with homelessness while pregnant or parenting a child under one as an indicator of infant mortality. As a participant in this project, MDH worked to address infant mortality disparities in African American/Black and American Indian communities with the goal to ensure that no child is born into homelessness, through identifying and engaging cross-sector partners and people with lived experience to generate systems level policies and strategies.

Specific questions guiding the project included:

• What actions can we take to create partnerships with alignment across communities and agencies with the goal of ensuring no child is born into homelessness?
• What actions can we take to develop a referral pathway for pregnant people with unstable housing and connect them to culturally specific resources?
• What actions can we take to expand funding and resources for affordable housing that will prioritize pregnant people with unstable housing?

Goals of the CAS project included:

• Identifying organizations and programs in Minnesota working to address the priorities identified by the CAS Team consisting of representatives from cross-sector state agencies, community-based organizations, and people with lived experience with pregnancy and homelessness.
• Identifying barriers within the systems we work in and determine solutions to address these.
• Identifying champions from our Home Team and Minnesota communities to engage more deeply with the CAS work to ensure no child is born into homelessness.
• Creating sustainability for this work to continue beyond the grant period and through collaboration across sectors and systems.

In FFY2022, the CAS team conducted the following activities:

• Engaged over 60 partners at the state, county, city, and community levels – as well as community members with lived experience – to identify the barriers to navigating services for pregnant people who are homeless.
• Completed a series of systems/process mapping workshops with partners – including the direct input and involvement of people with lived experience – to map the system/processes that those experiencing homelessness while pregnant or parenting a child under 1 have to engage with, including identifying what’s working well, where there are gaps, and where there are areas for improvement.
• With the CAS grant ending in June 2022, the CAS team worked with partners to develop a sustainability plan to determine how partners who had been involved in the project could brings pieces back into their own professional spaces to keep the work of the project moving forward.

C.  Strategy C: Create/Innovate Housing

1. State Level Activities

1.1  Provide Adequate, Dignified Shelter Options for Children and Families

The COVID-19 pandemic created additional burdens for families, leading to more families experiencing homelessness. A response priority for Minnesota was addressing the needs of homeless families by working closely with MHFA, the Minnesota Interagency Council on Homelessness (MICH), and local public health and human service departments. As a part of the MDH’s COVID-19 Incident Command Structure (ICS), a Title V staff was assigned as the lead for working with the homelessness population and families in emergency shelter (note: emergency shelter included both homeless shelters and domestic violence shelters). To expand and support the homeless response, MDH created a dedicated team that worked with residents and staff of homeless encampments, emergency homeless shelters, domestic violence shelters, board and lodges, transitional housing, and permanent supportive housing (PSH) to provide routine testing and vaccinations. Local hotels provided temporary shelter for families who were identified as needing to be isolated or quarantined. County-owned buildings that were vacant were converted to safe housing options for individuals and families experiencing homelessness. While this response was specific to COVID-19 response, it created partnerships and opportunity for beyond FFY2022. Many jurisdictions throughout the state, including MDH as the state health department, began re-evaluating what it means to provide adequate, dignified shelter, and what funding is needed, to improve and innovate as it relates to shelter options for children and families.

D.  Strategy D: Focus on Policy Change

1.  State Level Activities

1. Participate on the Minnesota Interagency Council on Homelessness (MICH)

The MICH is comprised of 11 state agencies, the Met Council, and the Governor’s Office, and is charged with leading Minnesota’s efforts to achieve housing stability for people experiencing homelessness in Minnesota. MDH is one of the 11 agencies participating on the MICH, including representation by MDH leadership. The Child and Family Health Division Director during FFY2022 was involved in the MICH’s activities prior to being assigned to the COVID-19 response. MICH developed Heading Home Together, an action plan to prevent and end homelessness, identifying what state agencies can do and is reflective of the input of people who have experienced homelessness, practitioners who work in the field, and Federal policy requirements and guidance. The focus of the Council in 2021-2022 was to prevent and end homelessness among youth and young adults unaccompanied by parents or guardians, as well as prevent and end homelessness among families with children.

