Cross-Cutting/Systems-Building: Annual Report
In 2021, 100 percent of Idaho was a federally-designated mental health professional shortage area, 97.7 percent of Idaho was a federally-designated shortage area in primary care, and 94.0 percent of Idaho was designated a dental health professional shortage area. Idaho had 69.1 primary care physicians per 100,000 population in 2020, and by 2020 ranked 49th in the U.S. for the number of active primary care physicians per 100,000 population. For 2018, it is estimated that a total of 962 physicians offer primary care to children. Specifically, there are 798 family medicine/general practice physicians and 164 pediatricians.
For the 2021-2025 state action plan, the MCH Program identified a new priority area in the Cross-Cutting/Systems Building domain to address the 2020 Needs Assessment findings and stakeholder input during the prioritization process. Stakeholders consistently identified the impact of adverse childhood experiences (ACEs) on the health outcomes for MCH populations across all domains. Some of the most frequently experienced ACEs among children included: economic hardship, parent or guardian separation or divorce, living with someone suffering from mental illness, and the impact of toxic stress. As a result of childhood ACEs, trauma-informed care was cited as one of the top five needs for women of reproductive age.
ACEs negatively affect a child’s health and social outcomes, including increased risk for lower educational attainment, unemployment, poverty, and chronic disease. A 2018 report from the Association of State and Territorial Health Officials (ASTHO) finds these outcomes “are also influenced by the social determinants of health, including access to healthcare and the ability to maintain a healthy lifestyle.”
To address this, the priority of improving social determinants of health for maternal and child health populations has been established to guide the 2021-2025 state action plan strategies. The creation of this priority aligns with the Division of Public Health’s (DPH) 5-year plan, Get Healthy Idaho: Building Healthy and Resilient Communities. This population-level plan aims to improve health outcomes, lower healthcare costs, reduce health disparities, and improve health equity across Idaho through shared alignment and collective action across programs and with diverse partners. One of the key ways Get Healthy Idaho (GHI) seeks to do this is by addressing social determinants of health.
Social determinants or influencers of health are the conditions in which people are born, grow, live, learn, work, and age that have a significant influence on a community’s health. While the phrase “Your zip code is a greater predictor of health than your genetic code” has been widely used by public and community health professionals over the past decade, DPH has taken it a step further to assert that your neighborhood is a greater predictor of your health. Social, economic, and environmental factors and their influence on health can vary greatly depending on the neighborhood one grows up in. Health happens in our homes, neighborhoods, and communities. Proactive, multi-sector, strategic investments that aim “upstream” to address the root causes of poor health and health disparities are needed to reduce the causes of poor health and premature death. By improving these influencers on health, it is also possible to advance health equity, which may also reduce the likelihood of ACEs.
By September 2025, the MCH Program aims to impact social determinants of health and promote health equity for MCH populations through workforce development strategies and supporting community-led models that build resiliency and improve health outcomes. State performance measure (SPM) 4 has been developed to measure the number of health care professionals who serve MCH populations that receive training with the goal of improving delivery and quality of care. As the GHI initiative continues to develop, the SPM may evolve in future years to focus on measuring the impact of this community-based approach.
The FY 2022 MCH-supported strategies to address this priority are discussed below.
A learning collaborative is an opportunity for healthcare providers and practices to participate in a structured quality improvement process to raise the quality of care they deliver. The Institute for Community Inclusion has defined learning collaboratives as an opportunity in which “researchers provide a fabric for stakeholders to interact” promoting a “constant feedback loop that benefits both the stakeholder and researcher” (Mitchell, 2014). The outcomes of learning collaboratives focus on relationships, knowledge sharing, and customized technical assistance (Mitchell, 2014), as well as the improvement in access to quality preventative visits for the MCH population (White, 2019).
In FY 2022, the MCH Program continued to fund the Idaho Children’s Trust Fund (ICTF) to facilitate a guided, quality improvement learning collaborative (LC) focused on ACEs and quality and practice improvement for MCH populations. The goal of this primary prevention strategy sought to increase the use of Positive and Adverse Childhood Experiences (PACES) screening in the pediatric setting and to create a human-centered approach to how medical providers screen and follow up with their patients who have experienced ACEs. Pediatricians are an important source of information and guidance for parents of young children. Pediatricians can play a significant role in breaking intergenerational patterns of trauma and improving the lives of children and their families.
The following diagram describes the process of Phase 1 into Phase 2 of the project:
Recruitment for Phase 2
Significant effort was spent on Phase 2 recruitment because the ambitious goal was to get 8-12 practices from around Idaho to participate. This goal was ambitious because familiarity with ACEs screening for adults and children is low in Idaho, and parental PACEs screening is almost unheard of. The hope was to re-engage practices that had participated in the 2019 Parental ACEs Learning Collaborative and recruit new practices.
Recruitment was done via an email announcement that included a simple response survey to gauge knowledge of Parental PACEs screening and interest in participating in a Parental PACEs Learning Collaborative. The announcement and survey link were sent to members of the Idaho Chapter of American Academy of Pediatrics, the Idaho Academy of Family Physicians, the Idaho Primary Care Association, and 2019 and 2021 collaborative participants. A total of 21 responses were received. Each respondent was sent a personalized follow-up email and asked to have a phone meeting. Fourteen personal meetings were held, and valuable information was collected to help structure the Learning Sessions as well as to understand past frustrations and current challenges.
