- Racial Equity Institute Training: Support staff to attend the Racial Equity Institute (REI) training to increase knowledge of health equity and the impact of racism on health outcomes. www.racialequityinstitute.com/
- Motivational Interviewing (MI) Training: Support staff to attend a two-day interactive training session, provided at most Area Health Education Centers (AHECs), focused on learning and practicing communication skills and strategies to increase motivation of clients and success in achieving lasting behavior change.
- Laptops Purchase: Purchase laptops for OBCM and/or CC4C staff members to provide access to Virtual Health.
- CFPTs Support: One-time purchase to support the needs of the CFPT in meeting its mandate which may include items such as a laptop or tablet for electronic data entry, car seats, play yards, and educational materials on topics such as safe sleep, infant plan of safe care, bicycle safety, and four-wheeler safety.
- Teen Friendly Clinics Upgrade: One-time purchase to set up or upgrade waiting areas and exam rooms to be more teen friendly. This includes work such as waiting area and exam room renovations and purchases of items such as posters, artwork, large monitors and DVD players to show looping educational DVDs, new furniture, accessible Wi-Fi, magazine subscriptions, computer/Internet stations, and charging stations. LHDs were to engage teens in the design upgrades.
- Equipment Purchase: One-time purchase of hearing screening equipment, vision screening equipment, laptops for clinical staff, and ADA accommodations (weigh scale for wheelchairs, adjustable exam tables, widening doors, automatic doors, ramps, wheelchair accessible bathrooms, etc.).
- Reproductive Life Planning Engagement: Engage women and men through use of “One Key Question – Would You Like to Become Pregnant In the Next Year?”, increase access to long-acting reversible contraception (LARC), and/or support women and men with implementing their reproductive life plan.
NPM#14.1 – Percent of women who smoke during pregnancy
NPM#14.2 – Percent of children who live in households where someone smokes
The WCHS is working hard to decrease the percent of women who smoke during pregnancy (NPM#14.1) and the percent of children who live in households where someone smokes (NPM#14.2). While birth certificate data prior to 2011 are not comparable because of the state’s change to the 2003 Revised Standard Birth Certificate in 2010, between 2011 and 2013, the percentage of women in NC who smoke during pregnancy remained just under 11% and this percentage dropped to 8.4% in 2018. Women with less education, those who are between 20 to 29 years of age, those on Medicaid, those who are unmarried, and those who are non-Hispanic White or non-Hispanic American Indian are more likely to smoke in NC than their counterparts. Per 2018 National Vital Statistics System data for NC, non-Hispanic Asian (.6%) and Hispanic women (1.6%) were least likely to smoke during pregnancy and American Indian women were most likely to smoke (21.8%). Non-Hispanic Black women (7.6%) were less likely to smoke than non-Hispanic White women (10.8%) or women of multiple races (11.4%). The 2017-18 NSCH indicated that 15.4% of children in NC lived in households where someone smoked as compared to 14.9% nationally. Children who are between 12-17 years old, whose parents are Black or White non-Hispanic, who live in households at less than 100% of poverty, and who live with single parent or unmarried parents are more likely to live in households with someone who smokes.
NC has a robust partnership of state and LHD partners, universities, and community-based organizations involved in efforts to decrease tobacco use and exposure. Efforts center on prevention, education, counseling, and care coordination. Tobacco screening and counseling is infused within all programs supported by DPH. The Women and Tobacco Coalition for Health (WATCH) shares and disseminates information associated with women's health and tobacco use prevention and treatment across the lifespan. Healthcare providers, including LHDs, are the major partners in the tobacco cessation effort for pregnant women. Support provided to program partners includes training, technical assistance, strategic planning, and educational materials development and dissemination around tobacco cessation treatment. WATCH assisted in the latest development and update of the You Quit Two Quit Practice Bulletin (issued May 2019; available at https://youquittwoquit.org/wp-content/uploads/2019/07/YQ2Q-Practice-Bulletin-May-2019.pdf). This 2019 update included a focus on perinatal substance use. This is one of several provider and patient tobacco cessation materials developed and distributed to health care partners throughout the state. All materials are distributed free of charge.