1.2  Engage in the Justice Strategic Planning led by the MICH

In May 2021, the MICH recognized homelessness as the most egregious form of housing injustice and committed to focus its next strategic plan on housing, racial, and health justice (Justice Plan). With the transitions of Title V staff back into their normal roles following the COVID-19 response, and new staff hired in 2022, including a Title V Maternal and Child Health Block Grant Coordinator, Title V staff were able to begin re-engaging in the work of the MICH and Justice Strategic Planning in FFY2022 – with plans to continue this engagement.

Phase one of the Justice Plan development occurred May 2021-June 2022 – which included five working group meetings and three community conversations, in a community-driven process to develop a definition of housing, racial, and health justice for people experiencing homelessness. Phase two began in June 2022, with a commitment to the definition developed in phase one, and is focused on developing strategies to advance housing, racial, and health justice. Results from phase one that are driving strategy development include the following:

• Homelessness is prevented whenever possible, and services and supports are provided to ensure no one returns to homelessness.
• A robust crisis response geared towards housing outcomes supports people staying outside, in emergency shelters, and in community. 
• People facing homelessness have access to housing options that meet their needs and honors their choice.
• Homelessness is treated as a crucial health and public health crisis wherever it occurs.
• The state shares power with Indigenous, Black, Brown, Poor, LGBTQIA2S+ people and people who have faced homelessness to strengthen natural supports within community.

1.3    Prioritize the Interconnection between Health, Homelessness, and Housing to Drive Policy and Systems Change

Homelessness and health are interconnected, and MDH recognizes that homelessness and housing instability significantly impact community and MCH population health, MDH created a homeless-specific senior-level position. The Senior Advisor on Health, Homelessness, and Housing was hired in Spring 2022, and to the best knowledge of MDH and the CDC, the Senior Advisor on Health, Homelessness, and Housing is the first position of its kind at a state health department. This position will continue to work with state and local partners on public health and homelessness post-COVID, including as a lead in the MICH work around the Justice Strategic Plan. Title V staff will work closely with this staff member with a focus on the interconnections between homelessness, housing, and MCH population health.

Domain: Cross-Cutting/Systems Building

Reporting for October 2021-September 2022

Objective

By 2025, increase the percentage of adolescents reporting positive mental well-being by 10%.

State Performance Measure

(SPM 4) Percent of Minnesota Adolescents who report having positive mental well-being, fulfilling relationships, contributing to community, and being resilient. 

With so many factors that make-up mental well-being it is difficult to succinctly answer questions about population mental well-being with existing data. There are multiple composite measures of mental well-being proposed in the research and many commonly agreed upon components of mental well-being.[11] Ten components of mental well-being are captured in the Minnesota Student Survey: positive identity, social competency, personal growth, empowerment, social integration, educational engagement, and positive family, community, teacher, and peer relationships. Positive mental well-being is measured by combining multiple components of well-being to create an overall well-being score. We are choosing this measure because of how richly it captures the multi-factorial nature of mental well-being.

In 2022, 27.7 percent of Minnesota adolescents (grades 8th, 9th, and 11th) reported having high mental well-being (i.e., having 8 to 10 of the mental well-being components) (Figure 1).

Figure 1. Proportion of Minnesota Adolescents reporting mental well-being components

Data Source: Minnesota Student Survey

Community-Identified Priority Need: Mental Well-Being

Minnesota recognizes mental well-being as more than the absence of illness. Mental well-being is about having fulfilling relationships, utilizing strengths, contributing to community and being resilient, which is the ability to bounce back after setbacks. Mental well-being is a core ingredient for success in school, work, health, and community life. Poor mental well-being, with or without the presence of mental illness, is a risk factor for chronic disease (cardiovascular, arthritis), increased health care utilization, missed days of work, suicide ideation and attempts, death, smoking, drug and alcohol abuse, physical inactivity, injury, delinquency, and crime.

