Cross Cutting and Systems-Building
Report for the application year: Oct 2022 - Sept 2023
The three priority needs depicted in the below diagram are addressed through overlapping work across multiple population domains. These areas are given dedicated attention in this domain.
Cross-Cutting Priorities
Over the past four years, WCFH work to address these priorities more intentionally has included efforts to integrate these priorities across public health practice in all domains. It has also involved identifying and naming examples of work in these areas and being more intentional about reporting and advancing such activities. Accordingly, some of the activities included in this chapter may receive only a brief mention here due to more detailed discussion appearing in other population domain reports and vice versa. The writers have endeavored to provide cross-referencing whenever possible to reduce duplication.
As WCFH increases attention to structural factors and social determinants of health, the interconnectedness of topics and domain activities becomes increasingly evident. During a time when many teams – both internal and external – have shifted to remote work, there is a growing need to create space for collaboration. At the close of this report year, the Alaska Title V Leadership Team was in the process of planning two in-person collaborative meetings to occur in December and January including all WCFH program staff to help address this need.
Cross Cutting Strategy 1: Utilize existing platforms and capacity to contribute to rapid assessment of needs and dissemination of data and best practice information during emergencies.
The impact of the COVID-19 pandemic on MCH populations has continued to be broad and varied. Although the need for WCFH involvement in emergent epidemiological response related to COVID-19 was minimal during this report period, to the section provided ongoing support for the systemic response in the wake of the protracted emergency. This public health emergency, which had no clearly defined intervention or postvention periods, lives on as an underlying factor in other emergencies and crises that are driven by supply chain issues, economic and housing circumstances, and mental health.
One possible downstream consequence of the shifted public health focus and funding during the COVID-19 pandemic was a rapid increase in congenital syphilis (CS) in Alaska. While not officially declared a public health emergency, it became a high priority for the Division, and the legislature passed a multimillion dollar increment to fund work in State fiscal year 2024 to address the topic. From 2018–2022, CS counts rose from 1–12 cases annually, and many of the more recent cases had little or no prenatal care (Figure). In 2021, the Alaska CS incidence rate was 54 per 100,000 live births. In 2022, the Alaska CS incidence rate was 119 per 100,000 live births. With turnover and high staff vacancies in the STI program leading to limited capacity, the State Epidemiologist approached WCFH to ask for help with this topic, specifically around data analysis and dissemination. The CSTE fellow and others in the MCH Epidemiology Unit worked closely with the Section of Epidemiology to conduct a rapid assessment of congenital syphilis cases linked to birth certificates. MCH Epi Unit staff were able to draw on expertise with birth certificate data and data linkages to enhance the analytical capacity of the STI team. The CSTE fellow was lead author on an Epidemiology Bulletin that provided descriptive epidemiology of recent cases, and he also presented preliminary data on CS to the HIV/STD advisory committee and the syphilis task force. MCH Epi Unit staff also presented data on congenital syphilis at the 2023 AKPQC-MCDR Joint Summit and a meeting of the Alaska Hospital and Healthcare Association Chief Nursing Officers. WCFH also partnered with the Section of Epidemiology and Department Staff Pediatrician in planning for a Perinatal ECHO on congenital syphilis which was scheduled to take plan in October 2023. Finally, the MCDR Program Manager and MCH Epidemiology Unit Manager provided technical assistance to the STI program team on the creation and implementation of a new congenital syphilis review board, building upon experience with MCDR.
Figure. Number of Congenital Syphilis Cases, by Number of Prenatal Care Visits and Year — Alaska, 2018–2022
During the fall of 2023, there was also a growing concern about the rising number of respiratory cases being seen in Alaska at a time when RSV season had not yet even begun. WCFH was able to collaborate with the Section of Epidemiology and the Department of Health Staff Pediatrician to plan for a Perinatal ECHO session on Alaska recommendations for RSV intervention for children and during pregnancy. This was scheduled to take place in November 2023.
