Cross-Cutting/Systems Building Annual Report
Primary Care Office Report
The Nevada Primary Care Office (PCO) improves health care access through its efforts to coordinate the federal shortage designation process, the J-1 Physician Visa Waiver Program, and other recruitment and retention programs. These efforts are supported by a strong collaboration between the PCO and MCH, Area Health Education Centers, the Office of Rural Health, health care training programs, community health centers, rural health clinics, tribal clinics, rural hospitals, and other safety net healthcare sites. The PCO receives base funding from the federal Health Resources Services Administration (HRSA) to support its efforts. Because this work helps to improve healthcare access for maternal, child, and adolescent populations, the HRSA MCH Title V grant to Nevada supports 0.29 FTE in the PCO. Staff in the PCO continue to support MCH initiatives through regular participation in Maternal and Child Health Advisory Board meetings and through quarterly reports of PCO progress relating to MCH goals. The PCO is also regularly briefed by and collaborates with MCH staff at quarterly Data Sharing Meetings hosted by the PCO and the PCO statewide medical provider listservs are routinely used to share information provided by MCH such as HAN Alerts, COCA, Technical Bulletins on child vaccines, maternal mortality warning signs, etc. This is also done with Medicaid provider listservs.
PCO Shortage Designation
Auto-HPSAs support Federally Qualified Health Centers, Indian Health Service and Tribal health care sites, and Rural Health Clinics throughout Nevada. The PCO strongly advocated for communication measures that support our state safety net clinics. The PCO provided technical assistance related to expansion and designations to 143 clients. The PCO facilitated quarterly meetings to identify key priorities and sources for our five-year Needs Assessment report. Thanks to these collaborative efforts, the Needs Assessment was finalized and submitted to HRSA in April for review. The PCO provided 6 instances of technical assistance to community stakeholders and conducted outreach to 6 community stakeholders relating to needs assessment and data sharing, reaching an audience of over 137.
PCO National Health Service Corps and Nurse Corps Program Coordination
National Health Service Corps (NHSC) outreach activities during this year included professional meetings with 5 NHSC sites. These activities increase awareness of the program and subsequent program participation, which leads to increased recruitment and retention of health providers for underserved maternal, pediatric, and adolescent populations. The PCO reviewed 11 NHSC site applications. These safety net health care sites serve all patients regardless of ability to pay and represent critical primary care, mental health, and dental access points for maternal, pediatric, and adolescent populations in Nevada. The PCO provided technical assistance to 46 NHSC participants.
PCO J-1 Visa Waiver Program
14 applications were reviewed, public hearings held, and letters of support completed for primary care, mental health, and specialist physicians to participate in the J-1 Physician Visa Waiver program. These doctors will serve underserved populations in Las Vegas, Carson City, Reno/Sparks, including maternal, pediatric and adolescent populations. Due to Covid-19 travel restrictions, the PCO was unable to conduct participant compliance site visits to provide technical assistance and to assure compliance with program requirements. However, the PCO was able to transition this process to a virtual format and begin conducting site visits via Zoom or Teams meetings; these numbers can be expected in next year’s reporting. The PCO provided 182 instances of technical assistance.
Interorganizational Collaborations
The PCO experienced some challenges due to the pandemic and position vacancies/absences but overall has been able to stay on track and fulfill the major responsibilities and goals of the program. The PCO was unable to travel or complete any in-person visits during the pandemic but was able to smoothly transition to mostly electronic processing and virtual visits through Zoom and Teams.
Adequate Insurance Report
The Title V MCH Program sought to increase the percentage of children, ages 0 through 17, who are continuously and adequately insured (NPM 15). According to the NSCH 2019-2020 report, 61.4% of Nevadan children, ages 0 through 17, were continuously and adequately insured compared to 66.7% nationwide. To improve the percent of children who are adequately insured in Nevada, the Title V MCH Program utilized several strategies to accomplish this goal. Title V MCH collaborated with other programs, agencies, and community organizations, and drafted and distributed informational brochures. Title V MCH also funded groups to provide insurance application assistance and referrals.
The Title V MCH Program increased access to care by actively promoting Medicaid referral, annual open enrollment periods, Katie Beckett information, and essential health benefits. Title V MCH provided training on what Medicaid expansion means for MCH populations to providers and community-based partners and allies.