Minnesota’s efforts to build capacity for mental health promotion and prevention involves working to 1) expand understanding about what shapes mental health, 2) expand community capacity to create change (e.g., leadership development), and 3) focus on policy as key drivers of change. Everyone needs opportunity to learn and practice skills to manage life and engage in the world. Skills to manage stress, find balance and focus, and engage socially are critical components that should be cultivated throughout the lifespan in both formal and informal settings. Skills and experiences that help people feel valuable and engaged in their family, community and economy are also critical.

Strategies and Activities

A.  Strategy A: Help Communities Build Mental Well-Being Capacity and Resilience

1.  State Level Activities

1. Develop an Outreach Plan for the Existing Minnesota Thrives Tool

Minnesota Thrives is an interactive and collectively sourced database to provide communities with a meaningful list of mental health promotion strategies, opportunities to connect and learn from others doing this work, and a comprehensive picture of current activities and gaps to support mental well-being. In FFY2021, the Minnesota Thrives tool was revised and launched with support from a workgroup that included staff from local public health, university extension, nonprofit organizations, and CFH and other MDH divisions. The workgroup, in partnership with MDH Communications staff, developed a comprehensive outreach plan. Throughout FFY2022 the workgroup prepared to launch a campaign to get 1,000 entries in the database. The following key steps were completed: 

• Finalized development of the site, a process to maintain the database, and utilization tracking with state IT partners. 
• Pre-populated the database with over 100 entries. 
• Hosted a formal campaign launch in January 2022 with a 2-hour webinar for Mental Well-being and Resilience Learning community, and hosted subsequent weekly office hours for direct support to submit content. 
• Shared the Minnesota Thrives launch announcement broadly through dozens of list-servs and social media channels, with a social media toolkit for partners and three videos to promote initiatives. 
• Created a monthly email, Minnesota Thrives Spotlight, to highlight initiatives that have submitted materials to the database.
• Developed a community champions program to highlight counties with a certain number or range of initiatives submitted. 

MDH promoted the tool internally and externally through the following training/professional development opportunities:

• Comprehensive Suicide Prevention grantee communications
• KMOJ Radio Station – a community-based radio station uplifting communications for communities of color
• The Peer Mental Health Leadership Conference - March 1, 2022;
• The Immigrant and Refugee Health meeting
• A Local Public Health Association webinar
• The Annual Growing Resilient Communities Gathering of Collaboratives & Tribal Nations Addressing ACEs – hosted by Family Wise in June 2022. 

1.2  Build Support for Expanding Community-Based Program Models Statewide

The Mental Well-being and Resilience Learning Community has highlighted many examples of community-based mental well-being strategies in Minnesota each month since 2017. Though several programs have garnered significant community interest, local leaders have identified a need for additional training and financial support to make these available and sustainable. With increased awareness of the models among key leaders, we can better identify opportunities to incorporate these into existing grants or programs. The learning community also hosted a number of webinars from January through September 2022 that amplified community-based program models, including: 

• The Confess Project in Minnesota: A Mental Health Barbershop Movement – an organization committed to building a culture of mental health for Black boys, men, and families by empowering barbers and others to talk about mental health and well-being, as well as bridging the gap in Black communities between unmet health needs and mental health care.
• The Creative Respond Fund with Arts Midwest – a project uplifting art as a powerful source of healing for individuals and communities, and which provides artist-led creative healing and support to Minneapolis Communities with particular attention to those who continued to be directly impacted by the lasting effects of the pandemic and the murder of George Floyd at the hands of Minneapolis Police in 2020.
• The Communities of Belonging Initiative – a project that supported communities to explore and implement strategies to improve the sense of belonging for everyone in their community, after identifying belonging and well-being as a community need in the Minnesota Community Health Improvement Plan (CHIP).
• Stronger Together Inspiring Resilience (STIR) – a network of community members, as well as leaders from the faith community, health care, education, substance use prevention, mental health and county systems, who are all invested in promoting well-being and resilience together. 

Additionally, in FF 2022, MDH aimed to build awareness, capacity and funding for community led supports for mental health across the population, through collaboration with partners. One partnership, WellShare International, is now contracting with Living Life to the Full developers to implement training for community health workers in several marginalized communities including Somali, Oromo, and Latinae communities.