WCFH School Nurse Consultants continued to support ongoing COVID-19 mitigation and testing resources in schools; as well as, during and after the transition away from federal COVID-19 specific isolation related guidance to a broader respiratory virus infection control guidance for schools when federal CDC recommendations shifted. School nurses were also supported with tools and resources to respond to the ongoing mental health impacts post-pandemic on children and youth. Efforts to re-establish access to preventative healthcare were emphasized, with ongoing efforts through school-based health centers (SBHC) to deliver essential services while working to connect youth and families with more sustainable and coordinated care by establishing medical homes. Child and Adolescent Health Unit Staff are working to address the public health crises of youth violence, including bullying, suicide, and overdose. Based on the 2023 School Climate and Connectedness Survey (AASB, 2023), in which 33 of Alaska’s 54 school districts participated, 23% of 6-12th grade students said they had witnessed three or more fights between students during the past year and 24% had witnessed bullying or threats three or more times. Only 62% of 6-12th grade boys, 56% of girls, and 36% of non-binary/other gender identity children and youth said that they feel safe at school. School violence and other emergency operations plans are among topics that were included in planning for School Health ECHOs and the Alaska School Nurse Association Annual Conference for the upcoming year. Additionally, resources and information were shared regarding opioid awareness among adolescents.
The Alaska Perinatal Quality Collaborative (AKPQC) Steering Committee engaged in dialogue about the challenges and needs associated with providing care for a high volume of patients whose pregnancies, births, and postpartum experiences were significantly altered by COVID-19 infection and other impacts. In response, a presentation was included in the 2023 AKPQC/MCDR joint summit by Sarah Switzer, a Behavioral Health Consultant Clinical Supervisor at Southcentral Foundation, on understanding and addressing the challenges of compassion fatigue and burnout. The session defined and distinguished between the concepts of empathy and compassion and the impact of working in healthcare. There was robust discussion regarding compassion fatigue, burnout, and secondary trauma and strategies were reviewed to build resistance, resilience, and recovery.
The Section continued to leverage its numerous listservs to disseminate best practice information, strategies, and data related to COVID-19 and other emergencies to providers and partners statewide, including the MCH Clinical listserv, the Home Visitors Resource Network Listserv, the AKPQC listserv, and the Title X listserv. Using ARP funding, the Home Visiting ECHO continued with a focus on supporting the field as they work directly with families during crises. The WIC Central Office continued to be a key partner in these efforts, as well as the Division of Behavioral Health, Tribal health programs, and Part C Early Intervention. WCFH continued to support home visitors and other groups with information and communicated directly with providers to share information and recommendations.
Cross Cutting Strategy 2: In partnership with emergency response agencies, promote and disseminate information to the public about policies being implemented and changes in availability of public health services during and in the wake of a significant traumatic event or emergency.
The Title V Director/WCFH Section Chief met with the new Section Chief over the emergency preparedness and response program to discuss the work of WCFH and considerations related to MCH during emergencies. By meeting with him, she hoped to ensure that in the event of a significant traumatic event or emergency, MCH would be considered and invited to be at the table from the beginning. The WCFH Section Chief also regularly advocates for collaboration and inclusion of MCH population needs and special considerations when attending leadership meetings that address emergency and disaster preparedness.
The WCFH Section Chief and Department of Health Staff Pediatrician also collaborated with the Emergency Preparedness Program to update the Department’s Emergency Operations Plan to ensure the needs of children were met. This included updating the pediatric annex of the document. The Section Chief and Emergency Preparedness program continued to partner on the coordination of bed capacity for respiratory infections in children, along with collaboration with the Section of Epidemiology on getting recommendations related to RSV out to providers statewide. The Section of Epidemiology leads the RSV Seasonality Workgroup, and this marked the first time WCFH and AKPQC Steering Committee physician leaders partnered in that workgroup. This included making Alaska-specific recommendations on Nirsevimab, along with pediatric prophylaxis. Supply chain issues were a challenge in Alaska.
Given that WCFH serves as a support for partner agencies, providers, and families related to linkages with MCH services, staff are often made aware of resources throughout the state which they can then relay to stakeholders through various channels including mailing lists, Project ECHOs, and workgroups. WCFH utilized these communication methods to provide information to professionals and members of the public to increase awareness about recommended safety measures and impacts to services availability.
