DOMAIN: CROSS CUTTING AND LIFE COURSE
Annual Report for FY19-20 (October 19-September 20)
Preventive Health – State Priority #5: Increase use of primary and preventive health care services across the life course.
A life course approach to preventive health care is essential to ensuring healthy families and healthy communities. Increases in chronic disease such as heart disease, diabetes and obesity impact longevity and health outcomes. Racial and ethnic minority communities experience higher rates of obesity, cancer, diabetes, and HIV/AIDS, and maternal mortality and morbidity disproportionally impact women of color. Children are becoming increasingly vulnerable as an increase in overweight or obesity predisposes them to chronic disease and the numbers are even higher in African American and Hispanic communities. NY's Title V program selected this as a state priority to focus on preventing disease and illness before they occur with an emphasis on how social determinants impact health to work towards supporting healthier homes, workplaces, schools and communities.
An essential component of any effort to improve birth outcomes must be a specific focus on improving access and utilization of preventive health care services. With 50% of all pregnancies in NY unplanned, impacting the overall health of all women in NY is a key step in improving pregnancy and birth outcomes. To that end, improving access to health insurance and preventive health care is a major priority across the life course. By improving the overall health of NY women before pregnancy and concurrently working to improve the intendedness of pregnancies, Title V can be assured that this work will improve the health status and birth outcomes for all women.
Preventive health care services encompass well-woman, preconception, prenatal, postpartum, interconception, well-baby, well-child, and well-teen care. Based on analysis of available data and stakeholder input, Title V staff identified access to health insurance as a necessary element to the increased use of preventive services. NY's Title V program continued to rely on key external resources to further develop this scope of work that included the U.S. Preventive Services Task Force (USPSTF) recommendation for preventive care, the AAP Bright Futures Guidelines for Health Supervision of Infants, Children and Adolescents, and Early and Periodic Screening, Diagnostic and Treatment (EPSDT) guidelines for state Medicaid programs.
Building on an initial assessment conducted during the last reporting period, the NYS Title V program worked to identify and evaluate various program requirements and measures currently used by Title V-funded programs to promote preventive care. Currently, 58% of all Title V programs include a requirement to promote well woman care and 65% of programs include a focus on increasing health insurance enrollment. To better understand the types of measures being used, Title V staff worked with colleagues to obtain examples of how requirements and measures promoting preventive health care were being used across all Title V programs. Staff spoke with colleagues across DFH and identified several key programs with a major emphasis on promoting access to preventive care. Broadly speaking, this emphasis was most often seen in program requirements that promote health insurance enrollment, annual well woman visits, as well as assistance accessing preventive services for children and adolescents.
One such program emphasizing the role of preventive care is the Maternal and Infant Community Health Collaboratives (MICHC) program. The MICHC program seeks to improve maternal and infant health outcomes for high need, low income or Medicaid-eligible women and their families by supporting the development of multi-dimensional systems of integrated and coordinated community health programs and services. Using a life course approach, MICHCs work to improve preconception, prenatal, postpartum, and interconception health of Medicaid-eligible women by working collaboratively with community partners to implement strategies to find and engage Medicaid-eligible women and their families in health insurance, health care and other community services; assess a woman’s needs and risk factors and make referrals to appropriate services; coordinate services across community programs; and promote opportunities and supports for women to engage in healthy behaviors.
Another Title V program, which promotes access to preventive health care and provides those services, is the NYS Family Planning Program (FPP). Comprised of a network of 48 subrecipient agencies operating 166 separate clinic sites, the NYSFPP aims to make sexual and reproductive health accessible and affordable to low-income women and men across NYS. This program includes several comprehensive strategies used to promote access to preventive care for residents across NYS. These include, but are not limited to, the provision of required preventive health visits and screenings (including annual well woman visits, routine breast and cervical cancer screenings, vaccinations, etc.), as well as community education and outreach activities aimed at increasing community awareness of the necessity of timely access of preventive care services. NYSFPP clinics are also able to screen and enroll clients in a range of public health insurance options including Medicaid, Family Planning Benefit Program (FPBP), and the Family Planning Extension Program (FPEP).
NYSDOH Title V staff also work to improve preventive care access through the continued promotion of developmental screening for all children in NYS. Currently Title V staff from across the DFH are participating in or leading several major initiatives aimed at improving developmental screenings in NYS. These initiatives include the following collaborations/projects supporting the inclusion of developmental screening in Title V’s maternal and infant health initiatives, ongoing steps to promote early identification of potential developmental delays and referrals to the NYS Early Intervention Program (EIP), participation in the Early Childhood Advisory Council (ECAC), ongoing work with the Early Childhood Comprehensive Systems (ECCS) grant with the Council on Children and Families (CCF), and collaborating on several statewide First 1000 Days in Medicaid Initiative workgroups.
NY’s Title V program remains committed to ongoing efforts to support the integration of improved developmental screenings in both Title V work and within the EIP; Title V, EIP, MICHC, and MIECHV are overseen by the Division of Family Health. Title V staff working in MICHC and MIECHV programs have continued to make the inclusion of developmental screenings, either directly by program staff or via referrals to appropriate providers, a priority of their work. Current MIECHV activities include facilitation of a parent-completed developmental screening which is reviewed by home visitors and used to determine whether a referral to the state’s EIP is necessary. MICHC activities include screening children with the Ages and Stages Questionnaire (ASQ) and providing referrals to the state’s EIP when appropriate. EIP staff continue to focus on increasing developmental screening for all children they serve. The Child Find component of the EIP, which coordinates efforts made by other agencies and community programs that serve infants and toddlers to identify, locate, and track at-risk children using available resources, will also increase emphasis on developmental screening.