1.3  Partner with Key Stakeholders to Develop Shared Objectives and Establish the Minnesota Community Resilience Learning Cohort

Communities need to have a deep understanding of what a comprehensive public health approach looks like, and what they currently have available. The objective of the Community Resilience Learning Cohort was to help develop a process in partnership with local communities to help them assess established community-based strategies for mental health promotion and to identify interest and opportunity for new evidence-based strategies to be utilized in each community. A grant to support this activity was delayed, and the budget was significantly reduced, which resulted in the learning cohort being dropped from the grant. In addition, the intended partners in this project were deeply invested in COVID efforts through most of the reporting phase. However, this objective has maintained relevance and has surfaced in various planning efforts since then, including an intensive planning effort in September 2021 and independently among several local public health leaders thereafter. In FFY2022, MDH regrouped to assess how this concept could build on the Suicide Prevention cohorts and if there is appetite to engage with one or two communities in this process.

2.  Local Public Health and Community Spotlight

1. Build a Culture of Mental Health for Black Boys, Men, and Families

The Confess Project is a national organization committed to building a culture of mental health for Black boys, men, and families by empowering barbers and others to talk about mental health and well-being, as well as bridging the gap in Black communities between unmet health needs and mental health care. In 2020, Kente Circle and Kente Circle Training Institute, a mental health agency in Minneapolis, began implementing the Confess Project in Minnesota, training over 30 barbers across the state in identifying common mental health conditions, active listening, using trauma-informed language, and healthy coping skills. “In the program, barbers and hairstylists are trained to spot mental health challenges from the moment a client sits in the chair. They also have the tools to point them in the direction of mental health resources.”[12]

B.  Strategy B: Implement a Public Health Communications Campaign on Mental Well-Being Across the Lifespan

1. State Level Activities

1.1  Expand Understanding of Key Research and Current Strategies to Support Social Connectedness and Other Factors that Influence Mental Well-Being

In FFY2022, MDH finalized a draft comprehensive summary of research and measures that was reviewed with key partners in FFY2021. This summary includes content regarding the scope of the issue surrounding social isolation and loneliness, language, data sources, and examples of community initiatives across different sectors. 

The Mental Well-being and Resilience Learning community has also continued to promote examples of community strategies to address social isolation and loneliness through monthly webinars. We highlighted a range of relevant initiatives including those mentioned in Strategy A, Activity 1.3 above.

In Spring 2022, MDH staff partnered with the Center for Community Health, an association of metro county health plans and local public health leaders, to plan a community dialogue about social connectedness and what these sectors can do to address it.

1.2  Partner with the Preschool Development Grant (PDG) staff on Shaping a Trauma-Informed Toolkit and Training Modules

Funding through the PDG supported a contract with the Minnesota Association of Children’s Mental Health to develop a trauma-informed toolkit for professionals working with families with young children. This toolkit provides an educational roadmap for professionals to continue to learn and implement trauma informed practices.  The complete toolkit is available here: Resources for Healing-Centered Practice – MACMH | MACMH, and includes several online training modules that can be used to educate and engage early childhood professionals. These modules provide an accessible way to learn about trauma, view various resources, and learn practical information about how to support children and families who may have experienced trauma. 

Throughout FFY2022, MDH staff participated in the advisory council for developing the trauma-informed toolkit and helped to disseminate the toolkit to various provider groups. While this work was completed at the end of FFY2022, MDH will continue to share the toolkit with new audiences across communities.

1.3  Identify Opportunities to Develop and Implement More Formal Marketing Campaigns on Mental Well-Being, Trauma, and Resilience

In FFY2021, MDH staff across multiple divisions developed a communications toolkit called #StayConnectedMN for organizations and communities to have a prepared series of messages about mental well-being. In FFY2022, this communications toolkit was revised and shared broadly with communities and organizations. Over 100 organizations participated in the campaign in some way. MDH also promoted several websites developed by counties to promote evidence based positive psychology tools. For example, the Strong Together Inspiring Resilience (STIR), Stearns County Yellow Zone Project and The People Project. While these are not the comprehensive mental health campaign imagined, the COVID-19 pandemic created urgent demand for immediate resources and limited capacity to develop a comprehensive marketing campaign. Minnesota will identify opportunities to support and/or develop a more comprehensive outreach and communications campaign to promote mental well-being and resilience.