As a component of the Substance Affected Pregnancies Initiative (SAPI), the AKPQC orchestrated multiple SAPI Facility Team Meetings throughout the reporting period aimed at cultivating connections and partnerships among participating facilities and community resources. One such meeting, held in October 2022, delved into Wrap Around Services. In May 2023, the Southcentral Foundation Detox program shared their insights with the participating facilities. Additionally, in August 2023, another SAPI Facility Team Meeting facilitated a panel discussion featuring addiction service providers. Representatives from treatment agencies like Breakthrough and Akeela were in attendance, shedding light on the range of services offered.
Cross Cutting Strategy 3: Provide staff training in responding to ACEs/trauma and strengths-based approaches.
Topics related to ACEs and trauma were strongly represented at the 2023 AKPQC/MCDR Annual Summit. Presentations covered topics such as trauma-informed approaches in working with patients in recovery or who use substances, along with additional training on interpersonal violence intervention and cultural/community-based interventions to enhance protective factors.
The AKPQC’s SAPI has provided a natural avenue for focusing on trauma and ACEs, as the connections between trauma, mental health, and substance use are well-established in the national literature, as well as reflected in MCDR’s data on maternal deaths from overdose and violence. Funds from the Office of the Assistant Secretary for Health (OASH) award to prevent maternal deaths from violence included a small share of the AKPQC Nurse Consultant’s personnel costs, which helps to ensured support for her time to work with MCDR on this topic. This grant also supported payments to contractors who consulted on patient experiences related to trauma and cultural safety, as well as the Section’s practices on collecting and disseminating data pertaining to violence against Indigenous women, girls, and birthing people.
A training on strangulation response (based on MCDR recommendations) was conducted in January 2023 for facility teams engaged in the current SAPI initiative. While much of the training focused on clinical skills, there was also a module on trauma-informed approaches for working with patients who are survivors of violence and trauma, and information to place the topic within the broader context of ACEs and trauma. This training was co-presented by the MCDR Program Manager and a forensic medical colleague.
Also at the 2023 AKPQC/MCDR joint summit, Dr. Annie Lewis-O’Connor presented on addressing health equity for pregnant people with substance use disorder (SUD) using a trauma-informed care lens. This session reviewed clinical practice guidelines, profiled evidence-based processes of care, and highlighted ancillary care services that support improvements in clinical outcomes. Further, this presentation clarifies what is trauma and the guiding principles of trauma-informed care and the application of trauma-informed approaches for pregnant people struggling with substance use disorder.
All WCFH staff are encouraged to participate in webinars and trainings about trauma, ACEs, and protective factors as the opportunities arise. All staff were provided with an opportunity and encouraged to attend an Alaska Strengthening FamiliesTM training, which provides an Alaskan perspective on historical trauma and the impact of ACEs, as well as practical training on everyday actions to promote the five Protective Factors: (1) Parental Resilience, (2) Social Connections, (3) Concrete Supports, (4) Knowledge of Parenting and Child Development and (5) Social and Emotional Competence of Children. WCFH staff include several professionals with experience working directly with traumatized populations, including staff with social work degrees and mental health or violence prevention experience. These staff can provide consultation and support for colleagues as needed. During this reporting period, plans were made and documentation submitted to create a new Mental Health Clinician position within the MCDR program. A goal for this position is for it to support some of these staff training and staff support efforts as well. As ACEs prevention and trauma-informed care have integrated into everyday public health practice throughout WCFH, the capacity of all staff to work on it collectively has reduced burden on staff with specialized field experience in this area.
The Alaska Blanket Exercise training, provided by the Alaska Native Tribal Health Consortium, is an experiential training that promotes empathy and awareness of the history of the Alaska Native people and the intergenerational trauma that has occurred in this population. It is based on a similar training focused on Canada’s First Nations Peoples which is a requirement for all Canadian healthcare providers and other professionals who provide care or services for Indigenous people. All WCFH staff will be encouraged to attend this training as part of professional development.