An important element of these strategies has been Title V’s long-standing commitment to the NYS ECAC workgroup. Convened by the NYS Governor’s Office, this council is comprised of partners from all sectors of the early childhood community. ECAC has a priority interest in promoting children’s development, and a specific focus on increasing rates of developmental screening. To further that goal, ECAC convened a workgroup to advance developmental screening and follow-up, with a focus on policy-oriented interventions. Members of the workgroup have been involved in Medicaid’s First 1000 Days initiative and the ECCS Impact grant. The Title V Director is the NYSDOH designated member of the ECAC and DFH staff are members of this group and will remain in this capacity throughout the upcoming program year.
The grant supports collaborative quality improvement projects in the three high need counties (Erie, Niagara, and Nassau) to improve maternal depression screening and follow-up as well as developmental screening and follow-up for young children. CCF is working closely with NYSDOH on this grant which was initiated in 2016. Progress is discussed in the Women’s/Maternal Health Domain annual report.
Another unique collaborative opportunity to promote developmental screenings can be seen through the NYSDOH support of the Connections Project (formerly referred to as the Albany Promise Project) which is a regional cross sector partnership where community leaders in Albany, NY come together to support a shared cradle to career education vision. Focused on increasing school readiness among young children in the city of Albany, the Connections Project targets children under the age of five with a range of cross-sector multi-dimensional interventions. The NYSDOH is partnering with Connections, Medicaid managed care plans, and pediatricians to create a pilot program in Albany County that incentivizes pediatricians and health plans to help ensure all children enter school ready to learn. Title V staff participate on the Early Childhood Success Team that has focused on increasing enrollment in quality early childcare programs and increasing the proportion of Albany children performing at or above benchmark when they enter pre-kindergarten. Concurrently, the NYS Medicaid Redesign Team is conducting a pilot program that is assessing a wide range of benchmarks associated with access and quality of developmental screenings available. This included number of well child visits, number of children screened above, close to, or below cut-off, the number of children who screened in need that were referred to either the NYS EIP or the Committee on Preschool Special Education (CPSE), as well as longer-term outcomes including the number of children screened and number referred who then received services and did or did not show improvement.
Early in the process, partners identified a key area of concern – the late identification of developmental delays in many school-aged children. Finding that many children were beginning school with delays that could have been identified earlier, partners began an intensive process to better understand the system of child health care and how improved developmental screenings could improve subsequent outcomes for youth. Screening children at ages birthto four and addressing any needs that are present at that point in the child’s life can significantly improve a child’s outcomes as they grow.
Beginning with a process map of the current screening, referral, and treatment systems with the community, the Connections Project worked through a collective impact framework. This work included development of mutually reinforcing activities to improve the identification of developmental delays, referral, and service provision systems. While this kind of collaboration is not without its challenges, this dynamic opportunity is working to better inform the NYS Title V program support for developmental screenings in ways that could be applicable in other communities across NYS.
The NYS Title V program is continuing work to support the First 1,000 Days initiative a multi-disciplinary effort to maximize access to services for children and families within the first 1,000 days of life. NY’s Title V program has been selected to partner on several activities as part of this initiative, chief among them working to expand access to Centering Pregnancy and evidence-based home visiting programs. Progress in these areas is discussed in the Maternal/Women’s Health Priority section.
Recognizing the unique barriers impacting the ability of adolescents to obtain preventive health care services and the need to identify strategies that address barriers, staff have been collaborating with adolescent health experts from Cornell University ACT for Youth Center of Excellence (ACT for Youth) to identify the most effective way to obtain adolescent feedback on this topic. Building on the literature review conducted by ACT for Youth, Title V staff collaborated with experts from ACT for Youth on the development and facilitation of a survey focused on obtaining feedback from adolescents on barriers to accessing preventive services. Title V staff met several times during the project period to review potential questions, brainstorm which topics should be included, and contribute to the development of a plan to distribute surveys to CAPP/PREP providers. The electronic survey was deployed to CAPP/PREP providers early in 2019. Full analysis of this information is expected in Summer 2019 and will be used to inform program development.
To compliment this work and generate a broader understanding of the state-wide health status of adolescents in NYS, a student intern was hired to compile a report of overall adolescent health across NYS. The student reviewed data and resources from the Division of Chronic Disease Prevention on adolescent health, cancer prevention, tobacco control, healthy schools, and obesity prevention. Final data sources included Youth Risk Behavior Survey System, National Survey of Children’s Health, National Youth Tobacco Survey, and others. A comprehensive report on the current state of adolescent health in New York State based on race, ethnicity, and socio-economic status was completed. Special health care needs populations, geographical location, gender, and sexual orientation were considered when analyzing data. The information gathered provides a comprehensive snap-shot view with the most available information (as of 2018) on a variety of health information that can be used by public health administrators in making informed decisions, assessing the needs of communities, developing adolescent health-related grant programs, and responding to providers and funders
Beyond ensuring preventive care is emphasized in Title V programs, staff also recognized the importance of assessing whether women of reproductive age receive preconception health care. To measure the actual implementation of preconception health during routine visits, Title V staff have been working to support the inclusion of a “preconception health” module in the NYS BRFSS sampling. This survey, which broadly represents the non-institutionalized civilian 18 years and older population of NYS, will be used to help Title V staff understand if women are getting these important health care services. The BRFSS contains seven questions on pre-conception health as part of the family planning module, and these data have been analyzed and reports issued.