2.  Local Public Health and Community Spotlight

2.1  Create Essential Building Blocks for Communities to Build a Community of Belonging

In 2021, Carver County Public Health launched the Communities of Belonging Initiative – a project that supports communities to explore and implement strategies to improve the sense of belonging for everyone in their community, after identifying belonging and well-being as a community need in the Minnesota Community Health Improvement Plan (CHIP). Eight communities were invited to participate with each community participating in various ways, including: outreach, assessment, development of a common language and framework around belonging, and implementation of developed tools. At least three county commissioners, along with three local city council members, have participated in this work to date, with the direction and pace led by community.

C.  Strategy C: Advocate for Legislative Policies that Promote Mental Well-Being for Everyone

1. State Level Activities

1.1  Develop and Support Infrastructure for Community-Initiated Care

In January 2022, the Governor’s Children’s Cabinet and DHS sponsored a four-day summit on Children’s Mental Health, during which MDH facilitated a mental health promotion and prevention workgroup with sixty participants. The workgroup recommended the state work to build key infrastructure to support non-clinical community-initiated care. These recommendations contributed to a proposed state legislation in the 2023 legislative session that would establish a grant program for communities to implement a Community-Initiated Care Model for mental health and well-being.

1.2  Partner with Key Stakeholders to Identify Policies and Practices to Support Mental Well-Being

Reimagine Black Youth Mental Health Initiative

In 2022, MDH launched the Reimagine Black Youth Mental Health Initiative in collaboration with the Brooklyn Bridge Alliance for Youth– supported through a federal grant from the Office of Minority Health. This is a policy demonstration grant that engages local partners to identify, assess, implement, and evaluation specific policies that will improve Black youth mental health. The Reimagine Black Youth Mental Health Initiative has three goals:

• Improve Black youth mental health
• Design a process that includes Black youth and communities in policy development
• Implement a mental health in all policies approach.

Statewide Health Improvement Partnership (SHIP)

SHIP is an initiative that supports every county in the state to improve health through a policy, systems, and environmental approach. SHIP supports community-driven solutions to expand opportunities for active living, healthy eating, and commercial tobacco-free living, helping all people in Minnesota prevent chronic diseases. During FFY2022, Title V staff continued to coordinate with SHIP to identify potential policy and system strategies that support mental health and well-being. This included facilitating a Mental Well-being Think Tank to assess potential evaluation and measurements to use with communities, guiding conversations to think more specifically about how to measure mental well-being within communities and how to implement policies and practices while capturing data to measure the impact.

1.3  Identify Public Health-Focused Recommendations for the 2022 State Mental Health Advisory Council Report

MDH staff participated on the State Mental Health Advisory Council and facilitated the Family Systems and Prevention Workgroup. The workgroup purpose was to identify policy recommendations, for the 2022 State Mental health Advisory Council Report, that could do the following:

• Help families with peer support, especially social and emotional support for those who have a child with a special health care need, including mental health. 
• Help families navigate systems when a child first presents with a mental health need before they enter any formal system of supports. 
• Help families manage stress and create a more nurturing environment for children, including programs that are available to all families. 
• Support youth and families with increased risk factors (e.g., families with an incarcerated parent, children in foster care), in crisis, and/or use higher levels of care. 

The Workgroup developed four proposals, which were all approved by the full Advisory Council and included in the 2022 State Mental Health Advisory Council Report to the Governor, including:

• Expanding wraparound care through the system of care initiative
• Expanding family peer support opportunities
• Growing family supports in schools
• Building community-initiated care to support young people and families. 