Cross Cutting Strategy 4: Promote or provide workforce training and support for self-care and responding to vicarious trauma exposures.
As mentioned earlier, the 2023 AKPQC/MCDR Annual Summit included a session on provider self-care. The session focused on comprehending and tackling the obstacles posed by compassion fatigue and burnout. It involved defining and differentiating between empathy and compassion and examining their effects within the healthcare profession. The discussion delved deeply into topics such as compassion fatigue, burnout, and secondary trauma, exploring strategies aimed at bolstering resistance, resilience, and recovery. The Perinatal ECHO was also scheduled to include a series of compassion fatigue, grief, and self-care which was scheduled for December 2023 and January 2024.
The School Nursing program continued to share training resources on trauma-informed care, ACES, and strengths-based approaches during School Health ECHOs and also via the School Health and Nursing Advisory Committee.
WCFH shared resources and training opportunities on these topics through its networks. Of equal importance, WCFH program managers strive to model trauma-informed principles by meeting providers and partners where they are at, and by making small but significant adjustments that acknowledge the burden of vicarious exposures and workload. This activity is difficult to quantify or describe with specificity as it looks different between programs and with diverse partners. However, it can include activities such as conveying a sense of compassion and gratitude during interactions with direct service providers, assuming positive intent and seeking common ground, offering scheduling options and flexibility, providing debrief and active listening following stressful meetings or situations, and facilitating opportunities for peer support and human connections as components of regular programming such as conferences and trainings.
Cross Cutting Strategy 5: Collaborate with Medicaid to improve reimbursement and/or increase access to services.
The purpose of this strategy is to recognize that WCFH’s many partnerships with the Medicaid program are a deliberate component of Alaska’s overall Title V Strategic Plan. However, most - if not all - of the work that WCFH does with Medicaid to improve reimbursement and/or increase access to services is also described in other sections of this report, specifically III.E.2.b.v.b Title V - Title XIX IAA, but also in several of the domain-specific reports.
Notable collaborations during this time include:
- Partnership between Medicaid, the Chief Medical Officer, and the Commissioner’s Office on the passage of legislation which extended postpartum coverage from 60 days to 12 months;
- Partnership between Medicaid staff and the MCH Epidemiology Unit to review and provide input on an analysis brief describing costs to Medicaid related to infants born with Neonatal Abstinence Syndrome.
- Regular monthly meetings attended by the Title V Director and CYSHCN Directors, MCH Epidemiology Unit Manager, Child, Adolescent Health Unit Manager, MIECHV Program Manager, along with Medicaid staff including the Medical Director, EPSDT Manager, and CHIP Director
- Participation in a workgroup with Medicaid centered on reimbursement for developmental screening; and
- Participation in a workgroup focused on improving the processed for reimbursement for genetic testing.
Cross Cutting Strategy 6: Provide staff training and development opportunities in health equity, implicit bias, and anti-racism.
Trainings on these topics are widely available, often provided by federal partners with content tailored to specific funding programs, and WCFH staff are always supported and encouraged to attend. In the past year, the State of Alaska launched updated trainings required for all staff on topics such as Valuing Diversity and A Respectful Workplace. These online trainings produced by national HR experts include multiple modules on addressing implicit bias and equitable practices in the workplace. Most WCFH have attained basic familiarity and knowledge of health equity and anti-racism in public health, and supervisors are now working to support staff with skills to transfer knowledge to action while the Section Chief and select staff with advanced competencies in health equity continued working over the reporting period with agency leadership to address more complex contextual factors and barriers. The MCDR Program Manager and the Adolescent Health Unit Manager both participated in a health equity workgroup at the division level. WCFH staff are encouraged to share their knowledge and resources in this area with peers and colleagues.
The WCFH School Nursing and Health Services Program’s School Nurse Consultant participated in a three-part series, Health Equity ECHO provided by Alaska Area Health Education Centers (AHEC) during May & June 2023, and was based on information gathered from the 2023 ACRH-HW Health Equity Analysis. The analysis was designed to gain better understanding of the health equity topics and challenges faced across the state of Alaska. The SSNC discussed institutional and organizational factors contributing to health inequities and bias, practical applications in rural and urban Alaska communities. The series sessions also addressed community health initiatives and organizational collaborations to address health equities in Alaska; as well as community-identified strategies and practical applications to address barriers and bias which contribute to health inequities in Alaskan communities.
