Cross-Cutting
Accessible and Affordable Health Care
A 2021-2025 cross-cutting priority need identified during Minnesota’s 2020 Needs Assessment was for comprehensive, quality health care services, that are available and affordable for all. Programmatic efforts from FY2021 aimed at addressing this priority need are discussed below. We conclude with information on how Minnesota is measuring our progress on improving accessible and affordable health care for people living in Minnesota.
Strategy A. Recognize and Reduce Systemic Racism, Discrimination, and Marginalization in Health Care
Activity 1: Monitor and Report Data on Racial and Linguistic Diversity of Health Care Providers in Minnesota
Mounting empirical evidence offers rationale for improving the cultural competency of the health care workforce by increasing the diversity of health care providers. As a first step toward increasing the diversity of our health care workforce serving MCH populations, the state needs to develop a better understanding of the racial and linguistic diversity of providers. Within MDH, the Office of Rural Health and Primary Care’s Health Workforce Planning and Analysis team works to collect data on racial/ethnic makeup of providers. In FY2021, Title V staff began to explore results of this data, potential uses, and how we can partner with this team to better promote the needs of MCH populations.
The Office of Rural Health and Primary Care has also reported on the impacts of COVID, as anecdotal and industry reports of alarming workforce shortages and insufficient access to care occur. These accounts suggest that early retirements, turnover, reduced hours, and high burnout levels threaten a health care system that was overburdened and plagued with workforce shortages well before COVID hit. While not yet clear how this will impact the racial and linguistic diversity of health care professionals, projected workforce losses in Minnesota’s small towns and rural areas are even more alarming than they were before COVID: nearly one in five rural health care providers say they plan to leave their profession within the next five years. The largest projected losses are among physicians: one out of every three rural physicians reports planning to leave their profession within the next five years, exacerbating existing shortages.
Activity 2: Promotion and Training of Accessibility in Health Care and Other Community Settings for Children and Adults with Disabilities
Persons with disabilities, including children, are another population that experiences 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 FY21, 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. This included:
- Crafting a “situation brief” to bring forward assessment data and real-life challenges to the attention of members of the State Emergency Operations Center and MDH ICS. Often policy or guidance change came as a result including Best Practices for COVID-19 Testing and Vaccination Sites: Disability-related Accessibility; Facemask Considerations for People with Disabilities and Special Needs and Key Considerations for Vaccinating Young People with Disabilities.
- Developed a webpage Disabilities and Unique Health Needs in the COVID-19 Pandemic under the Health Equity umbrella on the MDH website and was updated as the pandemic evolved.
- Participated in several advisory groups that were addressing the disability community needs during the pandemic to provide and hear updates and concerns and share MDH’s guidance. The groups include the Minnesota Interagency Disability Community Engagement Group, the Disability Rights Preservation Advisory Group, the Minnesota Consortium for Citizens with Disabilities (MNCCD) and the Deaf and Hard of Hearing Services (DHHS) advisory meetings on a regular basis.
The ability of patients with disabilities and pediatric patients to access support persons or their parents/legal guardians while hospitalized was a particular concern that rose to a high priority due to the poor sequalae of such patients without a caregiver while hospitalized. Title V staff worked with the Disability Advisory Group and the Minnesota Hospital Association to develop the guidance “Access to Support for Patients with Disabilities and Pediatric Patients in a Hospital Setting.” This guidance provided minimum standards for hospital visitation policies and was shared broadly via the Minnesota Hospital Association and other channels.
Strategy B. Expand Access to Health Care by Increasing Availability of Community-Based and Remote Services
Activity 1: Provide Road Map/Technical Assistance to Expand Opportunities for Collaboration between the Health Care System and Schools
One way to expand availability of community-based services is to provide them in places where families are already located or frequently attend, such as their child’s school. Building on the relationships with school nursing programs, Title V staff worked to improve collaboration with schools, school nurses, and school-based clinics as primary entry points to improve health care for children. During FY2021, Title V staff continued to work closely with the adopted Whole School, Whole Community, and Whole Child Model alongside staff in the MDH Statewide Health Improvement Partnership (SHIP) program as well as the Minnesota Department of Education. This initiative included building school health advisory teams and conducting standardized school health assessments.