1.4  Promote Policy, System, and Practice Changes to Support Children of Incarcerated Parents

An estimated 13% of youth in Minnesota have an incarcerated or previously incarcerated parent, making parental incarceration one of the most frequently reported ACE for this population (MSS, 2022). Additionally, Minnesota youth with an incarcerated parent have increased risk of poor mental health and illness, substance abuse, and poor academic outcomes. During FFY2022, Minnesota engaged in the following activities attempting to promote policy, system, and practice changes to support children of incarcerated parents:

• Hired a project coordinator to support the Minnesota Model Jail Practices Learning Community in January 2022. The Model Jail Practices Learning Community aims to improve parent-child relationships, reduce recidivism, increase child wellbeing, and improve public safety.
• Organized a second Parenting Inside Out cohort training – an evidence-based, cognitive-behavioral parent management skills training program created for incarcerated parents – which occurred in August 2022 and included 23 participants for a total of 44 PIO facilitators trained through this learning community initiative for jail and partner staff in Carlton, Ramsey, and Stearns County Jails. Each of these jails launched the PIO course despite the ongoing challenges with COVID and limitations on group meetings. 
• Partnered with the UMN and Minnesota Sheriff Association to develop an online modular training focused child development, trauma, and opportunities for jails to implement model practices that support children of incarcerated parents.  This training included a spotlight video from several of the DOJ partners about their family friendly initiatives and was finalized and incorporated in the Minnesota Sheriffs Association online training programs – available for all jails across the state.
• Began planning for the documentary tool to highlight the efforts and impacts of the Model Jail Practices Learning Community, including selecting a videographer and orienting them to the project efforts and scope. 
• Hosted a training on children of incarcerated parents for the Minnesota Housing Finance agency joint housing grantee meeting in February 2022. 
• Modified the Attitudes Related to Trauma Informed Care for jail settings to pilot the tool with partner jails to get baseline data about jail staff attitudes. 
  

Domain: Cross-Cutting/Systems Building

Reporting for October 2021-September 2022

Objective

By 2025, increase the percentage of children, ages 0-17, living with parents who are coping very well with the demands of parenthood by 5%.

State Performance Measure

(SPM 5) Percent of children, ages 0-17, living with parents who are coping very well with the demands of parenthood.

When parents and caregivers receive adequate support, they are more likely to be able to cope with the day-to-day demands of parenthood and can then build a safe and healthy home environment for their family. According to the 2020-2021 NSCH, only 56.2% of children in Minnesota are living with parents who report they are coping with the day-to-day demands of parenting very well. This is down from 59.4% in 2019-2020 and 63.3% in 2018-2019 (Figure 1). Minnesota’s goal for FY2022 was 66.5% - Minnesota did not meet our goal for FY2022.

Figure 1. Percent of children, ages 0-17, living with parents who are coping very well with the demands of parenthood

Community-Identified Priority Need: Parent and Caregiver Support

A major factor in a parent/caregiver’s ability to provide a safe and healthy home for their children is having needed resources and supports available to them. It is particularly important for parents to get support when they feel overwhelmed or stressed. Parents need a network of supportive relationships, strategies for coping with stress, resources, knowledge, and an understanding of child development. Unfortunately, a lack of these critical supports can cause otherwise well-intentioned parents to become overwhelmed and at times result in abuse or neglect. According to the Zero to Three National Parent Survey, almost half (48%) of parents of young children do not feel they are getting the support they need when they feel stressed – with moms being more likely to say they have inadequate support than dads (57% vs. 39%).

There are many reasons why parents and caregivers feel they receive inadequate support in parenting. Partners participating in the Strategy Team related to this priority area reported some of the following contributors to the problem:

• Many parents/caregivers report feeling isolated because they do not have a support system (formal or informal) built around themselves.
• Employers do not provide the wages, flexibility, or paid leave needed to support parents/caregivers.
• There is a lack of resources available to parents from diverse geographic or cultural/racial backgrounds related to parenting support and education.
• There is a societal-level stigma against asking for help that prevents parent/caregivers from seeking support or resources – this stigma is particularly pertains to seeking emotional/mental health support and is especially prevalent in certain racial/ethnic groups.