The WHB and C&Y Branches partner with the Tobacco Prevention and Control Branch (TPCB) to support continuing education training for health and human service providers and worked with other programs within DPH to ensure that the tobacco cessation and prevention efforts are embedded in their program efforts. In addition, LHD maternity clinics provide prenatal care which is inclusive of provision of tobacco cessation counseling for pregnant women. The staff in these clinics utilize the evidenced-based best practice 5A’s method for counseling about smoking cessation. This method includes screening and pregnancy-tailored counseling and referrals for pregnant women who use tobacco, with one of the primary referrals being to QuitlineNC, a free phone service available 24 hours a day, seven days a week to all North Carolinians to help them quit using tobacco. The www.quitlinenc.com website also has web coaches available and includes resources about helping others quit and secondhand smoke. Pregnant callers are enrolled in an intensive 10-call coaching series provided by a team of dedicated pregnancy quit coaches. LHD family planning clinics also utilize the 5A’s method in working with women and men of childbearing age, including adolescents.
Child health clinic providers in LHDs include efforts around assessment and counseling during preventive well child visits for youth tobacco use and for secondhand smoke exposure by caregivers during all well child visits for children and youth. In February 2019, staff from the TPCB provided a live and archived webinar to child health care professionals in LHDs about tobacco use and QutlineNC.
One strategy which will help NC improve in both NPMs#14a&b is to increase utilization of QuitlineNC, particularly by women of reproductive age (15 to 44 years). Thus, the WCHS has selected the following measure as its ESM for NPM#14a: number of women of reproductive age (15 to 44 years) who received at least one counseling session from the tobacco QuitlineNC in the prior 12 months. In FY14, there were 2,421 women who completed at least one counseling call, and there were 1,652 women in FY19. Of the women who were counseled, 5% were pregnant. Most of the women counseled used cigarettes only (78%); however, 17% were dual users of cigarettes and e-cigarettes in FY19 which double the dual users in FY16 (6.7%). In FY19, there were 12,082 total calls to QuitlineNC, with 19% of these being women of childbearing age (15-44 years). During FY19, there were 130 women of childbearing age who were pregnant, planning pregnancy, or breastfeeding who entered into the QuitlineNC pregnancy protocol.
In FY18, the WCHS also added ESM 14.2 (number of women who receive tobacco cessation counseling by care managers and/or home visitors) to its State Action Plan in an effort to help decrease the percent of children, ages 0 through 17, who live in households where someone smokes (NPM#14b). In FY19, at least 64,600 women received tobacco cessation counseling from CC4C case managers and other home visitors through NFP and Healthy Families America. OBCM case managers also provided tobacco cessation counseling, but data for FY19 on how many women received counseling is not available.
The PMC continued to serve as the medical director for QuitlineNC and provide advice and consult with other experts about protocols for nicotine replacement therapy for men and women, including women who are breastfeeding or pregnant.
The WHB continues to partner with the You Quit, Two Quit (YQ2Q), a program of the UNC CMIH. The goal of YQ2Q is to ensure that there is a comprehensive system in place to screen and treat tobacco use in women and pregnant and postpartum mothers. This project is unique in its focus on low-income women, new mothers, and recidivism prevention. In FY19, over 870 professionals, including physicians, nurses, certified nurse midwives, physician assistants, billing specialists, health educators, and social workers, were trained through YQ2Q to provide evidence-based tobacco cessation counseling to women of reproductive age. Fifty-seven trainings were conducted serving health care professionals from 100 organizations that serve women of reproductive age, including 56 LHDs, 13 Federally Qualified Health Centers, and six private practices. Professionals from 62 counties were trained, 16 of which had maternal smoking rates at least 1.5 times the state average.
The WHB continued distribution of smoking cessation materials to LHDs, hospitals, and private providers. These materials, available in English and Spanish, include:
- If You Smoke and Are Pregnant (maternal smoking brochure)
- Oh Baby! We Want to Keep You Safe from Secondhand Smoke (secondhand smoke brochure)
- You Quit, Two Quit (postpartum brochure)
- E-Cigarettes and Vaping
- Benefits of Being Tobacco Free/Facts About E-Cigarettes
- Tobacco Cessation and Counseling 5As/5Rs Pocket Card (provider resource)
- We Know You Want to Protect Your Family (secondhand smoke focused on male partners).
A Guide for Helping to Eliminate Tobacco Use and Exposure for Women (training manual) is hosted on the WHB webpage and on the YQ2Q webpage. These materials are also available for download on the WHB website and partnering organizations’ websites (e.g., mombaby.org and EveryWomanNC). The WHB partnered with the TPCB and YQ2Q to provide 5 A’s tobacco cessation counseling training for LHDs and health care clinics. YQ2Q also produced the 2019 Practice Bulletin for health care practitioners.