Oral Health: State Priority #6: Promote oral health and reduce tooth decay across the life course
Oral health remains a key health indicator for women, infants, children, and families throughout their lives due to the impact it has on learning, social-emotional wellness, and overall health. The prevention of tooth decay remains a high priority for the Title V program, not only because of the effects of this disease and the associated social and financial impacts, but also because it is largely preventable and entirely treatable. According to 2016 NYS hospital discharge data (SPARCS), the rate of caries-related outpatient visit for children aged 3-5 years was 90 for every 10,000 children. NY’s Title V Program is committed to promoting oral health through education, community-based interventions and programming that benefits all NYS residents.
One strategy to promote oral health is to provide financial and technical support for maintenance and expansion of community water fluoridation (CWF).
NYSDOH continues to provide both technical and financial assistance to communities to maintain and expand CWF. To ensure adequate technical assistance support, NYSDOH awarded a contract to the NY Rural Water Association (NYRWA) for the period of August 2018-July 2023. The contract is intended to provide technical assistance and guidance, increase water operators’ knowledge about CWF, and help ensure fluoridated public water systems (PWS) are maintained and operated in compliance with all laws, rules and regulations and optimal fluoridation levels are maintained. NYRWA conducts onsite visits at water treatment plants to provide guidance on operating issues, provides technical support to water operators to ensure PWS are fluoridating at the optimal level, and delivers continuing education trainings (CE) for water operators on the topic of CWF. During the recent reporting period, NYRWA completed 21 onsite technical assistance visits to 13 unique PWS and held four CWF trainings for 125 water operators.
Financial assistance was also provided to 13 PWS through the Drinking Water Fluoridation (DWF) Grant program. As reported in previous annual reports, the grants have been awarded in four separate rounds. The most recent funding (fourth round) was released in August 2017 and a total of $5.2 million was encumbered to support 14 executed contracts. The grant program can support either Planning and Feasibility Projects (i.e., development of an engineering report to assess the equipment and financial impact of CWF in a community) or Implementation and Maintenance Projects (i.e., upgrade of equipment to maintain CWF).
This strategy is measured by ESM LC-6: Number of public water systems that receive financial and/or technical support from NYSDOH to maintain or initiate community water fluoridation. Over the course of the reporting period, 25 different PWS received technical and/or financial support for CWF from the DOH DWF Grant program.
The State Priority is measured by SPM #5: percentage of NYS residents served by community water systems that have optimally fluoridated water. Approximately 70.8% of NYS residents are served by community water systems with optimally fluoridated water. This data is captured by the Safe Drinking Water Information System (SDWIS), which is an Environmental Protection Agency (EPA) database managed by the DOH Center for Environmental Health (CEH). The most recent data are from 2017.
A second strategy to promote oral health is to increase the delivery of evidence-based preventive dental services across key settings, including school-based clinics, primary care practices and public health nutrition programs.
The Title V program has prioritized access to preventive dental care through promoting the delivery of care through schools. NYS has the largest School-Based Health Center (SBHC) program in the US. SBHCs can provide both medical and dental services, medical only or dental only. There are 48 hospital or FQHC sponsors (regulated by NYSDOH under Article 28 of NYS Public Health Law) providing dental services in 2,206 schools serving areas with low-income children (as determined by the percentage of students who qualify for the free lunch program) and may have limited access to dental services. The Title V Program has allocated funding to establish the School-Based Sealant Program (SBSP), with the goal of expanding the application of sealants on first-year molars of 2nd and 3rd graders, which is an evidence-based approach to combatting tooth decay. Twenty-five SBHC providers of dental services were awarded $50,000 per year for five years. Columbia Memorial Hospital (CMH), a SBHC provider of dental services and SBSP contractor, closed its school-based dental program in December 2018 due to their inability to hire a dentist despite a year-long search. As such, 24 SBHC providers currently provide SBSP services. SBSP grantees are required to report data to NYSDOH to support the evaluation this strategy.
The Title V program continued to partner with the Madison County and Jefferson County local health departments (LHD), through funding from the HRSA Oral Health Workforce Grant, to address dental workforce needs and access to oral care in underserved areas of the state. DFH Oral Health staff and Title V Dental Director are supporting these LHDs, which have prioritized oral health initiatives in their counties, to promote evidence-based oral health strategies including community water fluoridation and fluoride varnish in the medical setting. Title V staff have supported the LHDs’ efforts by participating in community meetings, securing experts to provide consultation and technical assistance, and making connections to other agencies and support systems, such as Title V funded SBHCs, in their area. Staff also worked to identify additional LHDs to partner with for the 2020-2021 grant year. They presented on the HRSA grant, alongside Madison and Jefferson County, at the New York State Association of County Health Officials (NYSACHO) monthly membership meeting in December 2019. Staff also reviewed the community health assessments for the 7 counties that selected oral health as a priority and selected two counties (Cayuga and Essex) to engage in discussion. Calls were held in February 2020, and both agreed to partner with NYSDOH, but COVID-19 impacted progress. The grant is supporting the development of a public health detailing curriculum to promote and increase primary care providers’ application of fluoride varnish as part of a routine well-child visit. Two live webinar trainings on applying fluoride varnish in the medical setting were held in August 2020, one for LHDs and the other for medical providers. Thirty-nine people requested continuing education credits for the live events. The trainings were recorded and posted on SUNY Albany’s website as enduring continuing education credit activities through August 2023. All training participants received a copy of NYSDOH’s Children’s Oral Health kit, a folder of patient and provider resources. LHDs participating in the detailing pilot were also sent copies of the kit in preparation for detailing in 2021. This public health detailing curriculum builds off the work conducted by NYSACHO, as reported in previous annual reports.