Figure 2. Proportion of children who have parents that had had someone they could turn to for day-to-day emotional support with parenting or raising children in the past 12 months, by Race/Ethnicity, 2020-2021

Parents and caregivers of color and those who have children and youth with special health needs (CYSHN) are especially impacted by having inadequate support. The 2020-2021 NSCH found that 80.2% of all children have parents who, during the past 12 months, had someone they could turn to for day-to-day emotional support with parenting or raising children. Emotional help received is significantly higher for children who are non-Hispanic white (88.8%) compared with non-Hispanic Asian (59.9%), Hispanic (59.9%), and non-Hispanic Black children (54.3%) (Figure 2).

In addition, parents of CYSHN report spending several hours having to coordinate their child’s health care, subsequently then also reporting that they are more likely to have had to quit or change their jobs. They are also less likely to have someone they can turn to for day-to-day emotional support even though they express higher levels of stress (aggravation) in parenthood.

Strategies and Activities

A.  Strategy A: Advocate for the Redesign of a Network of Policies and Programs to Better Support Families

1. State Level Activities

1.1  Coordinate between Title V and FHV Initiatives to Serve More Families through FHV

Minnesota has worked to strengthen partnerships between our Family Home Visiting and Title V initiatives. Both initiatives are housed in our Child and Family Health Division, and our leadership structure actively promotes collaboration between the two programs. A need was identified in FFY2022 for better understanding for FHV Section staff of the umbrella of Title V and how family home visiting fits under that umbrella.

During FY2021, we had hoped to begin work on better understanding home visiting services provided via Title V funding; unfortunately, limited staffing capacity due to reassignments to the state’s COVID-19 response prevented us from being able to dig into this during the reporting period. We plan to continue this exploration.

1.2  Advocate for Policies that Promote and Support the Well-Being of Parents/Caregivers

Minnesota began the work to bring together partners to advocate for policies that promote and support the well-being of families – such as paid family leave, child tax credits, student loan forgiveness, work flexibility, living wages, and other areas. As with many other activities planned, the COVID-19 pandemic caused us to have to shift our focus away from this work to more immediate needs of families. We plan to regroup and figure out a plan for this advocacy work in FY2023 and FY2024.

B.  Strategy B: Build Capacity of Public Health Professionals and Family Home Visitors to Help Improve the Mental Health, Well-Being, and Resilience of Families

1. State Level Activities

1.1  Provide Training for and Support the Implementation of Best Practices Amongst Public Health Professionals and Family Home Visitors

The main activity aimed at building capacity of public health professionals is providing training and supporting the implementation of best practices. During FY2022, MDH FHV continued to promote on-line trainings that were developed by The Institute for the Advancement of Family Support Professionals that provide best practice principles and strategies to support home visitors. Regular reminders of these new and recorded webinars were published in the Family Home Visiting Tuesday Topics weekly newsletter that goes out to a listserv for family home visitors and other interested stakeholders in Minnesota.

1.2  Providing Training on Postpartum Depression Screening for Health Care Providers

In FFY2022, Child and Teen Checkups (C&TC) changed the wording from “maternal depression” to “postpartum depression” to reflect gender neutral language and recognize that any caregiver can experience postpartum depression and receive related screenings during C&TC visits. Additionally, C&TC Best Practices trainings include information about postpartum depression screening. Two live webinar Best Practices trainings were provided to 23 medical professionals, including public health nurses, community outreach workers, and school nurses. In FFY2022, the Best Practices webinars reached three advanced practice registered nurses (APRNs) and 24 family nurse practitioner students. In-person Best Practices trainings reached one APRN and 34 family nurse practitioner students, for a total of four APRNs and 58 students who will be entering provider practices and providing postpartum depression screening.  

C.  Strategy C: Build Supports for Multi-Faceted Ways for Parents/Caregivers to Connect with One Another

1. State Level Activities

1.1  Connecting Families to Family-to-Family Support

Family-to-Family support is an integral part of a comprehensive system of care for CYSHN and their families. In Minnesota, family-to-family support is provided by Head Start, Early Childhood Family Education, the University of Minnesota’s Extension Offices, Family Wise, mental health providers, and many other community-based organizations. During FY2022, Minnesota’s family-to-family support was provided via two main programs: 1) a family-to-family support program for parents of children identified as deaf or hard of hearing – MN Early Hearing Detection and Intervention Program Parent Support, and 2) the Family Support and Connections Program for the broader population of families of CYSHN. Both these programs provide support and assistance to families in navigating the system of care.  