Title V staff collaborated with Center for Emergency Preparedness and Response to submit a state application to Centers for Disease Control CDC Crisis Response Cooperative Agreement: COVID-19 Public Workforce Supplemental Funding (CDC-RFA-TP18-1802). The primary goal of the funding is to establish, expand and sustain a public health workforce to fill the gap left behind by the pandemic. The notice of award was received by the state of Minnesota on May 17, 2021. 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 determined. CFH will administer $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 . CFH will administer $2,493,508 to serve 26 school-based health centers (SBHC) via seven grantees and 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. 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.
Activity 2: Assess and Promote Accessible and Barrier-Free Access to Telehealth and Other Remote Methods of Health Care for MCH Populations
Telehealth has been identified as a promising solution to meet some needs for rural and underserved areas that lack enough health care services, including specialty care. Telehealth enables patients and providers to connect through video conference, telephone, or a home health monitoring device. Some approaches to increase use of telehealth include development of policies that expand access to primary care and other health services and reviewing existing reimbursement policies for telehealth services to remove barriers for health care practitioners who provide telehealth services. During the COVID-19 pandemic, implementation of telephonic and televideo health services expanded quickly, including use by Maternal and Child Health related programs including WIC, Minnesota’s EPSDT Program (Child and Teen Check-ups), Family Planning Special Projects, and Family Home Visiting programs. While numerous waivers and policy changes have allowed providers and patients to utilize telehealth services during the national and state-declared peacetime emergency, it is unclear how these changes have impacted the MCH population and which policies will remain long-term. During FY2021, 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.
Strategy C. Improve the Quality of Health Care by Promoting Person and Family-Centered Practices
Many people have difficulty navigating the health care system to get the care they need. Specific communities, such as people with disabilities and their families, people with limited English proficiency, people living in rural areas, and communities that have been historically discriminated against, require more unique approaches to accessing quality care than strategies that may be effective for the majority. Understanding that some populations may need different approaches in communication and outreach, it is important to leverage existing, trusted networks (such as Community Health Workers and other cultural brokers) to empower patients and families with information and tools needed to be engaged in their health care. The following activities seek to utilize these trusted health advocates as partners in Minnesota’s efforts to improve quality of health care and person-centered practices in communities.
Activity 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.11 MDH staff within the Health Promotion Chronic Disease section at MDH have partnered with the Minnesota Community Health Worker Alliance to expand CHW initiatives and promote the profession. In FY21, Title V staff met with HPCD staff to identify opportunities for partnership and to explore CHW models that exist in Minnesota.
Other cultural brokers who identify and provide ethnic and culturally specific care for pre and postpartum women within their communities are doulas and midwives. A doula is a trained individual that provides individualized physical and emotional support as well as evidence-based information and advocacy to the parent before, during, and after childbirth. Although doulas do not provide medical care, they do offer evidence-based information to women that support the informed decision-making process. An accomplishment of note this reporting period was one-time funding awarded during the FY 2021 Minnesota legislative special session to MDH. The purpose of the funding is to engage and partner with patient groups and community organizations to identify barriers to becoming a doula or midwife, explore ways to ensure midwife and doula training is culturally responsive and tailored to the needs of the communities they serve, and promote diversification of the midwife and doula workforce to align with childbearing population in Minnesota.
Activity 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 counties, Tribal governments, or nonprofit organizations to provide family planning services in communities throughout the state. In FY21, there were 24 grantees located throughout the state including one county- and one university-operated clinic, five local public health agencies, and 17 nonprofit organizations.
Minnesota’s Sexually Transmitted Infections (STIs) remained at near historic high levels with 33,252 STI cases reported in 2020. 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 collaborated with colleagues from MDH’s Division of Infectious Disease Epidemiology, Prevention and Control (IDEPC) to provide an educational webinar 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. In coordination with the National Coalition of STD Directors, MDH also presented two additional webinars about 340B program requirements, including provider eligibility, registering as a 340B covered entity, completing auditable records, and certification. 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, 2020 – June 30, 2021), FPSP grantees reached 46,587 individuals through outreach activities such as small groups and health fairs; counseled 20,000 individuals on reproductive life planning and contraceptive options; and provided 17,409 people with a range of family planning method services. The FPSP Statistical Report provides additional details (https://www.health.state.mn.us/docs/people/womeninfants/familyplanning/fpsp2021.pdf).