Title V staff continued to collaborate with the worked with NYSDOH Division of Chronic Disease Prevention (DCDP) on the closeout of the on addressing sugar-sweetened beverage (SSB) project which aimed to address SSBH consumption among adolescent males of color. The project ended in July 2019 and the final progress and evaluation reports were submitted to and accepted by CDC in November 2019. The posters developed under the SSB project continued to be promoted across Title V programming even after the conclusion of the grant.
A third strategy to promote oral health is to integrate oral health messages and strategies within existing community-based maternal and infant health programs.
From 2015-2018, BWIAH received funding from Health Resource and Services Administration (HRSA) for the Perinatal and Infant Oral Health Quality Improvement (PIOHQI) to integrate oral health strategies into community-based maternal and infant health programs through care coordination and public health detailing.
The PIOHQI Project was integrated into BWIAH’s Maternal and Infant Community Health Collaboratives (MICHC) Program. Title V staff worked with a MICHC program in Western New York - the Healthy Baby Network (HBN)- and their subcontractor, Eastman Institute for Oral Health (EIOH), to engage providers and community partners in finalizing the Oral Health Manual Toolkit and refining individual and systems-level strategies to improve maternal and infant access to oral health care and increase provider capacity. EIOH, in collaboration with HBN, trained 126 participants, ranging from dental care providers, perinatal care providers, and community health workers virtually and in-person on the use of the Toolkit and how providers can address oral health needs among high-need pregnant or parenting women and their families.
An Oral Health Manual and Toolkit was developed for providers and community health workers to provide a best practice resource and increase knowledge and capacity. The Toolkit was shared with the state’s MICHC programs. MICHCs also received training on use of the Toolkit and in turn trained their staff (Community Health Workers) and prenatal care and dental providers on best practices.
During the reporting period, MICHC programs continued to train new community health workers, and worked to identify oral health champions in their communities, share information with and/or train healthcare professionals through public health detailing, and/or educate partners at community network meetings.
The Pathways to Success initiative (which ended June 30, 2020) continued its work integrating oral health strategies into community-based maternal and infant health programs. Pathways to Success works to develop and implement programs to improve educational, health and social outcomes for expectant and parenting teens, women, fathers, and their families. The project was based in NYC with three community colleges and a community-based organization. These projects focused on building collaborations both internally within their organizations and externally with community providers and with other NYSDOH maternal and child health programs to strengthen support networks and referral systems to core services, including personal health, child health, education, employment, concrete supports (e.g. housing, transportation) and parenting supports (e.g. parenting education, healthy relationships). The goal was to establish solid and sustainable collaborations to ensure that young parents and their families are identified early on and receive referrals to needed resources and supports. The Pathways to Success program shared the Toolkit developed by the PIOHQI Project with these organizations to ensure that staff working with expectant and parenting teens were knowledgeable about oral health needs and made appropriate recommendations for this population.
This strategy is measured by ESM LC-8 Percentage of pregnant women served by Title V community health workers that have a documented screening or referral for dental services. NYSDOH tracks aggregate data reported quarterly by all 23 MICHCs to monitor the number of clients who are screened for oral health needs, received appropriate oral health information, and are referred for needed dental services. These data are reviewed quarterly, assessed for accuracy, and presented back to the MICHC programs for quality improvement purposes. In 2020, a reported 67.7% (12% increase from 60.5% in 2019) of prenatal and postpartum women who were served by CHWs had a documented screening for dental issues, and 15.3% of women screened were referred for dental services. Data collected allows tracking of completed referral rates and shows 27.6% of prenatal and postpartum clients referred for dental services completed the referral. This is a decrease from 2019, most likely due to the COVID-19 pandemic.
A final strategy in the SAP to promote oral health is to strengthen the NYS Title V program’s internal capacity, dental public health core competencies and workforce development for oral health surveillance and evidence-based interventions through continued support for NYS Dental Public Health Residency.
The NYS Dental Public Health Residency Program (NYSDPHRP) was designed to support and build capacity for all MCH oral health programs through the utilization of dental residents’ subject matter expertise in clinical dentistry and public health. The curriculum, based upon the core competencies as recognized by the American Association of Public Health Dentistry, focuses on MCH goals and objectives. Through collaboration and engagement with Title V staff on various MCH programs, the dental residents have a unique opportunity to apply concepts and tools in real public health settings, preparing them to assume critical roles in the practice of dental public health for improving health outcomes. Specifically, NY’s strategy is to strengthen Title V internal capacity by developing core dental public health competencies in residents. During their residency, the residents contribute to oral health program activities and analysis of evidence-based interventions implemented by the Title V program. Between 1998 and 2018, NYSDPHRP had 43 graduates, the majority of whom are working as public health dentists in state government, community-based clinics, and academic and hospital settings.
NYSDOH continues to partner with the Eastman Institute for Oral Health (Eastman). CODA granted the request to transfer the program to Eastman. As a result of the transfer, Eastman has become the accredited program to sustain operation of the dental public health residency program for current and future residents. NYSDOH and Eastman are currently finalizing an affiliate agreement that outlines NYSDOH’s roles and responsibilities as an affiliate site. These changes support the long-term objectives of the residency program to maintain a fully accredited training program for dentists interested in careers in dental public health.
