SPM #3 Address Social Determinants of Health Inequities

Please note that additional examples of how SDoH were addressed may be found throughout the annual report narratives for the other National and State Performance Measures by population domain.

Existing economic and health disparities indicate a continuing need for prioritizing efforts to address the social determinants of health (SDoH). Economic stability is one of the primary SDoH. Missouri’s poverty rate has declined each year from 14.8% in 2015 to 12.7% in 20211, which suggests increasing economic stability for some Missourians. However, additional examination indicates that poverty is consistently higher among Non-Hispanic Blacks and Hispanics compared to Non-Hispanic Whites. In 2021, the poverty rate for Non-Hispanic White Missourians (10.6%) was lower than that of both Non-Hispanic Blacks (22.9%) and Hispanics (18.9%).2 Geographic disparities in poverty also exist with a 13.0% poverty rate for urban counties in 2021 compared to an 11.0% poverty rate for the rural counties in the same year.

Health care access and quality is also a primary domain of SDoH. Racial disparities in both infant and maternal mortality indicate a need to explore improvements in health care access and quality as part of efforts to address the SDoH. Missouri Vital Statistics data denote the Missouri infant mortality rate for 2021 was 5.7 per 1,000 live births. Though there was a reduction in Missouri’s overall infant mortality rate from 2017 to 2021, the racial disparity between Non-Hispanic Black women and Non-Hispanic White women persisted (Figure 8). Additionally, the 2016-2020 maternal mortality rate for Non-Hispanic Black women (80.6) was considerably higher than that of Non-Hispanic White women (30.6).

To gain buy-in and build internal awareness and understanding across MCH programs and the Department of Health and Senior Services overall, Title V MCH has identified workforce development training on MCH core fundamentals, SDoH, trauma-response programs and services, and cultural competence. This workforce development training plan has allowed Title V MCH Block Grant-funded program staff to gain a better understanding of the impact of SDoH and how to effectively integrate strategies to address the root causes of health inequities into policies and program services and activities. The training plan was launched in FFY22 and 90 out of 100 Title V MCH program staff completed a series of three training videos from the Association of Maternal and Child Health Programs. The videos provided baseline knowledge on core MCH issues as well background information about the history of the Title V MCH Block Grant. Beginning in FFY24 the training plan will be extended to external contractors.

Other Title V MCH Activities Related to the Cross-Cutting & Systems Building Domain

The Bureau of Special Health Care Needs (SHCN) Service Coordinators and Family Partners continually focus on the SDoH for families of individuals with special health care needs served by SHCN. SHCN employs Family Partners to provide the unique perspective of parents of children and youth with special health care needs (CSHCN). Interpreters are utilized for conversations and forms are translated into various languages. The Service Coordination Assessment (SCA) is a comprehensive assessment that assesses, identifies, and addresses concerns beyond the scope of services provided through SHCN programs. Examples of topics covered in the SCA include: insurance coverage, military service, mobility, transportation, dietary concerns, emotional status, social/environmental (such as social inactivity and barriers keeping the participant from getting out into the community or participating in activities they enjoy, as well as home environment safety and stability of living conditions), cognitive concerns, educational/vocational, family functioning (such as risk factors and family support), and cultural belief system. Both SHCN Service Coordinators and Family Partners frequently connect families with resources for food, housing, utility services, social supports, transportation, and recreational/leisure opportunities. SHCN emphasizes improving the quality of life for participants and families beyond the direct care services provided through SHCN programs. Additional information regarding SHCN is included in the CSHCN Domain of the application and report.

DHSS leveraged funding from the Centers for Disease Control and Prevention (CDC) State Physical Activity and Nutrition (SPAN) grant to provide a free virtual lactation consultant preparation course that prioritized participants serving communities with low breastfeeding rates and/or health care disparities among women of color. Every effort was made to encourage women of color to become peer counselors or International Board Certified Lactation Consultants (IBCLCs) in regions where disparities in care exist. The SPAN grant also funded Uzazi Village in Kansas City to support candidates in its lactation internship program, which prioritizes candidates who choose to serve in communities of color. This program helps candidates who wish to become IBCLCs to finish their required training and mentorship hours and prepare for the credentialing exam.

The School Health Program (SHP) implemented the School Nurse Chronic Health Assessment Tool (SN CHAT). The SN CHAT helps school nurses gather information about students who have chronic health conditions. School nurses can use this tool to guide conversations in person or via phone with a student’s parents/guardians or caregivers; learn about the health needs of an individual student; determine if they should create an individualized healthcare plan (IHP) and/or emergency action plan for a student; and consider many of the SDoH in developing a coordinated plan of care. SHP piloted the SN CHAT in the 2020-2021 school year, and is promoting the resource broadly as a useful tool for school districts to improve the quality of student health information and plan to appropriately address student health and education needs. The SHP surveyed school nurses from seven school districts to determine if the SN CHAT tool was useful. The surveyed schools increased their overall participation in Emergency Action Plans by 50% from the previous year and increased staff teaching about the individual child’s condition by 70% from the previous year.

