CROSS-CUTTING AND SYSTEMS-BUILDING DOMAIN

Nebraska Annual Report for the 2021-2022 Year

 

In this section, Nebraska MCH Title V reports on the accomplishments and activities in the Cross-cutting and Systems-building Domain for the period October 1, 2021 to September 30, 2022. This represents the second year of activity in the Title V needs assessment cycle.  The numerical sequence of headings used to organize the narrative below correspond to the narrative guidance for the Annual Report year as found on page 42 of the Title V Maternal and Child Health Services Block Grant to States Program: Guidance and Forms for the Title V Application/Annual Report, OMB Number 0915-0172, Expiration Date 1/31/2024.

 

From the 2020 Needs Assessment, the Nebraska Priorities selected in the Cross-Cutting and Systems-Building Domain for 2021-2022, with NPM, SPM, and ESM statements for the period are as follows:

• Improved access to and utilization of mental health care services by MCH populations

SPM: Percent of children ages 0-17 years who are continuously and adequately insured

ESM: None

 

1. Context: Cross-cutting and Systems-building Priorities in Nebraska

In 2020, the stakeholder group convening to write the issue brief for the cross-cutting domain was the largest of the assembled domain work groups, representing statewide and cross-sector involvement.  The sustained engagement of participants throughout the needs assessment process resulted in two work products, the selected priority and an issue brief focusing specifically on increased mental and behavioral health screening in the population. The stakeholder group was interested in both provider-level and system-level considerations of access to mental and behavioral health, through a lens informed by equity, social determinants of health, and workforce development including Community Health Workers (CHW).

 

Through the group’s work, it became clear that rising and unaddressed mental health issues in the population were of paramount importance.  Stakeholders used a risk and protective factor framework for the social and environmental determinants of mental well-being and development of resilience in the population, resulting in two primary strategies:

1. Improving primary care practice with health literacy, family-centered medical home and integrated care approaches, universal screening for mental and behavioral health issues using normed and standardized instruments, and a skill set to make behavioral health referrals.
2. Build the capacity of Community Health Workers to help people increase access to and utilization of mental health services. 

Stakeholders envisioned this would involve training, better integration of CHW in primary care teams to receive a warm hand off from providers to help families with social needs and navigating care, CHW educating the public about availability of Heritage Health Adult (Nebraska Medicaid Expansion), and CHW working to decrease stigma about seeking care for mental health. 

 

For the 2020-2025 Needs Assessment, Title V worked with the Nebraska Association of Local Health Directors to bring forward a summary of current priorities identified through the Community Health Needs Assessment and Community Health Improvement Plans that local public health departments regularly undertake in their respective jurisdictions.  This summary allowed stakeholders to consider degree of alignment with local priorities when determining the final priorities for Title V for the coming five-year period.

 

Stakeholders noted in the Issue Brief for this priority that fifteen of Nebraska’s local public health departments identify Mental Health as a priority in the Community Health Improvement Plans and/or Community Health Needs Assessments. Eight local public health departments identify Access to Care as a priority as well.

 

Community Health Workers in Nebraska

Nebraska Title V has been making investments in Community Health Worker workforce development as an equity-focused strategy to improve access to care for approximately seven years.  Many stakeholders, allies, and Community Health Workers participate in Title V-led or hosted activities.  In the 2021-2022 period two reports on the CHW Workforce were published on the DHHS CHW webpage, www.dhhs.ne.gov/MCASH-CHW.  In collaboration with the University of Nebraska, Title V published an assessment of “Urban and Rural Differences in the CHW Workforce in Nebraska” and recommendations on “Developing the CHW Workforce to Promote Maternal and Child Health in NE.”  In 2022, Title V continued supporting the CHW Consultant-Trainer Cadre, a group of eleven diverse CHW from across Nebraska dedicated to guiding Title V workforce development activities, demonstrating fidelity to “nothing about us without us.”