Title V MCH staff arranged training for Nevada 211 call specialist staff on Medicaid enrollment and expansion at the beginning of 2021’s open enrollment period. Staff from DWSS, DHCFP/Nevada Medicaid, and Nevada Health Link provided an overview of Nevada’s public and private insurance system and how call specialists can assist individuals with the application process. The updated guidance to call staff was valuable since COVID-19 necessitated a shift to online or telephone services for enrollment, rather than individuals using local offices and outreach workers in the field.
Title V MCH staff disseminated 35,150 brochures (19,425 English/15,725 Spanish) highlighting the value of yearly adolescent checkups and how to apply for health insurance. Primary distribution partners included DWSS, DCFS, Nevada Health Link (state online marketplace), Title V MCH funded partners, and community agencies working to enhance the uptake of yearly adolescent well-visits. All distribution partners received electronic links to the documents for posting on their websites or dissemination to their listservs.
Adequate Insurance – Partner Efforts
CCHHS, a Title V funded partner in northern Nevada, disseminated brochures with information regarding insurance enrollment and partnered with DWSS for on-site Medicaid application assistance. Due to the pandemic, services were placed on hold until the last quarter of this report period. During these four months, 79 individuals were enrolled through the on-site activities. Promotion of services and resources to access insurance were distributed to clinic patients and displayed on the clinic's digital signage.
The MIECHV Program within the MCAH Section exists to develop and promote a statewide coordinated system of evidence-based home visiting supporting healthy child development and ensures the safety of young children and family members. MIECHV works directly with families to facilitate completion of insurance enrollment referrals to increase adequate insurance coverage and is partly funded by Title V MCH.
Community health nurses (CHNs) are part of the Title V funded DPBH CHS Program and provide access to medical services in underserved areas including, but not limited to, family planning, outreach and education, and referral and navigation to care as needed. CHNs provided insurance resources and referrals to uninsured people in Nevada's rural and frontier regions through Nevada Medicaid, Nevada Check Up, and Nevada Health Link. Undocumented residents and those not eligible for Medicaid or other insurance were referred to the AHN Medical Discount Plan.
Washoe County FIMR uses Title V funding to study a variety of factors affecting the health of the mother, fetus, and infant to understand how to reduce fetal and infant mortality. To identify insurer-specific opportunities to reduce infant mortality gaps and look for opportunities to expand care, FIMR tracks the mother's insurance type during pregnancy and separates categories based on private, Medicaid, and no insurance.
The DHCFP/NV Medicaid works in partnership with the U.S. Centers for Medicare & Medicaid Services to provide quality medical care for eligible individuals and families with low incomes and limited resources. Services are provided through a combination of traditional FFS provider networks and four large contracted MCOs. Medicaid partners with Title V MCH for informational and referral resources on the Katie Beckett waiver program, development of the one-sheet on Medicaid coverage for legally present children, and many other NPM 15-related efforts. Efforts between DHCFP/NV Medicaid, DHHS, and Title V MCH staff focused on increasing adequate prenatal care.
Office of Suicide Prevention and Hotline Report
The Title V MCH Program state general fund match helped support the OSP Manager's salary through outreach and education, facilitated information-sharing, and consensus-building among multiple constituent groups. OSP is Nevada’s office for training and technical assistance to identify, prevent, intervene, and provide suicide survivor support. Strategic partnerships resulted in changes to public policy around stigma reduction, mandatory training for most school districts, and training for staff and parents. Additionally, new partnerships were created with urban and rural hospitals to expand Nevada’s Zero Suicide Initiative among healthcare agencies to improve depression and suicide care in healthcare systems.
OSP conducted statewide suicide education and prevention courses. Due to COVID-19, most trainings were provided virtually. Evidence-based trainings were conducted for acute care hospitals, free-standing psychiatric hospitals, community-based providers, coalitions, faith-based groups, and volunteers. The OSP moved out of the MCAH Section Budget Account as of July 1, 2021, thus content in the bullet points represents the first three quarters of FFY21.
- The safeTALK training reached 251 community members and school staff. This course used the model Tell, Ask, Listen, and Keepsafe.