During the COVID-19 response the residency program curriculum is being assessed in recognition of emerging dental public health issues related to workforce and access to care, health equity and current resources available to support the program. The Dental Director is also seeking out evidence-based and evidence-informed training resources to enhance residency program experiences that address updates to CODA standards focused on social determinants of health; and identifying specific activities for residents to support oral health interventions including preventive services in school-based dental clinics and the Community Water Fluoridation Program.
This State Priority is measured by NPM #13.1 Percent of women who had a dental visit during pregnancy and NPM #13.2 Children age 1-17 who had a preventive dental visit in the past year. For 2017 as reported in PRAMs, 45.4% of women surveyed had a dental visit during pregnancy as compared to the 47.2% in 2016, which was a slight decrease. For children with a preventive dental visit, the NSCH 2018-19 combined data reports NY at 77.7, slightly lower than the national average of 79.6. For NOM #14 Percent of children ages 1-17 who had decayed teeth or cavities in the past 12 months, the NSCH 2018-19 combined data reports NYS at 11.2% similar to 11.1 on the level for 2017-18, although slightly lower than the national average 11.6. The NSCH 2018-19 combined data show a decrease in the decay rate yet showing a slight decrease in preventive visits.
The objectives and measures in this priority area address a variety of subjects, reflecting the broad scope of factors impacting MCH. This priority area aims to impact physical activity, obesity, wellness, safety, and community social cohesion. Title V programs cannot impact these areas alone, making collaboration a critical focus of this priority area's strategies. The sources of these metrics are national surveys including the NSCH, using the most recent data available. Measured by NPM #8 Percent of children ages 6-11 and adolescents age 12-17 who are physically active at least 60 minutes per day. For adolescents ages 12 to 17 years, daily physical activity increased slightly between 2016 (18.3%) and 2017-2018 (19.9%) and was better than the national percentage of 17.5%. For children aged 6 to 11 years, those participating in daily physical activity increased from 22.9% in 2016 to 27.0% in 2017-2018.
In the 2017-2018 NSCH surveys, 53.0% of NY parents reported that their child lives in a supportive neighborhood, which is slightly lower than the national level (56.3%), but higher than those reporting in 2016 (50.1%). This includes parents' responses about whether people in the neighborhood help each other out and watch out for each other's children, and whether they know where to go for help in their community. Fewer NYS parents reported they agree their child is safe in their neighborhood compared to all parents nationally (58.1% compared to 65.3%, respectively) and the perception of safety increased slightly from 2016 (57.2%).
Stakeholder input obtained in the preparation for this application identified factors, including access to healthy, affordable food, safe places, to engage in physical activity and social support as important elements of a desirable community and are believed to have significant impact on families' health and wellbeing. These perceptions are consistent with broader and longstanding public health approaches aimed at supporting healthy communities, including strong commitments to community-driven change, fostering policy, systems, and environmental change strategies, and addressing social determinants of health. These broad, policy-level issues require a collaborative approach; the health sector must work with social services, planners, transportation, and other partners to begin to create change in NY’s communities.
Title V staff also kept abreast of NYSDOH partners’ efforts to change community environments to improve health outcomes for women, children, and families. The broad scope of environmental-level issues impacting communities' health—physical activity, obesity, wellness, safety, and community social cohesion—require cross-sector involvement. Staff had varying levels of engagement with the following partner programs: Creating Healthy Schools and Communities, Healthy Neighborhoods Program, Regional Centers for Sexual Violence Prevention and NY Rural Water Association.
Staff monitor the accomplishments of Title V partnerships by tracking programs with activities focused on collaboration or partnerships and outcomes at the community, environmental, or policy levels. Measured by ESM LC-11: Number of community environmental changes demonstrated as a result of enhanced collaborations. During the past reporting period, of nine programs meeting those criteria, six met their community, environmental, or policy level changes as a result of their enhanced collaborative efforts.
Environmental change continues through enhanced collaboration with partnerships from activities of the six Regional Centers for Sexual Violence Prevention (Regional Centers). Since 2014, these Regional Centers have been implementing innovative primary prevention community-level (coalition-building, community mobilization, social norms and policy change) and individual-level sexual violence prevention strategies (Bringing in the Bystander, Shifting Boundaries) with youth and young adults, ages 8-24, from seventeen high-risk counties across NYS. In past years, the Centers for Disease Control and Prevention (CDC) State Profile of NYS indicated that at least 60% of the Regional Center program strategies were currently being implemented at the community/societal level of the social ecological model, exceeding the CDC requirement of at least 50% of strategies implemented at the community/societal-level. During the current reporting period (2/1/19 – 1/31/20), the Regional Centers worked to maintain this level of t community/societal-level strategies. This unique comprehensive approach will increase NYSDOH Rape Prevention Education program’s (RPE) capacity to access and use data, leverage support, and align state goals and proposed outcomes with implemented strategies at the local level. To ensure RPE continues to increase the capacity for implementation of community/societal level strategies, RPE will utilize guidance, evaluation, and continuous quality improvement efforts to direct activities to the outer layer of the social-ecological model and create multi-layer approaches to sexual violence prevention.
