Cross Cutting and Systems-Building

Report for the application year: Oct 2021 - Sept 2022

During this report period, selected areas of Title V work that spanned population domains was grouped into the following areas: Public health emergency response, addressing trauma and ACES and Health Equity including collaboration with Medicaid.

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.

As illustrated below, the beginning of this report period was marked by the largest number of deaths from all causes that had been observed in Alaska since the onset of the pandemic.

                         Observed and Predicted All-Cause Deaths by Month (2019-2020). Source: AK HAVRS

The impact of the pandemic on MCH populations has been broad and varied. Although the need for WCFH involvement in emergent epidemiological response tapered down during this report period, there was ongoing need to support the systemic response in the wake of the protracted emergency. This public health emergency, which has 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.

WCFH nurse consultants continued to support ongoing COVID mitigation in schools and supported school nurses with tools and resources to respond to mental health impacts of the pandemic on children and youth. Efforts to re-establish access to preventative healthcare were emphasized, with ongoing efforts through SBHC’s to deliver essential services while working to connect youth and families with more sustainable and coordinated care by establishing medical homes. Child and Adolescent Unit Staff are working to address the public health crises of youth violence, including bullying and 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 for the upcoming year, and resources and information was shared regarding opioid awareness among adolescents.

The AKPQC steering committee engaged in dialogues 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 AKPQC/MCDR joint summit in April 2022 by Dr. Torri Metz, a leading expert and NICHD-funded researcher on the impacts of SARS-CoV-2 infection on maternal-fetal outcomes.

Alaskan families were impacted by the shortage of infant formula due to global supply chain problems. WCFH staff supported providers and communities by disseminating information and resources about the shortage in collaboration with WIC, home visiting, and other state public health and communications partners. A Perinatal ECHO on the formula shortage was held in March 2022 that included participation with the State WIC program and grantees.

Near the end of this report period, a major flood event impacted Bethel and surrounding areas. MCH Epidemiology worked with other WCFH program managers to provide data about families with infants who may be impacted by this event and disseminated information to partners about response efforts. In collaboration with WIC after the event, the Alaska Breastfeeding Initiative (ABI) posted information about safety related to ongoing water quality through its listserv., including information about infant formula safety. In September 2022, the Alaska Perinatal ECHO focused on maternal and child health impacts of climate change, including a presentation from a University of Alaska Anchorage (UAA) researcher on the impacts of wildfire on birth outcomes in Alaska.

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. The Section continued to use the ECHO model for perinatal topics and received approval to use ARP funding to launch a Home Visiting ECHO with a focus on supporting the field as they work directly with families during crisis. 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 throughout the pandemic and communicated directly with providers to share information and recommendations.

Cross Cutting Strategy 2: Promote and disseminate information about community debrief/postvention response services following a significant traumatic event or emergency.

WCFH staff continued to relay information and resources about postvention response to providers and partners through various mailing lists, including those mentioned in the prior strategy.

The ongoing nature of the COVID-19 pandemic and other emergencies, which are at least partially connected to it, blur definitions of “debrief” and postvention, and several activities described under SPM Strategy 4.1 contain elements of both active response and postvention.

A key postvention activity, however, is emergency and disaster planning, which WCFH has been working to address intentionally as it applies across programs. The WCFH Section Chief regularly advocates for collaboration and inclusion of MCH population needs and special considerations when attending leadership meetings that address emergency and disaster preparedness.

Two separate American Rescue Plan grants through MIECHV were awarded to support response to emergencies. Of seven categories allowable, a combination was used – services include a needs assessment for potential expansion of home visiting programs into the Yukon-Kuskokwim Delta region, a remote area which was recently impacted by flooding, and workforce support including ECHOs, motivational interviewing training, and purchase of tablets for HV clients to engage in virtual visits.

Child and Adolescent Health Unit staff promoted and provided technical assistance on the use of rapid adolescent prevention screening (RAAPS) to support assessment and response to youth mental health, including the impact of traumatic events.

Using CDC workforce development funds, The Division of Public Health contracted with UAA on a training to address compassion fatigue and resilience that was first piloted with Public Health Nurses. This training became available to other Sections in 2023.

Cross Cutting Strategy 3: Through partnerships, promote the continued use of reflective practice to support direct-service providers who conduct screening in non-clinical settings during public health emergencies.

Direct service providers face unique challenges in their work during a public health emergency. WCFH continued to support partner agencies who provide such services by offering information about reflective practice. Reflective practice involves facilitated, attuned, non-directive client interactions which are modeled during reflective supervision to facilitate supportive, empowering engagement that helps a person develop a sense of how they wish to move forward.

DBH funding is helping to support development of additional Facilitated Attuned Interactions (FAN) trainers. New funding for these activities has been identified through a CDC injury prevention grant awarded to the Section of CDPHP and the Alaska Mental Health Trust Authority. A WCFH Perinatal Nurse Consultant was invited to be on the advisory committee for the UAA CHD Family Services Training Center which put in place a 0-1 early childhood mental health consultant position to support their trainings. There is strong interest and support in this topic, and a didactic is planned for an upcoming ECHO.

The Adolescent Health Program continued to support the trauma-informed school framework and helped recruit experts who spoke on this topic at the February 2022 MCHI conference.

Cross Cutting Strategy 4: Provide staff training in responding to ACEs/trauma and strengths-based approaches.