Early Hearing Detection and Intervention (EHDI) Program Parent Support.   

Minnesota’s EHDI Parent Support Program is housed in the CYSHN section of MDH and is a statewide parent support program for families of children who are deaf or hard of hearing. During FFY2022, family-to-family support was provided via a grant agreement with Minnesota Hands and Voices. The program utilized trained parents of children who are deaf or hard of hearing as parent guides. The guides are located throughout Minnesota, and many are from diverse communities including East African, Southeast Asian, and Spanish-speaking communities. Parent guides contact each family of a child newly identified as deaf or hard of hearing through the state’s Early Hearing Detection and Intervention program to provide ongoing parent support, information and referral, education, and networking opportunities. During FFY2022, 288 families of children newly identified as deaf or hard of hearing were served through the EHDI Parent Support Program.  

Family Support and Connections Grant Program  

MDH’s grant agreement with Family Voices of Minnesota to implement our Family Support and Connections Program ended in August 2022. MDH decided to discontinue funding this program as more statewide funding has become available for parent support. As a Title V program, we are also shifting our focus from funding direct parent-to-parent support toward work that can have a transformative impact on the system of care for CYSHN and their families. We discuss this new focus on building capacity of family serving organizations in Strategy C. 

That said, we still worked with Family Voices of Minnesota for most of FFY2022 and funded enhancements to the implementation of their Connected program. The Connected program includes the following components:  

• Provides outreach and support to families to help them connect with needed services and supports through a family peer-to-peer support model that utilizes trained parent/caregiver community navigators who assist families in a nonjudgmental manner.  
• Provides training to families and other stakeholders on navigating the health, human services, and education systems, including training on the principles of medical home and care coordination, and on insurance/financing options.  
• Assists the MDH CYSHN Program in assessing and reporting on the needs of families with CYSHN across the state, which can include utilizing and disseminating information gathered from conducting peer-to-peer support or other focus group or family input opportunities.  
• Educates families on the availability and benefits to the medical home structure and care coordination to ease familial stress and improve health and wellness outcomes for CYSHN and their families.  

During FFY2022, 324 families were served through the Family Support and Connections Program, with 2,661 instances of individual support, assistance, and training provided. The program facilitated 64 parent support groups, including a dad’s group, early childhood group, groups in the Twin Cities metro, Brainerd, and St. Cloud areas, and a Somali-speaking group. Family Voices of Minnesota provided individual assistance to 62 professionals/providers, and 528 instances of service or training for professionals/providers.

[1] Minnesota Health Access Survey (aged 0-64), 2021

[2] NSCH 2020-2021

[3] Minnesota Study of Telehealth Expansion and Payment Parity: Technical Advisory Group - MN Dept. of Health (state.mn.us)

[4] US Census American Community Survey (ACS) Microdata Sample, 2021

[5] US Census American Community Survey (ACS) Microdata Sample, 2021

[6] Minnesota Report Card, 2022

[7] Minnesota’s Out-of-home Care and Permanency Report, 2020

[8] Minneapolis|2040 - Housing. https://minneapolis2040.com/topics/housing/

[9] U.S. Census Bureau, Current Population Survey/Housing Vacancy Survey, March 15, 2023.

[10] Minnesota’s Homeless Management Information System (HMIS). Point of Time Counts.

[11] Reitzner, Michelle M., (2014). Signature Well-being: Toward a More Precise Operationalization of Well-being at the Individual Level. Master of Applied Positive Psychology (MAPP) Capstone Projects. Paper 64. 

http://repository.upenn.edu/mapp_capstone/64

[12] Minnesota barbers and hairstylists receiving mental health training - KSTP.com 5 Eyewitness News