With tobacco use during pregnancy being a prevalent risk factor for preterm birth, emphasis on interventions to assist women with tobacco cessation continue to be a priority for Pregnancy Care Managers. Medicaid recipients who report tobacco use at the same level as prior to pregnancy most likely will have a Maternal Infant Impactability Score of >200 to receive Pregnancy Care Management services. Among all of the priority risk factors for OBCM, tobacco use is the most prevalent. All women assessed by the Pregnancy Care Management Program receive the 5A’s counseling and the appropriate level of tobacco cessation intervention. Special emphasis is placed on harm reduction and postpartum relapse prevention, as well as the dangers of infant exposure to secondhand smoke. The PMH program has a companion piece for prenatal care providers that aligns with the Tobacco Cessation Pathway for care managers and guidance for screening and documentation of care management activity related to tobacco use in pregnancy and postpartum which will continue to serve as a resource.
The Healthy Beginnings program conducted assessments for tobacco use and secondhand smoke exposure with 492 pregnant and interconception minority women at enrollment and during monthly care coordination contacts in FY19. Program staff provide tobacco cessation counseling using the 5As brief tobacco counseling intervention, educational materials and referrals to QuitlineNC.
The Infant Mortality Reduction program provides funding to LHDs in counties that have experienced high infant mortality rates to implement at least one evidence-based strategy proven to lower infant mortality rates. Under the tobacco cessation and prevention strategy, LHDs provide tobacco use screening and counseling to all clients during health care visits. Tobacco cessation counseling services are provided by trained staff using the 5A’s brief tobacco counseling intervention and a trained certified tobacco treatment specialist. Clients are referred to QuitlineNC and/or appropriate community resources, and offered U.S. Food and Drug Administration (FDA) approved tobacco treatment pharmacotherapy support when clinically appropriate. In FY19, the four LHDs that implemented the tobacco cessation and prevention strategy screened 6,679 clients and counseled 120 clients who reported tobacco use.
ICO4MCH project sites provided tobacco cessation and prevention trainings during FY19 to reduce infant mortality and improve health status of children, ages 0-5. There were 170 practitioners trained in 5A’s, and 47 practitioners trained in becoming Certified Tobacco Treatment Specialist (CTTS). ICO4MCHsites also increased the number of public policies for smoke-free or tobacco-free workplaces and other indoor public places within the project service area. In addition, through the Clinical Efforts Against Secondhand Smoke Exposure (CEASE) strategy, a total of 3,380 children ages 0-5 were screened, and CEASE clinics began documenting parental smoking status in the child’s electronic medical record.
The North Carolina Sickle Cell Syndrome Program also utilized the 5A’s tobacco cessation tool to screen adolescent and adult clients as a component of the program’s required assessment activities. The 5A’s tool is embedded in the program’s Client Strengths and Needs Assessment.
Air quality in the home, including the impact of smoking, is a known trigger issue for many students with asthma. The statewide School Health Nurse Consultant (SHNC) Team impacted the health of children with asthma by providing technical assistance to school nurses and school staff that provide direct care to students. Of the 2018-19 NC public school population of 1,410,673 students (not including public charter schools), 105,326 students with asthma diagnoses received school nursing services during FY19.
Services that were delivered to these students were facilitated by the work of the SHNC Team and were reported to the state program on the North Carolina Annual School Health Services Report Survey. During FY19, services included the development and sharing of 80,504 asthma related Individual Health Care Plans and the development of 784 Section 504 Plans. In addition, 3,089 students attended presentations that were delivered through student and family asthma education programs such as Open Airways, Managing Asthma Triggers, and other related curricula. A total of 3,089 students/families and staff participated in school nurse led asthma education programs. School nurses provided asthma education to school staff in 36 districts. School nurses also completed 5,802 home visits during FY19 to address student health issues in the home environment. These were often completed as a component of local School Nurse Care/Case Management programs directed to students and families with asthma diagnoses. Of the students participating in School Nurse Care/Case Management, 94% remained within peak flow/pulse oximeter plan goals during the school year, 92% showed improved amount and/or quality of regular physical activity, 88% had decreased absences from school, and 81% reported improved grades. School Nurse Care/Case Management programs were located in 49% of local school districts during the 2018-19 school year and provided care to students with not only asthma but also diabetes, weight management, seizure disorder, severe allergies, and mental/behavioral health issues.