Of these individuals served, 54% of people had incomes below 100 percent of the federal poverty guidelines, and 80% were below 200 percent. Eighty-nine percent of people receiving method services were 18 or older, with 62 % between the ages of 18 and 29.
Measuring Progress in Accessible and Affordable Health Care
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 MDH Title V program gains access to this data through the Minnesota Health Access Survey (MHAS) hosted by the Health Economics program at MDH. The Minnesota Health Access Survey is a biennial telephone and mail survey that collects information on the health of Minnesotans and how they access health insurance and health care services. The survey measures how many people in Minnesota have health insurance and how easy it is for them to get health care.
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 (see Figure 1). 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. By 2025, Minnesota aims to decrease the percentage of Minnesotans who forgo routine medical care due to cost by 35%.
Figure 1. Proportion of Minnesotans reporting an unmet need for medical care due to cost
Systemic racism is pervasive within health care and has led to inequities in access to and affordability of health care by race/ethnicity. It shows up in our health care system in many ways that impact Black, Indigenous and People of Color (BIPOC) access to safe, affordable, and dignified health care. For example, due to structural racism which shapes things like who has opportunities for well-paying jobs with benefits, uninsurance rates among BIPOC Minnesotans are significantly higher than those among White Minnesotans (Figure 2).
Figure 2. Minnesota Uninsurance Rates by Race
American Indian Family Health
The 2021-2025 priority needs related to American Indian family health were identified because of data showing stark disparities for this population in our state. These disparities are the result of structural and systemic racism which have become embedded in our policies. Programmatic efforts from FY2021 aimed at addressing this priority need are discussed below. They were identified through focus groups with Tribal leaders, Tribal health care providers, and community members of our sovereign American Indian nations. We conclude with information on how Minnesota is measuring our progress on American Indian Family Health.
Strategy A. Increase Access to Culturally Specific Health Services
Activity 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 U.S. 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. In Minnesota, MA does cover doula care, but there are major issues about who is counted as a doula and the reimbursement rate is very low (see Infant Health domain for more information about advocacy efforts).
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 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:
- Family Home Visiting (FHV) provided funding for three home visitors to complete Indigenous doula training to augment their services for families in Fall 2021. These doulas also provide the Family Spirit evidence-based model with families 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 DHS on six occasions during FFY21 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 leadership held discussions on two occasions during FFY21 with DHS leadership on doula and CHW reimbursement rates.
- The FHV Tribal Nurse Consultant worked with NWICDC and state MNSCU system to reinstate the culturally normed CHW program offered. Ongoing efforts are needed to be able to return this valuable program to the community.
- An amendment in the statue 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.
Activity 2: Support Family-Centered Evidence-Based Programs and Practices that are Normed in the American Indian Community
Our focus groups also 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 Family Home Visiting Section at MDH continues to provide funding for nine of our eleven tribal communities to provide a range of services from TANF universal home visiting to targeted evidence-based models. Communities can utilize funding in ways that makes the most sense for them. In addition to funding, Minnesota provided additional services as follows:
- Technical assistance during the pandemic for staff reassigned to COVID work to remain engaged in family home visiting services as much as possible.
- Funding for a family home visiting Community of Practice developed and presented by Johns Hopkins and the MDH Tribal Nurse Consultant. The year-long event was held virtually because of COVID. Nine of 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. Staff from eight of our eleven Tribal Nations and five nonprofit organizations serving the metro American Indian population attended the training. Feedback was incredibly positive. Utilized cultural healers from around the area to speak.
Strategy B. Mandate Cultural Proficiency, as Defined by the Community
Activity 1: Convene a Group of Stakeholders and MDH Staff to Review Currently Available Training
This strategy was not completed as outlined. Tribal leadership did not feel they had the bandwidth during the pandemic to devote to this important strategy, but stressed they wanted to pursue it further when time allowed. In discussions with Tribal leadership around this strategy, it was their suggestion that MDH consult with other Minnesota state agencies that currently provide for cultural training and review the curriculum. An overview could be presented to them for their review and feedback.