 

During the 2021-2022 period, the University of Nebraska Medical Center, Creighton University, and the Nebraska Association of Local Health Directors applied for and received funding from the Health Resources and Services Administration to develop training programs for CHWs in Nebraska. Training activities for each award began in the 2022-2023 period, but the 2021-2022 period included the design and coordination of the applications. Title V was eager to hear about the awards. The newly funded programs will build CHW knowledge and capacity and organizational capacity to use CHWs.

 

Medicaid Expansion

As named in other domain reports for this period, Medicaid Expansion figures prominently in any discussion about access to care, whether physical, dental, or mental/behavioral.  Critical to improving access to care is the availability of health insurance.  Nebraska voters approved Medicaid Expansion in 2018, and enrollment opened in August of 2020, with benefits becoming effective in October 2020. According to the Nebraska Medicaid Annual Report for State Fiscal Year 2022, over 75,000 Nebraskans enrolled in Medicaid Expansion. This represents a significant opportunity for some of the most vulnerable Nebraskans to access health insurance.   The COVID-19 pandemic and the Public Health Emergency (PHE) declared by the federal government in 2020 also improved access to care during the 2021-2022 period. The PHE retained people enrolled in Medicaid without eligibility redetermination. 

 

The Rising Tide of Mental Health Needs

Stakeholders were concerned about mental and behavioral health issues of MCH populations in the 2015-2020 needs assessment cycle. These concerns continued to emerge throughout the population as the 2020 needs assessment was completed.  Mental health topics and considerations were pervasive in every domain group and coalesced in the Cross-Cutting Domain. Mental health needs were also prioritized in the Youth and Children with Special Healthcare Needs Domains.

 

3. Summary of Programmatic Efforts and Use of Evidence-based or Evidence-informed Approaches to Address Priority Needs

 

Priority: Improved access to and utilization of mental health care services by MCH populations

2021-2022 Objectives and Strategies

 

Objective XC10a: By 2025, increase awareness and decrease stigma around mental and behavioral health issues by ensuring that training, outreach, and provider tools reflect best practices in health literacy and are culturally and linguistically appropriate for underserved populations.

 

Strategy XC10a(1): Title V will continue Community Health Worker (CHW) workforce development activities, working with cross-divisional and cross-sector partners to assure all CHW have access to QPR Suicide Prevention training, Mental Health First Aid, and trauma-informed care, with the objectives of improving referrals, and reducing stigma about mental and behavioral health issues.

 

Strategy XC10a(2): Title V will continue CHW workforce development activities, including sustainable infrastructure, with CHW center and in the lead, through engagement of the CHW Consultant Trainer Cadre.

 

Strategy XC10a(3): Title V will conduct outreach and education on Heritage Health Adult (Nebraska Medicaid Expansion) to promote enrollment and improve access to care, particularly for disparate and disadvantaged women of childbearing age, and other parents/caregivers.

 

Summary of Programmatic Efforts

For the period 2021-2022, Nebraska proposed three significant strategies in this objective area.  The Maternal, Child, Adolescent, and School Health (MCASH) staff worked with partners to include mental health topics in continuing education activities for Community Health Workers, as well as continued work to enact recommendations provided by a state-level, state-wide consensus group to identify financing and sustainability strategies for the CHW workforce in Nebraska. Third, as has been seen in other population domains, Title V continued to promote Heritage Health Adult, Nebraska’s Medicaid Expansion program, particularly among diverse and disadvantaged parents and caregivers.

 

During the period, CHW met as a cadre monthly through June 2022, discussing multiple topics about sustainability and CHW training. In June 2022, the Title V project lead for the cross-cutting work left DHHS and CHW Cadre efforts were put on hold until a new lead was hired. The new lead was hired in August 2022 and the CHW Cadre began meeting again in September 2022.

 

Throughout the 2021-2022 period, a subgroup of CHW participated on a continuing education committee. They vetted speakers and topics and planned the logistics of offering continuing education credits. During this period, the CHW hosted trainings on the following topics: “CHW Resources and Networking Tools”, “Women’s Health 101”, “Anxiety”, “Depression”, and “Medicaid Expansion.”