NPM#15 – Percent of children age 0 through 17 who are adequately insured
The C&Y Branch has many efforts focused on increasing the percent of children age 0 through 17 who are adequately insured (NPM#15). According to the 2017-18 NSCH, 68.2% of parents in NC responded that their children were adequately insured as compared to 67.5% nationally. In NC, CSHCN (60.1%) were less likely to be adequately insured than non-CSHCN (70.4%). Children <6 years of age were more likely to be adequately insured than children in the 6 to 11 and 12 to 17-year age groups. Eighty-five percent of parents of children receiving Medicaid responded that their insurance was adequate, while only 65.3% of parents of children with private insurance did. Non-Hispanic Black (76.4%) children were more likely to be adequately insured than non-Hispanic White (62.6%) or Hispanic children (67.6%). According to data from the US Census Bureau 2018 American Community Survey, 5.4% of all children under 19 years were uninsured in NC, and 6.8% of children below 200% of poverty were uninsured.
In FY19, in the 31 SHCs funded by state dollars, 13% of the adolescents seen (ages 10-19 years) were uninsured or self-pay, and 60% were covered by public insurance (Medicaid, Health Check/ Health Choice). SHC staff work with families to enroll them in appropriate public or private insurance. The manager of this program is supported through Title V funds and provides credentialing, assuring SHCs meet National Standards on behalf of the NC Division of Health Benefits.
WCHS selected an ESM for NPM#15 that highlights the work already being done to promote access to health insurance, but which will also help target future activities to fill in gaps. The ESM is the number of outreach activities to promote access to health insurance done annually by the C&Y Branch’s Minority Outreach Coordinator, CYSHCN Help Line Coordinator, and CYSHCN Access to Care Coordinator. A quarterly report breaks down the activities by type of activity (presentation, exhibit, consultation, or collaboration), name of activity, participating audience (caregivers/families or professionals), target population (racial/ethnic), date, location, and staff member conducting the activity. The Minority Outreach Coordinator is Latina and bi-lingual, has been in the position for many years, and presents a trusted voice to the many partners with whom she works. The CYSHCN Help Line Coordinator position is an individual who is both African American and American Indian, and she continues to expand outreach efforts within the different tribes residing in the state. She attends Pow Wows and provides specialized outreach for health insurance and other services to this specific population. All three positions are funded through a Federal Financial Participation agreement with NC Medicaid. Collectively, they apply both data driven and targeted community approaches for Title XIX and XXI outreach. These approaches include: 1) applying state population data to prioritize under-insured or uninsured residents or communities, 2) providing an ongoing platform to share system-wide outreach and/or collaborative strategies, and 3) maximizing collaborative efforts for more focused, community-level outreach efforts. The three FTE staff continue to apply evidence-based and evidenced informed outreach approaches which include utilizing social marketing principles and consider the needs of diverse populations (i.e., preferred languages, ethnic and cultural social norms, the specific concerns for parents/guardians of children with special health care needs, and printed materials designed and developed for low literacy populations).
In FY19, there were 186 activities reported reaching an estimated 12,280 people. The type and frequency of outreach activities include: exhibits at local or statewide events (24%); presentations to families/caregivers or professionals directly working with families/caregivers (22%); and direct consultation/collaboration with community stakeholders to promote benefits of Medicaid/NC Health Choice enrollment (54%). Twenty-eight percent of the outreach efforts had special focus on reducing health disparities among African American, American Indian, Latino/Hispanic, and newcomer (refugees, immigrants) populations. The remaining outreach activities (73%) were inclusive in focusing on all populations who may be unserved or under-served regarding Medicaid/NC Health Choice enrollment opportunities.
The NC Coalition to Promote Children's Health Insurance is a quarterly platform that offers an opportunity to link with multiple partners in the state system to update strategic planning efforts and partner with CHIPRA grant recipients to ensure statewide coverage. The Coalition is co-chaired by the Executive Director of the NC Pediatric Society and the Latina bilingual/bicultural minority outreach member of the C&Y Branch. Additionally, the C&Y Branch’s Access to Care Specialist for CYSHCN provides staff support. The Coalition is comprised of state and local government, private not-for-profit and business sectors, faith and minority communities, child health advocates, and funders who share best practices, successful statewide and local outreach strategies to in promoting positive health outcomes via access to NC Medicaid and NC Health Choice (CHIP) programs. Coalition topics also include discussions of federal and state trends and its implications on child health. All 2019 Coalition meetings included regular updates on NC’s transformation to Medicaid managed care.