Activity 2: Collaborate with Minnesota DHS to Develop Specific Training for those Working with Tribal Communities
Minnesota acknowledges the sovereignty of Minnesota’s 11 federally recognized Indian Tribes 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 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). MDH has its own internal policy that aligns with M.S. 10.65. Currently, State Tribal Relationship training is being offered for state agency staff; however, further evaluation needs to be done to look at data to see the percentage of state staff attending and if elements of TSRT need to be added or edited.
Strategy C. Shift Power and Policies to Address Structural Racism
Activity 1: Establish an Office of American Indian Health within MDH
In responding to the COVID-19 pandemic, tribal nations once again demonstrated their effectiveness in responding to the needs of their community utilizing cultural strengths. Acknowledging the abilities of American Indian communities to know what is best for their communities, MDH created an Office for American Indian Health to ensure the efforts to communicate, coordinate and consult with tribal nations to address health equity and reduce disparities, which also may include developing and implementing policies and programs, are done in partnership with tribal nations – following their lead. Establishing collaborative relationships with Minnesota’s 11 tribes is an ongoing work in MDH’s efforts to shift power and policies to address structural racism and systems of colonization that continue to impact American Indian communities.
Activity 2: Evaluate satisfaction and efficacy of project pilot to shift Ending Health Disparity Initiative (EHDI)/TANF/MCH bi-annual reports to oral and in-person methodology
Anecdotally, Tribal health care staff have shared that the shift to in-person (when pandemic restrictions are not in place), oral reporting has been very well received by Minnesota’s Tribal Nations. Informal feedback has been collected on this strategy during this reporting period and positive comments have prompted MDH programs collecting Tribal data to look at further expanding this strategy. Further satisfaction data from our communities will be gathered after another round of in-person reporting is able to be completed once pandemic restrictions allow.
Activity 3: Develop Request for Proposal Processes that Demonstrate a Knowledge of American Indian Communities, their Norms, and Values
In April of 2022, MDH anticipates releasing 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 leadership and 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.
Measuring Progress in American Indian Family Health
Structural and systemic racism plays an integral role in perpetuating poor health outcomes among American Indian populations. This includes the micro-level standards that govern how MDH interacts with and receives information from tribal communities. Tribal leaders across the state have told staff 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 collaborated with tribes to develop personalized technical assistance plans to provide meaningful services that meet their needs in a culturally relevant way.
Staff have also engaged leadership at MDH to work towards addressing policies that are barriers for tribal communities as they work to meet the needs of their communities utilizing strengths-based, culturally centered approaches. As such, the only performance measure being tracked is the percent of tribes agreeing to collaborate with MDH in developing technical plans. During this reporting period, 9 of the 11 tribes collaborated with MDH to develop TA plans, four are currently being implemented.
CFH/FHV staff and leadership meet monthly with the Director of American Indian Health at MDH to review MCH and evidence-based services that serve our AI 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 will allow for the AI Director to set up an Office of American Indian Health. Our work and discussions helped to inform the work of that office, and a State-Tribal Policy Specialist/Planner will be hired to address this need. 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.
During this reporting period Minnesota has implemented work plans with Mille Lacs, Red Lake, Leech Lake and Bois Forte tribal nations. Family Spirit, an evidence based FHV model developed by and for the American Indian community, included in each of these tribal nations work plans were implemented. Additionally, nine tribes that received TANF funding for maternal and child health services determined their own culturally specific approaches.
Housing
The 2021-2025 priority need related to housing aims to increase safe, affordable, stable housing for all people living in Minnesota. Programmatic efforts from FY2021 that addressed this priority need are discussed below. We conclude with information on how Minnesota is measuring our progress/impact on housing in Minnesota.
Strategy A. Expand Funding Opportunities
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.
An additional MHFA program is the Family Homeless Prevention and Assistance Program which 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. These services are provided through 20 grantees that serve all 87 counties in Minnesota. It is intended to complement a community’s Continuum of Care and provide funding for coordinated entry, street outreach, prevention, and rapid re-housing. Like Homework Starts with Home, 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.
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. There are 10 CoC regions within Minnesota that establish priorities for the household type of housing units needed within their region. Minnesota’s CoCs receive over $30 million annually through the U.S. Department of Housing and Urban Development McKinney Vento Homeless Assistance Program. CoCs focus on prevention, outreach and assessment, emergency shelter, transitional housing, and permanent supportive housing. During the pandemic 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 2020-2021.