In addition to the CDC’s four focus areas, the RPE has created four initiatives through which the Regional Centers will focus primary prevention efforts. Each Regional Center is required to work within two, but no more than three, of the following RPE initiatives:
- Healthy School Communities
- Healthy Nightlife Communities
- Healthy Sport Communities
- Healthy Neighborhoods.
Within each chosen RPE initiative, Regional Centers must incorporate the following components:
- Implement individual/relationship level curriculum from either CDC’s STOP Sexual Violence Technical Package or that meets CDC requirements
- Media/marketing campaign
- Policy scan and recommendations
- Environmental scan and recommendations.
A monthly tracking tool will estimate the proportion of each Regional Centers’ effort towards community and societal level strategies per month. Effort may be measured in the form of meetings with partners, description of changes to documents such as posters, letters, or strategic plans, delivery of curriculum, targeted recruitment efforts, and other steps along the path to producing outcomes.
The Regional Centers and community partners continue to invest considerable time and effort in the development and/or implementation of healthy community-level strategies including healthy nightlife (an initiative aimed to promote a healthy community by engaging bar owners, bar staff, and community patrons to create and build safe nightlife establishments) and healthy school initiatives (an initiative aimed to promote a healthy school community by providing sexual violence prevention education and establishing policies). Studies have shown a significant link between increased sexual violence and alcohol consumption for both perpetrators and victims. As a result, training bar proprietors and their staff on what is sexual violence, how to observe and assess situations for signs of sexual violence, bystander intervention skills building, policy change assistance and environmental assessments are all components of a comprehensive approach addressing all levels of the social-ecological model. The Regional Centers have been implementing the Healthy School and Healthy Nightlife initiatives since the previous five-year (2/1/14 – 1/31/19) RPE project period. The Healthy Sports and Healthy Neighborhood initiatives are new as of February 1, 2019 and are in the preliminary stages of development with assistance from the Regional Centers as well as the Statewide Center for Sexual Violence Prevention Training and Technical Assistance (Statewide Center). Between February 1 to July 31, 2019, Regional Centers conducted 30 nightlife trainings in bars/restaurants to 378 participants and 19 trainings within school communities to 1,846 students.
The settings of sports and neighborhoods are important settings to address for sexual violence prevention. For example, the Statewide Center has been in contact with Kansas RPE Director to discuss their work with Crime Prevention Through Environmental Design (CPTED) and how Kansas is utilizing this approach to address the environmental safety. While CPTED is a possibility for use in this initiative, it is important to ensure that NYSDOH RPE assesses potential challenges this model may present for the SV framework, such as reinforcing ideas about bystander intervention and the effects of gentrification. Unfortunately, environmental safety design is an area where there is a significant lack of individual-level curricula and overall research specifically regarding SV For the sports initiative, the NYSDOH RPE evaluation team contacted the Coaching Boys Into Men (CBIM) and Athletes as Leaders (AAL) developers to assess the effectiveness of the programs and how we may be able to utilize the curricula within the NYSDOH RPE sports initiative to address this community. Additionally, the Statewide Center has communicated with the Director of Prevention at the New York State Coalition Against Domestic Violence (NYSCADV) about partnering to together to offer CBIM and AAL trainings to NYS.
Studies also indicate there is a higher incidence of sexual violence, and accompanying behaviors and attitudes, within schools among youth and young adult populations. The Regional Centers and community partners prioritize ages 8-24 years old as studies have shown this is where the problem persists most. School-based interventions for adolescents have shown emerging evidence of effectiveness in “improving gender-equitable attitudes and increasing self-reported likelihood to intervene in situations of bullying and partner violence” (Lundgren & Amin, 2015). Currently, the Regional Centers have been implementing bystander intervention curricula, such as Bringing in the Bystander; other programs for implementation include Shifting Boundaries, Girl’s Circle and Council for Boys and Young Men, and Mentors in Violence Prevention. Currently there are 12 schools, 818 individuals trained, and 53 trained trainers throughout the six Regional Centers. From February 1, 2018 – January 31, 2019, the Regional Centers have trained 12 schools in various sexual violence prevention/healthy relationship curriculum. Currently, there are 53 trainers across the state qualified to train in various healthy relationship, sexual violence prevention, and bystander intervention curricula such as Shifting Boundaries, Mentors in Violence Prevention, and Bringing in the Bystander.
Further community-level collaborative efforts are supported through the MICHCs. The MICHC initiative seeks to improve maternal and infant health outcomes for high need, low income or Medicaid-eligible women and their families by supporting the development of multi-dimensional community systems of integrated and coordinated community health programs and services. MICHCs work to improve preconception, prenatal, postpartum, and interconception health of Medicaid-eligible women by working collaboratively with community partners to implement strategies to find and engage Medicaid-eligible women and their families in health insurance, health care and other community services; assess a woman’s needs and risk factors and make referrals to appropriate services; coordinate services across community programs; and promote opportunities and supports for women to engage in healthy behaviors. MICHCs utilize Community Health Workers (CHWs) to assist Medicaid-eligible women of reproductive age to effectively access continuous and coordinated health care and other needed community services responsive to their needs and risk factors. On a systems level, MICHC programs work with community partners in the health and social services arena to assess resources, prioritize community needs and strengths; and implement community-level strategies to address the needs identified. For example, Many of the MICHC programs have established formal and informal agreements with their local Regional Perinatal Centers and birthing hospitals to allow CHWs access to NICU and maternity wards to engage with new parents, offering support with breastfeeding and other psychosocial needs and connecting parents to home visiting services as appropriate.