- Applied Suicide Intervention Skills Training (ASIST) taught 185 providers or caregivers skills though the Pathway for Assisting Life model.
- Gatekeeper trainings provide information about suicide prevention, signs to look for, and how to assist those in crisis. These trainings reached 2,233 participants, including nurses and other healthcare providers, school personnel, family and youth-serving staff from DCFS, Clark County Department of Family Service, and Washoe County Human Services.
- Youth Mental Health First Aid (YMHFA) and school-based suicide prevention programs taught 59 adults to better recognize and assist adolescents in need of intervention. This number was a significant decrease from in-person sessions before the pandemic.
- OSP provided technical assistance and resources to help school districts implement requirements passed in the previous legislative session.
OSP has a longstanding partnership within the Department of Education. NDE provided OSP funding for a Youth Suicide Prevention Coordinator which was deemed crucial due to COVID-19’s impact on youth mental health and wellbeing.
NDE awarded OSP an additional five-years of funding to continue Project AWARE. This evidence-based program was designed to increase mental health awareness, screening, and connections to community-based mental health services within a framework of a MTSS. The program raised awareness about mental health issues among school-aged youth and provided training for school personnel and other adults to detect and respond to mental health issues. School-aged children with behavioral health issues and their families were connected to needed services. Furthermore, the program strengthened state and local infrastructures to expand and sustain an integrated MTSS in several schools.
COVID-19 continues to impact children’s mental wellbeing. The Surgeon General released an advisory on Protecting Youth Mental Health, July 2021. OSP increased the number of suicide awareness trainings for agency staff, health care providers, and parents with children. Additional activities included several bilingual social media campaigns focused on safety for children and youth. The messages included safe firearm storage, coping skills during social isolation, and awareness of school peer support programs. The campaign providing coping skills during social isolation complimented the TPP funded messages promoting emotional wellness which linked viewers to the DPBH awarded Nevada Resilience Project at https://www.nevada211.org/nevada-resilience-project/.
The OSP funded CCSNV phone and text lines which served 71,860 people for the first three quarters of FFY21. The most common issues of concern were:
- Family/relationship issues
- Finances/basic needs
- Mental health worries
- Suicide ideation/attempts
Suicide-related concerns represented 12% of users. Of those who provided gender, 38% were female, 26% male, and less than 1% reported as transgender or non-binary. Most users were between ages 25-40 years old with 5% under age 18 y.o.
Beginning July 2020, the Federal Communications Commission adopted rules designating a new 988 phone number for individuals in crisis to connect with suicide prevention and mental health crisis counselors. CCSNV partnered with DPBH and established a core team and a planning group to develop these implementation plans. The state plans to be fully operational for the July 2022 national launch for all 988 calls to be sent to the National Suicide Prevention Lifeline.
OSP Success Story
Shared by a participant who works in healthcare:
“I had a fellow physician reach out to me yesterday morning because of a ‘career ending medical outcome.’ This physician wouldn’t promise me by text that they wouldn’t do anything to harm themself. I immediately went to their house with permission and met with this physician and spouse for a few hours, talking through and listening to sense of shame, failure, fear of what could happen to medical license, thinking spouse and kids would be better off financially if they ended their own life, etc. After talking for a long while, this person agreed to make a counseling appointment. They also allowed me to remove two firearms for safekeeping. Thanks to you and the safeTALK training I had the skills needed to intervene and bring hope.”
Tobacco Cessation Report
All Title V MCH funded programs promoted the Nevada Tobacco Quitline to pregnant persons and women of childbearing age. CCHHS and CHS clinics provided tobacco education and counseling to users of tobacco. CCHHS staff made 609 referrals to the Nevada Tobacco Quitline. CCHHS promoted the Nevada Tobacco Quitline through Facebook and reached 6,345 individuals with 24 clicking on the link to learn more. CCHHS collaborated with health care providers working in behavioral health settings and substance use treatment facilities to educate them on Nevada Tobacco Quitline. These collaborations are intended to help a disparate population (with behavioral health conditions and/or substance use issues) be connected to a Tobacco Quitline resource.