 

The COVID-19 pandemic and staffing changes limited Title V’s ability to convene partners to identify financing and sustainability strategies for the CHW workforce in Nebraska. Funding of three training programs in late 2022 has renewed stakeholder interest and need for CHW sustainability.

 

Finally, CHWs participated in planning for, hosting, and speaking at the Nebraska Minority Health Conference in April 2022.  Agenda items of note included a speaker from the National Association of Community Health Workers and a breakout session for CHW titled “Community Health Worker Networking Session.” One of the CHW Consultant Trainer Cadre members was a panelist in a session titled “Community Organizing and Community Building for Health and Social Equity.”

 

Objective XC10b: By 2025, increase capacity of primary care providers to screen, refer, and treat mild-to-moderate mental health issues in children, youth, and women of childbearing age

 

Strategy XC10b(1): Title V will continue as lead agency in Nebraska Pediatric Mental Health Care Access Program, NEP-MAP.

 

Summary of Programmatic Efforts

For this objective, Nebraska Title V continued its leadership role in NEP-MAP, the Nebraska Partnership for Mental Healthcare Access in Pediatrics, Nebraska’s project in the HRSA-funded Pediatric Mental Health Care Access program.  In 2021-2022, Nebraska was in Year 4 of 5 planned years of project operations, primarily continuing the clinical demonstration project (providing consultation services to rural-based primary care providers needing assistance treating or referring patients) and offering other screening/referral tools to encourage more community-based services.  Other projects included Reach Out and Read (an early childhood reading program which draws on the relationship between primary care provider and young families to distribute books), the school nurse behavioral health consultant project, continuing to facilitate the Advisory Committee and associated technical workgroups, and initiating a care coordination project with UNMC.

 

Objective XC10c: By 2025, assess impact of tele-behavioral health on improving access and utilization of mental and behavioral health services by MCH populations in Medicaid

 

Strategy XC10c(1): The MCASH Program will undertake a collaboration with Medicaid to measure tele-behavioral health utilization trends in Nebraska.

 

Summary of Programmatic Efforts

The strategy underlying this objective was to be an activity undertaken with Nebraska Medicaid administration to measure tele-behavioral health utilization trends in NE.  Demands of the pandemic and its associated response meant that, while tele-behavioral health access was as needed as ever, the project to measure utilization could not occur.  National and state level policy measures allowing telehealth during the pandemic relaxed some restrictions, including removing the requirement for a written agreement with a patient’s signature and broadening the scope of allowed applications that can be used.  These efforts ensured that telehealth was easier to use during the pandemic, though staff were unable to measure any change in usage as planned.

 

Use of Evidence-based or Evidence-informed Approaches in this Priority

The use of Community Health Workers is supported by some evidence of effectiveness in providing education, referral and follow-up, case management, home visiting, etc. for those at high risk for poor health outcomes, according to the site County Health Rankings and Roadmaps, What Works for Health directory at https://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health

 

Assessment of Alignment of NPMs, ESMs, SPMs, and SOMs with Priority Needs

 

Priority: Improved access to and utilization of mental health care services by MCH populations

SPM: Percent of children ages 0-17 who are continuously and adequately insured.

ESM: None.

 

Alignment: 

The State Performance Measure of children ages 0-17 years who are continuously and adequately insured does not speak to the central topic of access to mental and behavioral health care services, nor to impacts of the Community Health Worker workforce which are central to the strategies deployed in this area.  Likewise, the structure of national performance measures provides no framework for equity-focused work to improve access to care, other than measurement of preventive visits or health insurance coverage.

 

There is no ESM assigned to this population domain, however Results-based Accountability measures as described in the following section offer some additional insights related to activities.