Efforts such as Pathways to Success also demonstrate a strong community partnership to enhance the lives of young parents. The Pathways to Success initiative funds three community colleges and one community-based organization to create and sustain supportive systems that help expectant and parenting teens and young adults succeed through health, education, self-sufficiency and building strong families. The initiative utilizes an Asset and Risk Assessment (ARA) tool that helps Pathways staff to assess the needs and existing resources for young parents and their families. This structured interview tool enables funded projects to identify and prioritize assets and needs and develop a tailored list of referrals for each program participant. The ARA tool is also conducted over multiple client contacts, helping build a relationship between program staff and student participants, as well as providing opportunities to reassess needs and outcomes of referrals previously made. From July 1, 2018 to June 30, 2019, the program served 737 expectant and parenting students/community members, developed 190 new partnerships, and made 817 referrals. The most frequently cited needs of the program participants were: childcare resources, referrals and placement; parenting education and resources; child needs; transportation services; housing assistance; food; academic or educational supports; workforce development; other self-sufficiency, education, or employment services; and benefits eligibility screening or application services.
This State Priority is also measured by NOM #15 Rate of death in children aged 1 through 9 per 100,000. In 2017, NY’s rate was far below the national rate (13.1 compared to 17.2 per 100,000). NOM #16.1 Rate of deaths in adolescents age 10-19 per 100,000. In 2017, NY was again below the national rate at 22.1 vs. 33.7. Finally, NOM #20 Percent of children and adolescents who are obese (BMI at or above the 95th percentile). NY again is below the national percentage of 15.5% at 13.4% as reported in 2019 YRBS for high school students.
Health Equity - State Priority #8: Reduce racial, ethnic, economic and geographic disparities and promote health equity for MCH population.
While numerous interventions have positively impacted MCH health outcomes over the years, persistent health inequities, especially racial, ethnic, and geographic, have continued to manifest. As stated in NY's FY 2019 application, NY's Title V program includes health equity as a life course priority to ensure a stronger concentration on improving access to quality, comprehensive health, and supportive services across all domains.
To fully meet the needs of all New Yorkers, NY’s Title V program has made a concerted effort to incorporate a Health Equity framework into all aspects of NY’s Title V program. Since Fall 2016, Title V initiated the development and implementation of a series of strategies aimed at improving health equity in NYS as it relates to MCH.
As with all State Priorities (SP) across Domains, Title V staff focused on improving data collection and measurement of Title V initiatives to identify health disparities. Coordination expanded among the Title V staff and research groups within the NYSDOH Bureau of Chronic Disease Research and Evaluation, Bureau of Injury and Occupational Health, Office of Minority Health and Health Disparities Prevention (OMH-HDP), OHIP, and PHIG, to provide performance and outcome measures for each SP area.
For several years, NYSDOH has had a Prevention Agenda (PA) dashboard which tracks many public health elements at the county level. The PA dashboard enables partners to use these data to tailor their efforts and track impact. Title V program decided to pattern the MCH dashboard on the NYSDOH PA dashboard. Plans for the MCH dashboard were developed and Title V staff worked with OPHP to identify pertinent data elements that could be tracked at the county level. The ability to view county-level data that mirror national and state metrics in NY’s SAP that include race and ethnicity will allow partners to address Title V priorities on the local level and strengthen NY’s efforts to promote health equity and improve the health and wellness of the MCH population. Targets were established by the Title V data committee for each of the measures and the dashboard is now live and regular updates are planned.
Social determinants impact health equity, and therefore it is imperative that staff develop an understanding of the complex interconnection of various social, environmental, and systemic issues that often manifest in health inequity. Additionally, NY’s Title V program recognizes that all staff members bring with them their own experiences, history, and bias which can make proactively addressing health equity even more challenging. To improve Title V staff’s understanding of health equity, additional training and support beyond the typical onboarding process and education is being planned.
Title V staff worked to improve the internal capacity of Title V staff to promote and support health equity in all aspects of work. Promotion of health equity requires a unique, often tailored, approach. As noted in earlier applications, DFH established a cross functional health equity team for this purpose. Team members are drawn from all areas of DFH broadly representing the various population domains and programs funded by Title V. By engaging a diverse range of staff on the Health Equity, Title V staff is working to ensure that a Health Equity framework is incorporated all work within DFH at various levels. Title V staff investigated the disparities that exist, strategies and mechanisms that Title V programs are currently using to address disparities and/or health equity, possible additional areas for intervention and committed to at least one health equity area on which to focus for each SP. Increasingly, health equity team members are called upon by Title V to lend their expertise in program discussions and new initiatives to ensure that they include ways to improve equity.
Continuing to emphasize the importance of increasing staff capacity to proactively address health equity issues, Title V staff worked to finalize implementation plans for a comprehensive health equity curriculum. Required of all Title V staff, including administrative and support staff as well as interns, this multi-session curriculum was selected and compiled by the Title V Health Equity team with a goal of building a solid foundation of health equity understanding. Using the DOH Learning Management System (LMS) ensures that participation in training modules are effectively tracked across all Title V Staff. Using resources from a variety of partner organizations including; HRSA-funded Region 2 Public Health Training Center (PHTC), a partnership of three Council on Education for Public Health accredited schools of public health, including Columbia University Mailman School of Public Health, Rutgers School of Public Health, and the University of Puerto Rico Graduate School of Public Health, along with the University of the Virgin Islands Community Engagement and Lifelong Learning Center, and NYSACHO, this training series is meant to ensure all Title V understand the ways in which the can work to directly improve health equity through their day-to-day work.