Strategy B. Person-Centered Approach/Services
Activity 1: Increase access to safe and affordable housing for clients who are pregnant or parenting infants
Family home visiting routinely screens for clients and families who are experiencing homelessness. In 2021, approximately 4% of families served were identified as homeless. Of the families identified as homeless, 4.5% were pregnant and 3.3% were parenting. Home visitors provided referral and support services to community resources to help find stable housing for families who are pregnant or parenting infants and/or young children.
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 provide every client with a housing assessment along with housing assistance or community referrals for clients in need. Four PA grantees provide long-term residential housing including wrap around services for client support and self-sufficiency. In addition, 11 grantees provide rental assistance funds for clients needing stable and safe housing. In 2021 the total PA clients receiving residential housing support or financial/rental assistance totaled 1,346 participants.
Also, in 2021 PA grantees served a total of 5,208 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 2021 one grantee, through a network of 180 affiliate sites in Minnesota, provided 301 participants financial assistance for housing and related living expenses.
Strategy C. Create/Innovate Housing
COVID 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 Child and Family Health 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, it created partnerships and opportunity for the future. Many jurisdictions throughout the state are currently re-evaluating what it means to provide adequate, dignified and shelter with considerable funding from the Department of Human Services to improve and innovate as it relates to shelter options for children and families.
Calling All Sectors (CAS) is a Pew Charitable Trust and Robert Wood Johnson Foundation[F(1] national collaborative intended to create lasting partnerships across state agencies and with community-based organizations to identify innovative solutions to public health issues. As a participant in this project, MDH is working to identify cross-sector collaboration to generate systems level policies and strategies that reduce inequities in the African American/Black and American Indian communities to ensure that no child is born into homelessness and recognizing quality housing access as an indicator of infant mortality. The project grant period is 2020-2022 and the CAS team is working to engage multiple stakeholders to identify the barriers to navigating services for pregnant people who are homeless. Specific questions guiding the project include:
- 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 include:
- Identifying organizations and programs in Minnesota working to address the priorities identified by the CAS Home 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.
Strategy D. Focus on Policy Change
The Minnesota Interagency Council on Homelessness (Council) 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 all Minnesotans. MDH is one of the 11 agencies and is represented by Assistant Commissioner Mary Manning. The CFH Division Director was involved in the Council’s activities prior to being assigned to the COVID response. The Council 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 2020-2021 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.
During the COVID response, Governor Walz issued an executive order that paused eviction actions and lease terminations at the height of the pandemic. The legislature passed a law in June 2021 that created the Eviction Moratorium Off-Ramp beginning on June 20,2021. Prior to the passage of this law, landlords were prohibited from evicting tenants, which offered some protection for families who were safely housed. Additionally, federal CARES Act funding supported the Minnesota COVID-19 Housing Assistance Fund to prevent homelessness and help maintain safe, stable housing for individuals and families impacted by the public health emergency.
Measuring Progress in Housing
To measure progress in housing, a new state performance measure has been created. We are tracking the proportion of students reporting having stayed 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. This information is collected every three years in the Minnesota Student Survey. Data for the 2022 survey is being collected right now and will end in June, so there is currently no updated data for comparison with our objective of 4.4% for 2021.
Below is data from the previous three Minnesota Student Surveys about students experiencing homeless broken down by whether they are living with adult family or not. Across the board, 2019 saw reductions in homelessness compared to 2016. The same is true comparing 2019 to 2013, except for the group of homeless youth living with adult family which has marginally increased.
Figure 4. Proportion of Homeless Youth from Minnesota Student Survey 2013-2019 (SPM 3)
On the other side of the coin from homelessness is homeownership. Minnesota has the highest rate of owner-occupied home ownership in the nation at 75.8%. However, when this statistic is stratified by race, a different picture emerges. In 2019, the home ownership rate for non-Hispanic white Minnesotans was more than double that of black or African American Minnesotans. Based on the below data, Minnesota has the 4th largest gap 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.