During this reporting period, WCFH Staff including the Section Chief, MCDR staff, MCH Epidemiology Unit Manager, and the AKPQC Nurse Coordinator finished AMCHP’s Healthy Beginnings Learning Collaborative on anti-racism and increasing health equity principles. This involved collaboration with the Alaska Native Birthworkers Association (ANBC) and was a great learning experience for Title V Staff. Since the cohort ended, collaboration with ANBC continues on a number of areas related to MCH.
Cross Cutting Strategy 7: Conduct ongoing assessment of equity impacts of Title V strategies across domains.
WCFH continued to conduct ongoing discussions about health equity in Title V activities during quarterly meetings with each of the population domains. These meetings, which include progress updates, team-based problem-solving and collaboration, are facilitated by the Title V Block Grant Coordinator. All program managers responsible for at least one strategy in the applicable domain are included in meetings, as well as the Title V Director and the MCH Epidemiology Unit Manager. One meeting per year is dedicated to an intentional discussion of health equity, including an in-depth analysis of the equity implications of each strategy, while the other three meetings integrate health equity into the discussion as applicable. As teams gain competence in analyzing health equity implications of their work, it is expected there may be less need for a structured space to conduct this analysis, but currently teams are at diverse levels of familiarity and confidence with translating training they’ve received on equity-related topics into action.
Cross Cutting Strategy 8: Promote equitable use of resources to work towards elimination of structural racism.
Alaska’s postpartum Medicaid extension, which was supported by WCFH leadership and knowledge, is a significant health equity achievement that will increase access to services for BIPOC and economically disadvantaged people who have given birth. Some of the most common causes of maternal mortality in Alaska, including overdose, untreated mental health conditions and violence, are most likely to cause death during the late postpartum period, and extension of this coverage can provide key opportunities for prevention.
During the report period, most of the funding from the OASH award to prevent maternal mortality from violence was directed to Indigenous-led community-based organizations to conduct culturally tailored prevention work centered around community-based doula support. These types of partnerships and funding arrangements have not previously been a routine practice for WCFH and there have been numerous challenges and barriers, but the project has provided a rich learning experience and paved the way for more partnerships with community-based organizations from within the communities experiencing the most significant impacts of the health disparities Title V services aim to address.
Cross Cutting Strategy 9: Collect, analyze, and disseminate data and information on health equity topics.
PRAMS launched the Phase 9 survey which included updates which will improve available data on experiences of discrimination and access to services, starting with 2023 births. A new question was also added regarding the respondent’s access to doula support during pregnancy, birth and postpartum. The results from this question will be used to support evaluation of the OASH funded maternal violence prevention work, as well as to provide information requested by community partners about access to birth support services for people residing in remote/rural regions compared to those in urban locations.
The Alaska Health Equity Index (HEI) is an online tool created by the MCH Epi Unit that incorporates U.S. Census data on households, income and education levels, and other measures to help public health professionals and community program planners focus resources on areas with the highest need. The MCH Epidemiology Unit continued to promote the use of the HEI and shared it at relevant meetings throughout the year. The Public Health Informaticist and Senior Scientist met to discuss the HEI with a team from the CDC that was interested in developing an Alaska-based Social Vulnerability Index. A link to the HEI was also featured in a new online Public Health Data Hub sponsored by the Section of Epidemiology and created as part of the Division’s Data Modernization efforts.
The MCDR program continued work with subject matter experts from diverse backgrounds, including cultural knowledge bearers and individuals with lived experience. Their insights complement the expertise of inter-disciplinary experts who review cases and make recommendations for prevention of child and maternal mortality. The panel’s diverse knowledge also contributes to in-depth case discussions during which complex factors are identified and captured as data points. These data are later analyzed and presented by MCDR staff in the numerous presentations and fact sheets which are mentioned in the applicable population domain report narratives.
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