The Child Care Health Consultation (CCHC) Program consultants continued to assess for referral needs at every training, consultation, and health promotion. To improve health care access, they referred children, providers, and parents to resources, including MO HealthNet, developmental screening, and WIC. CCHC Program services also increased the child care provider’s awareness of services available within their communities. The CCHC Program continued to provide services at regulated and unregulated child care facilities that serve families eligible for the Child Care Subsidy Program. CCHC Program services, including CPR/First Aid certifications and renewals, were provided at little to no cost to the child care provider. This was for the optimal health and safety of children and their families and to ensure that all child care providers and children in child care learned about health and safety topics that address SDoH inequities. CCHC Program services also provided consultation and training for child care providers on implementing individualized care plans, and implementing policies and procedures that promote inclusivity and family partnerships. The CCHC Program Manager continued to assist CCHC Program trainers in the distribution and development of resources that address SDoH and racial justice. By providing these resources, more children and families received education about resources available to them and had access to health care. The CCHC program encouraged family participation in all program services, and services continued to be required to be inclusive of adults and children of all abilities. The capacity for LPHAs to deliver CCHC Program services was severely impacted by the COVID-19 pandemic.

The TEL-LINK Program referred 223 callers to MO HealthNet services to increase insurance coverage. The program continued to provide targeted outreach campaigns through online search engines to the underserved population through effective marketing strategies. The campaign reached over 175,000 Missourians resulting in 7,491 individuals taking action to find out more.

The Newborn Health program continued to partner with a wide-variety of community health providers to distribute the Pregnancy and Beyond booklet, which contains information about financial resources, including MO HealthNet for pregnant women and children.

The DHSS Newborn Screening Program collaborated with midwives across the state to ensure uninsured and low income clients had access to affordable blood spot screening. The Missouri State Public Health Laboratory maintains agreements with approximately 40 midwives primarily caring for clients who otherwise would decline blood spot screening due to cost. The midwives purchased blood spot collection cards at a discounted rate and passed those savings on to qualifying clients. The midwives reported an increase in compliance and fewer refusals due to the more affordable cost. On September 9, 2022, DHSS staff attended the Missouri Sickle Cell Disease State Action Planning Initiative meeting at Washington University in St. Louis. The goal of this initiative was to convene collaborators with a vested interest in improving health outcomes for individuals with sickle cell disease. The meeting served as a kick-off and vision-casting event to initiate a yearlong process to develop a comprehensive and cohesive State Action Plan for sickle cell disease and trait. The group envisioned the Action Plan to be a roadmap that will transform healthcare delivery including access and cost effectiveness of care for Missourians with sickle cell disease. At the meeting, workgroups were established and will meet regularly for a year with the goal of developing a written Action Plan by August 2023.

The MCH funded Home Visiting programs’ contracted home visitors assessed all home visiting clients for insurance status at initial enrollment and periodically throughout enrollment. As need for health care coverage was identified, home visitors assisted clients/families in the Medicaid enrollment process and to the Affordable Care Act marketplace by linking clients to their nearest Federally Qualified Health Center (FQHC) to speak with a trained navigator in order to obtain eligibility and enrollment assistance. Annual data on insurance coverage through Medicaid, private, or other insurance was collected on children and primary caregivers enrolled in home visiting. In FY22, 53.9% (387/717) of primary caregivers with medical insurance coverage maintained it continuously for 6 months. Insurance coverage is vital to assuring children access adequate preventive health care including well child care. In FY22, 92% (692/752) of children enrolled in home visiting received the last recommended well-child visit based on the America Academy of Pediatrics (AAP) schedule.

The Safe Cribs Program has worked to increase access to crib resources and education to areas of the state that are considered underserved.

As a member of the Medicaid Advisory Council, the SHP continued to collaborate and partner with the MO HealthNet, Managed Care plans, Department of Social Services (DSS), FQHCs, state agencies and programs, as well as funding organizations to provide information, tools, and resources to school nurses related to Medicaid and access to health care. These materials equip school nurses with information about health care plans and services to aid them when assisting parents and families to obtain adequate health insurance coverage and access health care services and health plan benefits. The SHP uses data shared by DSS to review the reported number of children enrolled in MO HealthNet annually for trends and comparison to the trending number of students reported as uninsured from school nurse reporting. With the passage of legislation to expand Missouri Medicaid eligibility to healthy adults, the SHP worked with school nurses to provide information and resources to support them in assisting families with MO HealthNet enrollment. The SHP supports school nurses in assessing student insurance status and assisting families with MO HealthNet applications and accessing benefits through a variety of training opportunities including virtual seminars attended by over 100 school nurses, email blasts and presentations at school nurse conferences.