The Tobacco Control Program Annual Report
The CDPHP TCP disseminates Nevada Tobacco Quitline (NTQ) promotional material to Nevada providers, WIC clinics, early childhood educators, and Nevada Head Start sites. The promotional materials are given to pregnant and postpartum women who use tobacco. The NTQ continues to provide callers 13 years and older with up to five scheduled personalized, culturally competent coaching sessions, unlimited inbound calls, web and text support, and Nicotine Replacement Therapies (NRTs) free of charge to callers ages 18 and older, upon availability. The Pregnancy/Postpartum Program (PPP) offered mothers in Nevada a designated trained coach throughout each session along with incentivized gift cards for each completed counseling call. According to the guidelines of the PPP program, each pregnant caller was enrolled before giving birth to ensure eligibility for both programs. PPP provides five (5) coaching sessions during pregnancy and four (4) coaching sessions postpartum, and the same coach administers each session. This allows the parent to focus on their health and the baby, creating longevity for both through cessation. Comprehensive printed educational materials on the benefits of quitting smoking during pregnancy and harmful effects on babies were provided upon each enrollment process.
The NTQ enrolled 1,828 callers during the program period, which included five (5) pregnant people. The NTQ offers a free program specializing in helping pregnant people quit smoking. The tailored treatment plan meets their needs by providing intensive behavioral support, including an increased number of coaching calls compared to the general population. As an incentive, reward gift cards for $5 and $10 are given after scheduled and completed counseling calls. For pregnant and new parents who have quit, additional postpartum support is available to prevent relapse. NTQ uses evidence-based treatment practices to help pregnant smokers quit and remain tobacco-free. Although the call volume was limited, outreach was expanded to CHWs, women’s health care providers, WIC clinics, and events in the community. MCH opportunities to heighten NTQ awareness are being implemented, including promotion by all Title V MCH funded partners and the Chronic Disease Coalition monthly newsletters.
Sober Moms Healthy Babies Report
Title V MCH Program staff continued to work with Substance Abuse Prevention and Treatment Agency (SAPTA)-funded treatment providers to update the SoberMomsHealthyBabies.org website. The goal of the website is to prevent substance use in pregnant people, as well as provide information to women of childbearing age, providers, and concerned family and friends. The website provides the substance use helpline number, Nevada 211, Crisis Call Center, the Nevada Tobacco Quitline, and other resources. The website specifies the treatment priority status for pregnant people at SAPTA-funded agencies and the importance of people identifying they are pregnant. SAPTA-funded treatment centers must not deny treatment to persons unable to pay. All treatment centers listed on the website are SAPTA-funded.
The website had 3,109 total sessions with 2,577 users, of which 2,492 were new users. New users represent 96.7% of the total number of users and 3.3% were returning visitors. A total of 5,901-page views occurred. 28% of sessions came from Nevada, followed by Oregon, Virginia, and California.
Nevada Broadcasters Association conducted television and radio PSAs in English and Spanish throughout the state to promote the SoberMomsHealthyBabies.org website, in addition to the distribution of outreach materials and referral cards. The 2021 media campaign had a total of 6,873 total spots aired (5,943 radio advertisements and 930 television advertisements), promoting the SoberMomsHealthyBabies.org website and the importance of pregnant persons receiving treatment and preventing substance use in persons of childbearing age. All LHAs and Title V MCH subgrantees promoted SoberMomsHealthyBabies.org and shared SMHB referral cards; OMNI partners also widely shared the site URL.
To raise awareness on the priority admission of pregnant people at state-funded treatment centers, Title V MCH Program staff disseminated outreach materials promoting the SoberMomsHealthyBabies.org website. The Title V MCH Program is in contact with state agencies and LHAs who have agreed to help with distribution and promotion. Partnerships include the Department of Taxation, Division of Health Care Finance and Policy (DHCFP), SAPTA, local hospitals and providers, March of Dimes, faith based and MCH Coalitions, and other DPBH programs.
All three LHAs participated in sharing substance use in pregnancy resource distribution. CCHHS used Title V MCH funds to endorse pregnant and postpartum persons being substance-free through their clinic’s digital signage and social media. These Facebook messages with information about SoberMomHealthyBabies.org reached 4,237 families with nine individuals clicking on the link for more information.