Figure 5. Minnesota Home Ownership Rates by Race, 2019 Census Data
Source: Census Bureau, 2019 American Community Survey
Mental Well Being
Minnesota’s 2020 Needs Assessment identified Mental Well-Being as a priority need for the 2021-2025 Title V MCH Block Grant cycle. Improving Mental Well-Being means ensuring all people living in Minnesota have the opportunity and skills to manage day-to-day stress, have meaningful relationships and contribute to their family and community, including building resilience in those who experience childhood trauma. Programmatic efforts from FY2021 aimed at addressing this priority need are discussed below. We conclude with information on how Minnesota is measuring our progress on improving Mental Well-Being for people living in Minnesota.
Strategy A. Help Communities Build Capacity and Resilience
Activity 1: 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 a 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. At the same time, the Suicide Prevention unit developed a cohort series to provide select communities across the state with key training series on building community coalitions, effective organizing, and strategies to access community data that could help support decision making about mental health strategies at the local level. Amid these various factors, it did not seem feasible to engage communities in the proposed process. This objective is still relevant 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. In FY 2022, MDH intends to regroup and 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.
Activity 2: Develop an Outreach Plan for the Existing Minnesota Thrives Tool
Minnesota Thrives website is an interactive and collectively sourced database to provide communities 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 FY 2021, the MN 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 departments. The tool can be accessed on MDH website at: https://www.health.state.mn.us/communities/mentalhealth/mnthrives.html. The workgroup, in partnership with MDH Communications staff, developed a comprehensive outreach plan. Throughout this year, the workgroup has been preparing to launch a campaign to get 1,000 entries in the database. The following several key steps have been 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 Thrive 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.
- Developed community champions program to highlight counties with a certain number or range of initiatives submitted.
The workgroup will continuously review and modify outreach steps throughout the course of the yearlong campaign. In FY 2022, MDH staff will continue to implement these action steps.
Activity 3: Train Key Stakeholders on Several Community-Based Programs to Build Support for Expanding these Models Statewide
MDH has made several attempts to establish funding for this type of investment through existing program funding, American Rescue Plan proposals and other COVID resources. We built awareness and support for several model programs including Wellness Recovery Action Planning (WRAP) and Living Life to the Full. During this reporting period, we met with the Copeland Center to learn about implementation of family WRAP throughout California, and to organize a webinar for key stakeholders in Minnesota. Recently, we started a partnership with WellShare International, who is now contracting with the Living Life to the Full developers to implement training for community health workers in several marginalized communities including Somali, Oromo, and Latinx communities. The Governor’s budget currently includes a proposal focused on community healing that may support training in model practices such as those named here.
Strategy B. Implement a Public Health Communications Campaign on Mental Well-Being across the Life Span
Activity 1: Expand Understanding of Key Research and Current Strategies to Support Social Connectedness and Other Factors that Influence Mental Well-Being
In FY 2021, MDH developed a draft comprehensive summary of research and measures and is in the process of being reviewed with key partners. This 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 such as:
- A county initiative to connect people to their culture and traditional cultural practices,
- Men’s Shed program aimed at promoting social connectedness among senior men,
- Beyond Differences program designed to help children and youth connect, and
- Healthy Together Willmar, a community wide initiative that included cross community and cross-cultural leadership opportunities to direct funding for well-being and equity.
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. Planning started in 2021, but it was postponed due to a peak in COVID cases. It is now scheduled for spring 2022.
Activity 2: Partner with the Preschool Development Grant Staff on Shaping the Trauma-Informed Toolkit and Training Modules
Funding through the Preschool Development Grant supported a contract with the Minnesota Association of Children’s Mental Health to develop a trauma toolkit for professionals working with families with young children ages 0-7. This toolkit provides an educational roadmap for professionals to continue to learn and implement trauma informed practices. See what’s currently available and watch for additional resources as they become available: Resources for Healing-Centered Practice - MACMH | MACMH. The toolkit 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 FY 2021, MDH staff participated in the advisory council for the trauma-informed toolkit and supported changes to increase the accessibility and outreach for this resource. Staff provided some input on the content and layout of the toolkit. The toolkit was only recently launched along a series of trainings for providers and will be shared with the staff working under the Preschool Development Grant. MDH will continue to engage in this project throughout FY 2022.