Topics related to ACEs and trauma were strongly represented at the 2022 AKPQC/MCDR joint summit. An opening session was delivered by Dr. Charlene Apok, an Alaskan leader who works on violence prevention and the movement to end the crisis of Missing and Murdered Indigenous Women (MMIW). She framed the summit with narrative story about the transformative impact of trauma-informed and culturally sensitive care to improve maternal safety and health outcomes. This session was followed by a data presentation about the impacts of interpersonal violence – a key Alaskan ACE and driver of poor maternal outcomes – by the MCDR Program Manager and a session by a partner agency representative from the Alaska Network on Domestic Violence and Sexual Assault, who provided information for perinatal health and other service providers about identifying and responding to interpersonal violence. While this session offered foundational information and skills, the audience response was positive, with many participants expressing an appreciation for covering this topic, and that although most felt the level of information was appropriate, there was also a desire for more advanced skill building. Lastly, the summit dedicated a half day to cultural safety, which was presented by Dr. Erin Tenney and Dorene “Waubanewquay” Day, whose interdisciplinary and cross-cultural partnership is the foundation of a curriculum on this topic offered through Frontier Nursing University. The session, which covered culturally tailored and trauma-responsive approaches through a combination of didactic and cultural knowledge-sharing such as storytelling and song, received strongly positive reviews from participants.

The AKPQC’s Substance-Affected Pregnancies Initiative (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 include a small share of the AKPQC Nurse Consultant’s personnel costs, which helps to ensure 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. Planning for the next annual summit began to occur during the last weeks of this report period. Topics on trauma-informed approaches in working with patients in recovery or who use substances will be included, along with additional training on interpersonal violence intervention and cultural/community-based interventions to enhance protective factors.

A training on strangulation response (based on MCDR recommendations) was planned for facility teams engaged in the current PQC initiative. While much of the training will focus on clinical skills, there will also be 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. Planning for this session began during September of this report period, and it will be co-presented by the MCDR Program Manager and a forensic medical colleague in January 2023.

All WCFH staff are encouraged to participate in webinars and trainings about trauma, ACEs, and protective factors as the opportunities arise. All staff are 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 several staff with social work degrees and mental health or violence prevention experience. These staff can provide consultation and support for colleagues as needed. 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, had limited availability due to the COVID-19 pandemic, but many staff have already received this training and in person offerings resumed during the next report period. Two MCDR staff are scheduled to attend a special session of the Blanket Exercise in October, which is limited to select partners of the Children’s Justice Act Task Force (of which the MCDR Program is a member) This 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.

One of the Adolescent Unit’s program managers is a certified facilitator of Motivational Interviewing, which employs a trauma-informed approach and protective factors/resilience focus to engage youth in self-determined positive change. Youth health literacy curriculum includes a component of self-efficacy/self-determination, such as developing and recording personal history and identity development narrative for foster youth.

Cross Cutting Strategy 5: Promote or provide workforce training and support for self-care and responding to vicarious trauma exposures.

The session on Cultural Safety at the 2022 AKPQC/MCDR summit included an integrated emphasis on provider self-awareness and care, which is viewed in this approach as an essential element of trauma-informed care. There is a plan to include a session on provider self-care at the next summit.

WCFH shares 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 6: 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, Commissioner’s Office, and an outside contractor which resulted in a policy decision to create a carve-out for long-acting reversible contraception (LARC) for those hospitals using DRG methodology for billing;
• Submission of a white paper to Medicaid, the Chief Medical Officer, and the Commissioner’s Office regarding why Alaska should extend postpartum Medicaid coverage to 12 months;
• Participation in a workgroup with Medicaid centered on reimbursement for developmental screening;
• Participation in a workgroup focused on improving the processed for reimbursement for genetic testing.

Cross Cutting Strategy 7: 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. 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 are working 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. For example, the MCDR Health Program Associate was invited to lead a skill-share on incorporating land acknowledgements into the maternal mortality review process during a learning session with peers.

Cross Cutting Strategy 8: 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 9: 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, the majority of 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 10: Collect, analyze, and disseminate data and information on health equity topics.

PRAMS underwent a revision process that included updates which will improve available data on experiences of discrimination and access to services, starting with 2023 births. A new question was 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 HEI was presented to the Healthy and Equitable Communities Unit in May 2022, and the Public Health Informaticist responded to questions from staff in that unit on how to appropriately use the tool. Within MCH Epi, staff linked a PRAMS cohort to census tract-level HEI domain values as part of a planned examination of impacts of declining response rates on the statewide representativeness of respondents. The PH Informaticist also met with a researcher at the UAA Institute for Circumpolar Health Studies to discuss the HEI. He shared the 2020 raw data with him and explained the changes in census geographies resulting from the 2020 decennial census. The UAA researcher is working on a health equity training for the North Slope Borough Health Department and indicated he would include the HEI as a resource. The Public Health Informaticist also worked on updating data in the HEI tool for a planned release in October 2022.

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.

Numerous presentations and publications by MCH Epidemiology Unit staff during the reporting period highlighted health equity considerations. The ALCANLink program released two publications: a peer-review journal article titled Pre-Birth Household Challenges Predict Future Child’s School Readiness and Academic Achievement, and a white paper on Pediatric Abusive Head Trauma Trends in Alaska (2005 – 2019). Additionally, staff presentations at conferences and meetings included topics such as MCH Data on the Asian and Pacific Islander Population in Alaska, Youth Mental Health, COVID-19 Impacts on Alaska Families, Suicide Prevention through Maternal Support, Covid experiences among women delivering live births during 2020, How COVID-19 Modified our Trajectory: An Examination of Death, Child Maltreatment, and Women's Health Screening Visits, Partnerships with Community-Based Birthworkers to Promote Positive Birth, Moving Upstream to Predict and Promote Children’s School Readiness and Academic Achievement, Alaska Maternal Child Death Review: Health Equity Considerations in Fatality Review and PQC Collaboration, Strategies to Address Maternal Mortality from Suicide and Interpersonal Violence (IPV), and Alaska PRAMS: Putting Comments to Good Use. Whether presenting surveillance data or discussing programmatic strategies based on data, all presentations included discussion of health equity topics.