Title V MCH Program staff participate in CARA and Neonatal Abstinence Syndrome (NAS) focused efforts and serve as a core team member on the ASTHO OMNI/PHI and PRISM Nevada Team. Title V MCH Program staff also serve on numerous subcommittees focused on reduction of substance use in pregnancy and building systems of referral for families with substance exposed infants. LARC and Community Reproductive Engagement Committee Title V MCH Program staff involvement intersects with substance use prevention efforts, as does engagement on possible Title V MCH Families First efforts.
Marijuana Efforts Annual Report
The Nevada Title V MCH Program continued to disseminate Spanish and English marijuana awareness materials to partners statewide. These materials were developed in prior funding years in response to Nevada’s legalization of medical and recreational marijuana. The Title V MCH Program developed informational resources on marijuana use during pregnancy, breastfeeding, injury prevention, and the harmful effects for children. Efforts to reduce substance misuse in pregnancy and improve interconception care are funded by the Title V MCH program and include promoting the SoberMomsHealthyBabies.org website and associated media campaigns and focusing perinatal activities on the reduction of NAS. Title V MCH funded partners promote SoberMomsHealthyBabies.org through social media and print materials developed by Title V MCH, in addition to the CARA and OMNI resources, marijuana use, and pregnancy information, posters, and marijuana and childhood injury prevention warnings. Informational sheets are distributed widely through FIMR and the LHAs.
COVID-19 Efforts
COVID-19 guidelines requiring masks to be worn in public can pose communication barriers for individuals who are living with D/HH. The Title V MCH Program funded the purchase of face masks with a clear window to nine school districts and 13 partners working with children or parents who are experiencing D/HH. The transparent section of the mask allows the wearer's lips to be visible, making lip-reading and the speaker's facial expressions possible.
MCAH staff added COVID-19 MCH population related content into the DPBH website http://dpbh.nv.gov/Programs/TitleV/TitleV-Home/. Materials contained Nevada’s response to the pandemic, as well as information and resources for children with and without special health care needs, in addition to all other populations served by the award. Identified links sent viewers to the CDC COVID-19 resources in American Sign Language via YouTube and Spanish language content. The CDC materials and placement of the links were shared widely with funded partners and collaborators. The statewide MCH Coalition and PCO disseminated the materials through listservs.
MCAH staff are engaged in COVID-in-pregnancy surveillance monitoring discussions with CDC as part of an OPHIE-led team. MCAH staff also focus on MIS-C efforts, share COVID-19 resources and technical bulletins to partners to support rapid information sharing, and communicate with partners to see how COVID-19 is affecting their efforts to provide technical assistance or fiscal redirects as needed.
Title V MCH Program staff requested all funded partners promote the DPBH awarded Nevada Resilience Project https://www.nevada211.org/nevada-resilience-project/ helping individuals and families with children experiencing struggles and challenges due to COVID-19. Bilingual ambassadors provided education, information, counseling, and resource navigation over the phone, text, and video chat, and face-to-face while promoting resilience, healthy coping, and empowerment. Additionally, state staff shared the launch of two Nevada 211 mobile apps to help Nevadans connect with needed resources in response to the pandemic. The Nevada 211 Youth app complements the initial one for individuals and families and specifically helps young people locate services and resources such as health care, crisis support, employment services, food pantry locations, and emergency housing programs.
Securing a CDC Foundation MCH-Immunizations Assignee helped MCH capacity in preparedness related COVID-19 response in increasing education to MCH populations on COVID-19 vaccines. This position was supported by CYSHCN Coordinator, MCH Manager, MCAH Section Manager, and MCAH staff sharing partner networks and expertise and reported to the MCH Director and Immunization Section Manager.
Emergency Preparedness and Response Action Learning Collaborative
MCAH staff participated in the Emergency Preparedness and Response Action Learning Collaborative (EPR-ALC). The EPR-ALC is a collaboration between the CDC and AMCHP to provide technical assistance to states to aid in developing or enhancing the integration of MCH populations in their EPR plans. PHEP drafted Nevada’s first Pediatric Medical Surge Annex and received support from MCAH staff. The plans address access and functional needs, behavioral health, newborn screening, coordination of services with WIC and other MCAH components during a medical surge event.