Based on a comprehensive review of available modules, the four courses selected were: 1) From Concept to Practice: Health Equity, Health Inequities, Health Disparities & Social Determinants of Health, 2) Health Literacy for Public Health Professionals, Center for Community Health Lecture Series: 3) Bridges out of Poverty and 4) Health Equity Data to Action. All staff working in the Title V program will be required to complete the training over a four-month period. Objectives from the four courses were collected to form the basis for an evaluation plan for the curriculum.
Building on last year’s work Title V staff continued to support the completion of this training across DFH. This work included a large-scale training roll out for all existing staff, followed by a comprehensive audit to ensure completion. Any staff identified as failing to complete the training were re-issued instructions and required to complete the training within a specific timeframe. In addition, new staff were directed to the LMS system and given instructions on completing the required training within their first six months as a new hire. As part of ongoing performance management initiatives, Title V staff continues to track quarterly completion of each training to ensure all staff have completed the required health equity trainings.
Title V staff also continued to ongoing in person training opportunities related to health equity for any interested Title V staff. This continues to include regular meetings of a health equity-focused book club held during hours outside of the normal workday, for any staff who choose to participate. The purpose of the book club is to offer a non-threatening venue in which issues related to health disparities can be discussed by a diverse group of interested members to increase awareness and understanding. Since its inception the book club has continued to generate positive employee feedback and participation. To date the book club has read and discussed several different books including: The Immortal Life of Henrietta Lacks by Rebecca Skloot The Hillbilly Elegy: A memoir of a Family and Culture in Crisis by J.D Vance, My Beloved World by Sonia Sotomayor, and “How to Be Antiracist” by Ibram X. Kendi.
Much of the health equity work accomplished in DFH and done by Title V staff continues to emphasize new and innovative ways to center community and participant voice in program planning. DFH employs several different mechanisms to capture community voice and incorporate that feedback into the development and improvement of programs. The most consistent way in which this is achieved is through a series of community listening sessions. Allowing participants to direct conversation and collectively identify what they perceive to be the barriers and assets of their respective communities, listening sessions have been an invaluable tool in aiding Title V staff to better understand priority populations and individuals receiving services.
Following the facilitation of seven listening sessions centered around maternal mortality in 2018, DFH staff spent much of 2019 completing a comprehensive analysis of the data collected in order to develop a report outlining barriers, challenges, and suggestions for improvement form those women most impacted by poor maternal health outcomes While participants at each session brought up regionally or locally specific issues, DOH analysis revealed that the majority of feedback shared revealed common themes across the state. Based on the data collected from each forum, DFH staff identified six recurring areas of concern for women across the state. This included health systems, providers, racism, information and education, disrespect, and social supports.
Common barriers expressed across all seven listening sessions included:
- Access to health care (limited facility choice, quality of provider and facility care).
- Poor communication with health care providers (especially feeling providers were not listening to them, that they were not given enough time with providers, and that few providers reflected their lived experience).
- Lack of information and education from providers.
- Racism and its impact on the quality of care received.
- Disrespect from health care providers, including support and administrative staff.
- Lack of social supports.
And common suggestions for addressing the racial disparities in maternal mortality included:
- More black and Hispanic health care professionals, reflective of the community.
- Increase health care professionals’ awareness of racial disparities in health outcomes.
- Train health care professionals on the impact of implicit bias on health care outcomes.
- Increase provider support during the postpartum period.
- Increase availability of social support for example, birthing classes, group prenatal care, doulas, midwives, community health workers and parenting classes.
- Increase availability of community services and resources, for example, community health worker services and home visiting services.
The final report created based on this feedback was completed in early 2019 and approved for publication in summer 2019. This report was shared with those organizations that hosted sessions as well as other maternal child health providers across the state.
The Department’s commitment to promoting health equity continues to extend well beyond NY’s Title V program. Title V staff have continued to play a major role in the NYSDOH’s Center for Community Health (CCH)’s Racial Justice (RJ) Workgroup. The workgroup is charged with proactively promoting a racial justice framework throughout the work of CCH, including Title V activities, epidemiology, WIC, SNAP, tobacco control, and cancer prevention services. Activities of the RJ workgroup take place within the context of a performance management infrastructure leading to the development of a series of RJ focused performance measures to guide the work of CCH.
Each division was charged with creating two measures, one internally focused (e.g., staff development, training, and capacity building) and one externally focused (e.g., community collaboration, coalition building, engagement of priority populations). The Title V program continues to play a major leadership role in the development of these performance measures. Building on several years of successful health equity focus, RJ workgroup members elected to develop a single internal performance measure to be used across CCH, based largely on Title V MCHSBG activities led by DFH for the past several years. This performance measure mirrors the format and evaluation of Title V MCHSBG work and dramatically expanded the staff who are required to complete a comprehensive online training on health equity. Title V staff further impacted the development of several external performance measures (PMs) by modeling a community listening session protocol that was adopted by several other divisions to increase community input and participation in program development.
The Title V program recognizes the value and importance of understanding and addressing health equity to improve the health and wellness of all New Yorkers and will continue efforts to ensure all families have access to quality primary and preventive health services. The priority placed on addressing health disparities is integrated throughout NY’s work and in this report. It is clear through efforts spearheaded by Governor Cuomo related to maternal mortality and efforts through NYSDOH and Title V, there is a strong commitment to addressing this significant public health priority.
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