Using a data-driven approach provides the foundation and justification for prioritizing communities. The NC Division of Health Benefits’ enrollment dashboard for Medicaid and NC Health Choice (https://medicaid.ncdhhs.gov/reports/dashboards#enroll) reflects the number of people by county and program aid category who are authorized to receive Medicaid or Health Choice services for each report month. This real-time data platform is an effective resource in targeting the under-insured or uninsured, along with reinforcing reenrollment for current beneficiaries. NC maintains a 95% enrollment in health insurance for children which may be a collective result of stakeholders’ ongoing commitment via outreach interventions.
Many of the statewide activities are reliant on local, grassroots outreach through all our partners. Gaining the trust and building relationships with these gatekeepers is essential to any effective outreach. The three C&Y Branch outreach staff conduct collective outreach efforts by being available to attend their local functions during weekdays, at night, or on weekends. These partnerships among local, community stakeholder promote enrollment, retention, access to a quality medical home, and the importance of preventive services and appropriate utilization. Outreach strategies include exhibits at local community events (Latino health fairs, Back-to School events), population specific events via consultation (Refugee Stakeholders meetings, faith-based initiatives), and presentations to statewide stakeholders (UNC Pediatric residents, NC Pediatric Nurse Practitioners Association, NC Child Care Health Consultants).
Childhood Immunizations
While most of the funding for childhood immunizations does not come from Title V, the WCHS supports the work of the Immunization Branch (IB) to raise immunization rates across the lifespan. The 2018 National Immunization Survey (NIS) results were released in the fall of 2019. North Carolina’s coverage estimate for the 4:3:1:3:3:1:4 series (which protects against Diphtheria, Tetanus, Pertussis, Polio, Measles, Mumps, Rubella, Haemophilus influenza type B, Hepatitis B, Varicella, and pneumococcal invasive disease) was 75.2%, which was slightly higher than the national estimate of 68.5%. Results of the 2018 NIS-Teen, also released in the fall of 2019, showed that the rate of North Carolina teens aged 13 through 17 years who have received one or more doses of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) since the age of ten years was 89.1%, compared to the national estimate of 88.9%. Regarding the percent of teens up to date on the HPV series, the North Carolina estimate was comparable to the national estimate (52.1% v. 51.9%). Meningococcal conjugate and MMR (measles, mumps, and rubella vaccine) coverage estimates in North Carolina were also equivalent to national estimates (92.5% v. 91.9% and 86.1% v. 86.6%, respectively). 2019 NIS results are expected to be released in the fall of 2020.
The IB conducted 242 childhood and 190 adolescent Assessment, Feedback, Incentive, and eXchange (AFIX) visits during FY19 for a total of 432 visits. On July 1, 2019, the AFIX program transitioned to Immunization Quality Improvement for Providers (IQIP), in which all visits require a childhood and adolescent assessment.
In FY19, the IB, based on past successful media campaigns, incorporated the following media mix to increase influenza vaccine awareness and flu prevention education: TV (local news programs), cable TV (utilized specific targeted cable networks to increase media campaign), digital internet/online (mobile-smartphones and tablets, desktops, banner ads, and TV station websites). The television (broadcast/cable) campaign ran for seven weeks, from November 12 – December 30, 2019. The digital campaign ran for nine weeks, from October 29 – December 30, 2019.The campaign performed well in many aspects. Overall traffic increased significantly, up 126% over the same period last year (a total of 96,800 visitors compared to 42,900 for the same period last year). The percentage of new vs. repeat visitors also rose by 3%. The IB also hosted a statewide conference for providers in the Vaccine for Children Program (VFC) in August 2019.
Overall, the NC Immunization Program distributed a total of 2,264,753 doses of vaccine, including 409,650 doses of influenza vaccine in FY19.
The PMC continued to work with IB staff members to review a subset of medical exemption requests for immunizations that were non-standard from physicians licensed to practice in NC. The PMC continued to work with the attorney general’s office on an average of three appeals per year to medical exemption requests.
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