The SHP leveraged funding from another grant to release a contract to provide school health services to small rural schools without a formal health services program. In the 2022-2023 school year, there were 60 schools without a formal school health program. This program is currently serving 64 school districts with a student population of 20,597 school age children in rural settings. These schools received onsite and virtual supervision and support by registered professional school nurses. The schools also received the equipment necessary to offer sensory screenings.

The SHP and the MCH Director participated in the Show-Me School-Based Health Alliance as a partner on the steering committee. This Missouri affiliate of the National School-Based Health Alliance works with partner organizations and community stakeholders to increase the number and expand the service offerings of school based clinics. Missouri has seen the number of school based health centers rise from five in 2017 to 106 (not including satellite clinics) in 2022. The Alliance also works to enhance access to health care services for all students since a barrier to care is that students may have to miss school for medical appointments and parents miss work to take students to those appointments.

The SHP collaborates with school health staff in local education agencies (public, private, parochial, and Charter schools) to collect annual reporting data utilizing an online database. This system has been in place for over a decade and the information is used to identify trends, facilitate planning of state resources, and ensure up-to-date communication with lead school nurses. The SHP uses the data to monitor staffing of school health services and to identify school districts without designated school health services staff. The program then offers additional support and technical assistance to assure a minimum level of health services are available. The database also collects district-level data for students with health insurance. The SHP reviews this data to identify needs of school nurses. The program also uses this information as an indicator for reporting to state and local leaders on the status of healthcare access in schools and communities. The SHP continued to engage school nurses to utilize the reporting system and investigate options to update the database to improve collection, access and data sharing.

The Early Childhood Comprehensive System (ECCS) received a five-year grant in August 2021, “ECCS Health Integration: Prenatal to 3 Program,” in the amount of $255,600 per year. This funding will support the ECCS Program in leading the first integration of health needs, resources, and systems into the existing Statewide Early Care and Education (ECE) Strategic Plan and will build on current collaborative efforts to increase the impact for the prenatal to three population. A System Assets Gap Analysis was completed and confirmed a lack of integration of the Maternal Child Health and ECE systems at both the state and the local level.

The MCH Services Program supports local public health agency (LPHA) efforts to:

• increase the number of clients that receive a risk assessment or screening and referral for Medicaid eligibility;
• assure that all women of childbearing age receive preconception care services that enables them to enter pregnancy in optimal health;
• develop and promote strategies to increase the proportion of women receiving prenatal care beginning in the first trimester; and
• assure that women of childbearing age and children eligible for Medicaid maintain coverage during the “unwinding of the COVID-19 Public Health Emergency”.

LPHAs continue to:

• screen clients for MO HealthNet or other insurance coverage;
• screen for an identified primary care provider;
• perform pregnancy testing, prenatal education, and OB/GYN referrals as indicated;
• provide prenatal case management and/or referral for pregnant women;
• assist pregnant women with MO HealthNet program eligibility and enrollment; and
• screen clients for an identified dental care provider and provide dental referrals as indicated.

The MCH Services Program and the MCH Director continued to facilitate collaboration between DHSS, DSS, and the LPHAs to provide MEDES (Missouri Eligibility Determination and Enrollment System) updates, maintain open and effective interagency communication, promote adequate health insurance coverage, and improve health care access for MCH populations.

In addition, the MCH Services Program continued to contract with 111 LPHAs to address priority MCH issues in their communities. The MCH Services Program worked with the LPHAs in year one of their five-year work plans to address their selected priority health issue. The LPHA work plans include evidence-based strategies to address their selected local priority health issue (PHI), which includes addressing SDoH, existing health inequities, and gaps/weaknesses in access to care.

• The Jackson County Health Department chose addressing SDoH inequities among preconception/prenatal/postpartum women of childbearing age as their PHI. The Jackson County Health Department leadership reported increased awareness of local initiatives that impact the public’s health as a result of implementing a local policy tracking process. This policy tracking process tasks Community Engagement and Policy Division staff with monitoring and reporting local legislative updates to inform leadership on city and county initiatives. An increase in stakeholder and elected official knowledge in regards to public health policy has been achieved as a result of developing a quarterly policy newsletter that is shared with stakeholders and elected officials, sharing state and local legislative updates, community partnerships, and public health policy in the news.