Multiple emergency response annexes or components may need to be activated simultaneously to address the needs of those affected by a disaster, including CYSHCN, and expectant parents. Other examples include providing contraception for nonpregnant and postpartum people and preventing intimate partner violence.
Equity Efforts
MCAH staff and partners received training related to equity, disparity reduction, and diversity and participated in webinars and trainings related to health equity, diversity, culturally and linguistically appropriate services (CLAS), intergenerational trauma, racism and MCH, implicit bias, reproductive justice, minority health and wellness, Tribal partnerships, SDOH, ACEs, stigma, race and disparity, and health literacy. The SDOH IM-CoIIN 2.0 included surveys related to implicit biases and readiness for change in support of enhancing capacity to address biases and disparities. Nevada’s Title V MCH Program works with community members to expand the MCH presence across populations to address gaps and expand service scope to engage all state MCH communities. The Title V MCH Program collects accurate statewide and regionalized demographic information and shares information and trends across all funded community partners and is participating in the Language Access Plan. MCAH staff discussed Nevada Office of Minority Health and Equity (NOMHE)-planned equity and COVID-19 toolkit distribution opportunities and shared materials from NOMHE and other quality organizations about racism and public health, health equity, health disparities and racism, and racism and pregnancy outcomes.
Cross Cutting Domain Accomplishments
Despite challenges posed by the pandemic, funded partners were able to dedicate efforts to help MCH populations with education, resources, and referrals to improve overall health. MCAH staff added COVID-19 MCH population-related content into the DPBH website and shared pandemic information and resources with partners pertinent to all populations served by the Title V MCH award. To gain more data about opioid use during pregnancy, Nevada PRAMS staff applied for supplemental opioid funding in 2017 and were awarded funds in September 2018. Thirteen additional questions pertaining to opioid use during pregnancy were included in the 2019 survey. In response to Nevada’s legalization of medical and recreational marijuana, informational resources on pregnancy and marijuana use continue to be disseminated. Nevada’s Title V MCH Program partnered with the Department of Taxation to distribute Child Injury Prevention and Pregnancy and Marijuana prevention materials to all marijuana dispensaries in Nevada.
Cross Cutting Domain Data
NPM 14.1- Percent of women who smoke during pregnancy
According to NVSS data, the percent of women who smoke during pregnancy in Nevada has been steadily declining from 2012 to 2019, from 6.3% to 3.5%. In 2020, the percentage increased slightly to 3.6%. This is significantly lower than the 2020 U.S. national average of 5.5%. Nevada ranks 9th lowest for this measure of the 50 states and D.C. When 2020 Nevada data is stratified by health insurance, 5.9% of women on Medicaid were found to smoke during pregnancy, compared to 4.1% of those who were Uninsured, 1.8% of those who had other public insurance, and 1.7% of those who had private insurance.
NPM 14.2- Percent of children, ages 0 through 17, who live in households where someone smokes
The 2019-2020 NSCH found 15.8% of Nevada children ages 0 through 17 live in households where someone smokes, a percentage which has been fluctuating but overall declining from a high of 17.7% from 2016-2017. Nevada is slightly higher than the national average of 14% from 2019-2020. Nevada ranks 29th lowest of 50 states and D.C. When stratifying Nevada data by health insurance, uninsured households have the highest percentage for someone who smokes at 22.9%. Households with Medicaid insurance 17.6%, followed by households with private insurance at 14%.
NPM 15- Percent of children, ages 0 through 17, who are continuously and adequately insured
According to data from the NSCH the percent of children who are continuously and adequately insured has remained relatively stable from 62.2% in 2016 to 61.4% from 2019-2020. This is significantly lower than the 2019-2020 U.S. national average of 66.7%, and Nevada ranks 48th lowest out of the 50 states and D.C. Disparities exist in Nevada for this measure, as Non-Hispanic Black children are least likely to be continuously and adequately insured (52.7%). Hispanic and Non-Hispanic Asian children are also slightly below the Nevada average at 61.8% and 55%, respectively. Non-Hispanic White and Non-Hispanic Multiple Race are above the Nevada average, at 62.6% and 68.5%, respectively.
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