Activity 3: Identify Opportunities to Develop and Implement More Formal Marketing Campaign(s) on Mental Well-Being, Trauma, and Resilience
In FY 2021, 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 (see the Adolescent Health domain for further information). This was revised and the second version was also shared broadly with communities and organizations. MDH staff hosted a webinar to launch the campaign. Over 100 organizations participated in the campaign in some way. Staff supported the development and promotion of the Trauma Informed Toolkit described above. 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.
Strategy C. Advocate for Legislative Policies that Promote Mental Well-Being for Everyone
Activity 1: Partner with the MDH State Health Improvement Partnership, Minnesota Public Health Law Network, and MDH Healthy Minnesota Partnership to Identify Legislative Priorities to Support Well-Being
Title V staff continue to coordinate with State Health Improvement Partnership (SHIP) colleagues to identify potential policy and system strategies that promote mental well-being. During FY 2021, MDH staff promoted awareness of policy and systems changes through direct technical assistance to local communities and sharing resources, such as the Healthy Places by Design report on Socially Connected Communities. Policy examples could include decriminalizing loitering, expanding public access to community spaces, improving safety in public parks, and promoting service-learning in workplaces and schools.
MDH promoted awareness of various strategies through the Minnesota Mental Well-being and Resilience Learning Community. Many local State Health Improvement Program coordinators participate in these monthly webinars.
MDH support for the Green Schoolyard project continued through FY 2021, through active participation in the advisory council and by serving as a bridge between partners. For example, we were able to connect the Children and Nature Network (CNN) to the Whole School Whole Child (WSCC) interagency team to expand awareness about the intersection between nature, well-being and the WSCC model. Through this intersection, CNN connected with the Minnesota Department of Education to identify administrative policy opportunities to prioritize access to nature in the school building project approval processes.
Activity 2: Include Public Health-Focused Recommendations in the 2022 State Mental Health Advisory Council Report
MDH contributed to the State Mental Health Advisory Council and facilitated the Family Systems and Prevention Workgroup. The workgroup purpose is to identify policy recommendations that could:
- 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) crisis and/or use of higher levels of care.
During FY 2021, the workgroup identified resources such as: family peer support for those with a child involved in clinical mental health services, limited family peer support for those with a child with a special health care need (CYSHCN), and a pilot family navigation model through the early childhood resource centers.
Activity 3: Partner with MDH Statewide Health Improvement Partnership (SHIP) in Identifying Policies and Practices that Promote Mental Well-Being across the Population
As noted above, during FY 2021, Title V staff partnered with SHIP colleagues through the technical assistance team and participation in monthly Coffee Chats with the local SHIP coordinators. COVID-19 diverted attention from SHIP well-being efforts, and the SHIP staff decided to continue this as a building year before launching work plans in earnest. Local SHIP developed initial well-being proposals and were given latitude to include COVID related efforts that may or may not be systems or policy changes.
Measuring Progress in Mental Well Being
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.[1] 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.
Figure 6 shows the percentage of Minnesota 8th, 9th, and 11th grade students who report experiencing each mental well-being component. These data capture Minnesota youth experiences, which are shaped by the opportunities and resources in their community. This offers some tangible ways to think about mental well-being and can point to opportunities to improve mental well-being by ensuring the environment supports these skills and experiences for all youth.
Figure 6. Percentage of Minnesota Youth reporting Mental Well-Being Components, 2019
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. By 2025, Minnesota aims to increase the percentage of adolescents who report positive mental well-being by 5%.
Parent and Caregiver Support
A 2021-2025 cross-cutting priority need identified during Minnesota’s 2020 Needs Assessment was for increased support for parents and caregivers socially and emotionally with family-focused activities, policies, and education. Programmatic efforts from FY2021 aimed at addressing this priority need are discussed below. We conclude with information on how Minnesota is measuring our progress/impact of providing support to parents and caregivers.
Strategy A. Advocate for the Redesign of a Network of Policies and Programs to Better Support Families
Activity 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 major step toward better collaboration was ensuring our Title V and MIECHV needs assessments were coordinated. In addition, Family Home Visiting staff actively participate in action planning and reporting in nearly all Title V domains.
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 into FY2022 and FY2023.
Activity 2: Advocate for Policies that Promote and Support the Well-Being of Parents/Caregivers
During FY2021, we had proposed bringing together partners to advocate for policies that promote and support the well-being of families – such as paid leave, student loan forgiveness, work flexibility, living wages, and other topics. 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 (including the family support grant projects discussed in Strategy C). We plan to regroup and figure out a plan for this advocacy work in FY2022 and FY2023.