Through the Inclusion Services (IS) project, the Inclusion Specialists provided referrals to appropriate services, including services provided by local public school districts, as part of child-specific action plans. Specialists helped child care providers in identifying SDoH such as housing, food access, poverty, and/or exposure to violence as some possible reasons behind children’s behaviors. Because child care providers increased their knowledge and skill set on how to better work with and maintain care for children with special needs, there has been a reduction in preschool expulsions. At the 6-week follow-up, an average 16.5% of children/families were referred for additional services with an average of 7.5% receiving additional services. When a child scored close to the cut-off on the Ages and Stages Questionnaire: Social-Emotional (ASQ-SE), the teacher and family received activities to support the child’s overall growth and development. The Inclusion Specialist problem-solved with the teacher on how to address any potential concerns. When a child scored “at-risk” or above the cut-off on the ASQ-SE, a referral for further evaluation was made to First Steps or the local school district depending on the child’s age.

The Office of Dental Health (ODH) continued to promote the importance of oral health for the entire MCH population through LPHAs, school districts and FQHCs. The ODH also continued to assess oral health screening results from schoolchildren in the state in order to promote services in those areas. The ODH leveraged other funding to educate the general public on the importance of water fluoridation, which is one of the most equitable public health intervention measures since everyone no matter their race, sex, age or gender can enjoy the benefits of community water fluoridation. The ODH also continued to develop posts for the DHSS social media site on the importance of oral health.

The CLPPP Program worked to connect case managers with language appropriate resources for their patients with elevated blood lead levels. The program utilized resources from across the nation to meet the needs of children and families impacted by lead poisoning. The program received several requests for information in Dari and Pashto and a link to translated information was provided.

The CLPPP staff are collecting data on disparities in lead poisoning to help guide programmatic decisions and identify areas of most need. Once identified, a strategic plan will be developed to address ongoing disparities across Missouri in an effort to reduce rates of lead poisoning for the most vulnerable Missourians.

The Missouri Newborn Hearing Screening Program (MNHSP) incorporated culturally and linguistically appropriate services into the program’s activities to assure that all babies born in Missouri receive a hearing screening and appropriate follow-up. The MNHSP empowered families with limited English proficiency by training all new and current MNHSP staff on use of phone interpretation services, updating imagery on the MNHSP brochures to reflect diverse populations, and creating bilingual parent literature in English and Spanish.

The Office on Women’s Health (OWH) incorporated cultural competence into multiple dimensions of their work. The OWH leveraged MCH funded staff to lead the rape prevention and education program. This program built capacity for cultural competence by contracting with the Missouri Coalition against Domestic and Sexual Violence (MOCADSV). MOCADSV developed a training for community health workers on health equity and violence prevention. By incorporating cultural competence into all of the work, the OWH had a larger impact on improving health for women in Missouri.

To address the SDoH inequities and continue building a comprehensive maternal-child public health system to address the priority needs of Missouri’s MCH population, the MCH Director:

• Used web-based platforms to engage in virtual meetings and continued to build relationships with statewide MCH stakeholders;
• Provided virtual and in-person presentations on the Life Course Perspective and facilitated a simulation of the Life Course Perspective for students enrolled in the MCH-focused MPH graduate program at St. Louis University;
• Initiated and engaged in discussions related to the SDoH, health literacy, health disparities, diversity, and inclusion;
• Promoted trauma-responsive and culturally competent MCH programs and services;
• Contributed to Department efforts to create a diverse and inclusive work environment and promoted incorporation of the principles of cultural competence and humility, diversity and inclusion into programs and initiatives;
• Promoted activities and initiatives to ensure access to care, including adequate insurance coverage, for MCH populations and to promote partnerships with individuals, families, and family-led organizations to ensure family engagement in decision-making, program planning, service delivery, and quality improvement activities; and
• Practiced, promoted and supported efforts to recruit and retain a qualified, diverse and well-trained MCH workforce.

The Injury Prevention program continued to partner with the Safe Kids coalitions to implement evidence-based programs and identify gaps in current services. The Safe Kids coalitions addressed priorities including child passenger safety, bicycle safety, crib safety, TV and furniture tip-over, pedestrian safety, poisoning, farm safety, safe sleep, teen driver safety, medication, fire and water safety and other areas based on community needs. The coalitions offered a broad array of activities including: providing cribs, car seats and parental education, conducting car seat checks and certification training for child passenger safety technicians (CPST), promoting the National Safety Council’s Defensive Driving Course (DDC), conducting media campaigns with prevention messages, and working with policymakers to address gaps in policies that could prevent injuries.

The Adolescent Health program (AHP) used some SDoH factors to determine the highest need areas of the state to direct federal funding for pregnancy prevention. The needs assessment for this is reran every 5-6 years depending on grant applications to determine if counties have increased or decreased needs.

The AHP continued its partnership with the Chafee Program and DSS to provide Making Proud Choices (MPC) Out of Home Edition to older youth who are aging out of foster care. These youth learn not only pregnancy prevention, but also adult preparation topics to prepare them for life after foster care. Over 160 foster youth participated in this program.

1 U.S. Census Bureau, American Community Survey 1-Year Estimates Subject Tables.

2 U.S. Census Bureau, Small Area Income and Poverty Estimates (SAIPE).