 

4. Progress in Achieving Established Performance Measure Targets along with Other Programmatic Impact

 

Results Based Accountability (RBA) measures Improved access to and utilization of mental health care services by MCH populations
	Proposed 2021-2022	Achieved 2021-2022
How much did we do?	Number of CHW trained in QPR suicide prevention, mental health first aid, trauma informed care, and/or motivational interviewing during the period?   How many CHW are active in the CHW Consultant Trainer Cadre?   How many training activities are delivered by CHW to CHW?	CHWs hosted in five cross-sector trainings. None of them were QPR suicide prevention, mental health first aid, trauma informed care, and/or motivational interviewing.   10     CHWs hosted in five cross-sector trainings.
How well did we do it?	What is the distribution of participation of CHW, by Behavioral Health region? Is statewide reach successful?	Statewide reach is successful. Attendees for the CHW led trainings were located in each of the behavioral health regions in the state.
Is anyone better off?	What proportion of CHW trainees indicate they will change their practice as a result of training?	It’s unclear if this data was collected.

 

Other Programmatic Impact

Despite little impact on proposed RBAs for the period, the success of the Title V CHW Consultant-Trainer Cadre is significant. The Cadre has provided space and opportunity for CHWs to be visible in leadership and training roles of significance.  In the CHW continuing education project, organizers including CHW have been intentional about applying principles of Popular Education in developing and delivering sessions.  Each session features CHW Cadre members discussing ways that CHWs encounter the topic of interest in the population, and the significance of the topic in CHW experience. The sessions include polls, chats, and other interactive tools to invite sharing of expertise and perspective between peers.

 

Similarly, within the NEP-MAP project there has been significant success regardless of the lack of provider-specific data from enrolled clinics.  NEP-MAP has provided training opportunities, clinical consultation services, and a screening resource/referral guide that have laid the foundation to help primary care providers increase their screening and referral practices within their clinics, as well as to treat mild cases if appropriate.

 

5. Challenges and Emerging Issues

Nebraska has many engaged, ready stakeholders, Community Health Workers, and allies who would like to see the workforce grow and thrive to promote equity and improved population health outcomes.  However, Nebraska lacks a single focal point for convening, organizing, and sustaining these workforce development activities.  Stepping into this space, Nebraska Title V has made numerous substantial, impactful contributions to workforce development, from formation of the Cadre, to publishing original reports giving life and voice to the diverse CHW workforce, as well as offering continuing education and 2022 Community Health Workers are Heroes recognition awards.  However, a more robust internal infrastructure will need to be established to sustain or coordinate several small program areas of activity, as well as to move this workforce to the next phase of formal, sustained recognition. The formation of the Cadre has itself resulted in an exponential acceleration in the capacity of Title V to accomplish activities, yet at the same time only one staff member is assigned to support all components of emerging and dynamic activity, along with other existing responsibilities in other program areas.   Some areas of anticipated activity, including moving towards a certification model for Nebraska CHW, require sustained and coordinated efforts across systems, partners, and time.  Title V will need to evaluate its own capacity as well as that within the broader agency and in partner organizations to offer a solution for this next phase of CHW development. 

 

6. Overall Effectiveness of Strategies and Approaches: Addressing Needs and Promoting CQI

 

As noted above, the effectiveness of the formation of the CHW Consultant-Trainer Cadre in growing workforce development activities has been considerable, however, this is paired with thoughtful consideration regarding the extent to which Title V staff at DHHS can keep pace with expanded and accelerated growth in activities. The visibility and credibility of Title V leadership in CHW workforce development is well-regarded by many stakeholders statewide, and many express hope Title V investments will continue. In addition, consideration needs to be made about how to measure the short-term and long-term returns on Title V investments in CHW workforce development.  

 

There is an immediate imperative to work with others to effectively address mental and behavioral health issues in the population and implement strategies to improve mental wellbeing and resilience.  Development of the CHW workforce suggests an untapped resource to deploy in response to this need, particularly in a state where the rural nature of many areas means a lack of formally trained and licensed mental/behavioral healthcare providers.