Strategy B. Build Capacity of Health Professionals to Help Improve Mental Health, Well-Being, and Resilience of Families
Activity 1: Provide Training 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 FY2021, MDH worked in coordination with the Minnesota Department of Human Services and infant mental health consultant, Michelle Fallon, to co-design a four-part online training series on infant mental health. The series introduced the multidisciplinary field of infant and early childhood mental health (IECMH) with a focus on strategies for home visiting. The first three sessions included PowerPoint/lecture, opportunities for virtual participation and activities to support learning. The fourth session included a conversational reflective learning session focusing on participants’ integration of strategies into their own work. Topics included:
- An overview of IECMH: Promoting relationships with relationships in home visiting
- A review of the brain science that supports our work
- The need for four lenses—development, attachment/relationships, trauma/stress and culture—to inform our interactions and interventions
- The need for self-awareness and coping strategies to promote our own sustainability in the work.
During FY2021, MDH FHV also promoted on-line trainings that were developed by The Institute for the Advancement of Family Support Professionals to specifically provide best practice principles and strategies to support home visitors in maintaining meaningful connections with families during times of increased anxiety and need related to the pandemic. Regular reminders of these new and recorded Rapid Response webinars were published in the Family Home Visiting Tuesday Topics weekly newsletter.
Strategy C. Build Supports for Multi-Faceted Ways for Parents/Caregivers to Connect with One Another
Activity 1: Maximizing Technology to Increase Options for Families to Communicate with One Another
During FY2021, MDH partnered with the Minnesota Department of Human Services to fund grants for family-led organizations to offer peer-to-peer opportunities for families. A major component of this grant program focused on pursuing electronic or other innovative ways to connect families with one another in physically distant ways. These grants, including their goals and outcomes are discussed in more detail in the CYSHN domain. More specifically, though, one of the projects focused on this issue of helping families to connect with one another virtually using podcasts and virtual discussions. One grantee, Communities Engaging Autism, developed podcast episodes aimed at providing information and support for parents of children with autism. The podcast, called Oxygen Mask, released several episodes during the grant project with content driven by parent needs, including:
- Strategies for managing expectations parents set for themselves and their children.
- Helping parents face stigma and feel seen and supported.
- Impact having a child with special health needs has on fathers and how two men started a support group to help bring together fathers.
- Neurodiversity in parents who are also raising neurodiverse children.
- Using the Charting the LifeCourse tools for planning and advocacy.
This grantee also held a virtual book club with families, where they read through the book, Just Give Him the Whale!, by Patrick Schwartz and Paula Kluth. Virtual book club discussions were well received and focused on how to use passions, areas of expertise, and strengths to support students with autism.
Activity 2: Connecting Families to Family-to-Family Support
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 FY2021, work was done to ensure that many of these resources were included in the Help Me Connect resource directory tool. A whole section of the tool focuses on resources that help promote family well-being and mental health, including parenting support programs. More information on Help Me Connect is included in the child health domain.
Measuring Progress in Parent and Caregiver Support
Minnesota has chosen to focus on the percentage of children with parents who report being able to cope with the demands of parenthood as a State Performance Measure. According to the 2019-2020 NSCH, only 59.4% of children in Minnesota are living with parents who report they are coping with the day-to-day demands of parenting very well, see Figure 1. By 2025, Minnesota aims to increase the percentage of children with parents who are coping very well with the demands of parenthood by 5% (i.e., approximately 68.5% of children will live with parents who are coping very well by 2025). See Figure 7 for tracked progress in this area. Disparities exist in parent coping levels based on the certain characteristics of the child. However, the NSCH works off a small sample size and as such, some of these differences should be interpreted with caution. As more data are available, we continue to evaluate the disparities in this priority area.
Figure 7. Percentage of Children with Parents who are Coping Very Well with Demands of Parenthood Over Time
[1] Hone, L.C., Jarden, A., Schofield, G.M., & Duncan, S. (2014). Measuring flourishing: The impact of operational definitions on the prevalence of high levels of wellbeing. International Journal of Wellbeing, 4(1), 62-90. doi:10.5502/ijw.v4i1.4
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