Overview of Phase 2 Implementation
The collaborative hosted four Learning Sessions and three Peer Sessions between September 23, 2022, and January 13, 2023. Participation was free of charge. Project expenses, including contractor and consultant expenses, screening resources, and printing were paid for with Title V MCH funds.
Formal presentations were made at the Learning Sessions while the Peer Sessions were designed to facilitate peer-to-peer discussion and problem solving. All sessions were recorded and could be viewed on demand by cohort members and their teams. Independent work was expected to be completed between Learning Sessions. Continuing medical education (CME) evaluations were created for each Learning Session in cooperation with St Luke’s Health System for physicians to obtain educational credit.
Three physicians provided expert assistance to the collaborative during the Learning Sessions and Peer Sessions: Dr. Keith Davis, Dr. Tom Patterson, and Dr. R.J. Gillespie. Five physicians completed the Learning Collaborative: A) Dr. Omer with Saltzer Health in Nampa; and B) four providers from the Full Circle Health pediatric residency program in Ada County (Dr. Bradford, Dr. Butt, Dr. Mantzor and Dr. Labor). Two registered nurses (RNs) from Full Circle Health also participated. While we hoped for a larger group, we were pleased to work with the residency program and teach the teachers. Each participant was provided with one or more Parental PACEs resource kits for use in their practice.
The physician learning sessions centered the five high-priority recommendations created by the Parent/Caregiver Advisory Council (PAC) in FY 2021 for how pediatricians can respectfully conduct an ACEs screening and provide supportive follow-up. The PAC grouped the recommendations into four themes: commitment, education, relationship, and process. The PAC provided the reasoning behind their recommendations and outlined specific action providers can take.
High-priority Recommendations:
1) Parents/caregivers should be given written or verbal assurance their ACEs score and their specific ACEs won’t be used to judge or test their parenting ability and that the information is confidential and won’t be shared with anyone without permission.
2) Parents/caregivers should know there will be follow-up and the provider has helpful resources available before being asked to do the screening.
3) Parents/caregivers should be given information about ACEs before the screening.
4) The provider needs to be respectful, listen, and be compassionate.
5) The provider needs to make it easy for the parent/caregiver to do the screening by creating a calm, unrushed and private environment, and a flexible and respectful process.
The recommendations are supported by evidence from the FY 2021 focus groups and examples of ways providers can implement the recommendations are provided. Comments from the focus groups were included to bring the parents’ voices into the report. Follow-up was so important to the parents that a special section examines three types of follow-up: concrete supports, referrals to professionals and creating opportunities for peer support and self-help. The final report and screening guidance was published in October 2021 and is available online at: www.idahochildrenstrustfund.org/resources-research/aces-learning-collaborative
Next Steps
The collaborative will transition from MCH funding and coordination by ICTF and Idaho Resilience Project to management by Cornerstone Whole Healthcare Organization (C-WHO). This will allow for the project to be scaled up and supported by C-WHO’s existing training infrastructure and working relationships with providers around the state. Both ICTF and MCH staff have agreed to work with C-WHO in an advisory capacity during Phase 3.
Phase 3 will build on the lessons learned during Phases 1 and 2 and address what to keep and what to change:
1) The work will continue to use the guidance document developed by parents in Phase 1 of the project to maintain fidelity to the parent-centered approach.
2) The Steering Group developed to guide the Parental PACEs Learning Collaborative will continue to work with C-WHO staff. The diverse Steering Group has provided important perspective on the work.
3) C-WHO will move the content to an online learning platform so physicians and other clinicians can engage with the content asynchronously. Phase 2 experience demonstrated that many clinicians found it difficult to join the real time classes.
4) Both the real time and on-line content are eligible to earn CME.
5) Practice opportunities are critical. Physicians report they get more comfortable talking with parents about childhood trauma each time they do it.
6) C-WHO will continue to facilitate peer to peer sessions to help clinicians learn from each other as they proceed along this journey.
The MCH Program looks forward to supporting the growth of this work within the pediatric and family physician communities, and believes it can have a profound impact on the wellbeing of current and future Idaho families.
Support and Improve Health Equity
Department of Health & Welfare Strategic Plan Goal 3
Each year the Department of Health and Welfare (DHW) takes the opportunity to update and refresh its strategic plan. The agency’s 2023-2027 plan highlights the course for addressing state and community issues alongside healthcare providers and partners. It seeks to address the unprecedented changes resulting from the pandemic and population growth.
Goal 3, to help Idahoans become as healthy and self-sufficient as possible, was expanded to focus on four tasks as outlined below:
In FY 2022, the MCH Director supported cross-divisional work aligned with Goal 3, task 3.3, by co-leading monthly planning meetings with DPH’s Deputy Division Administrator over policy, performance, equity, and strategic partnerships. Staff from the divisions of Behavioral Health, Family and Community Services (FACS), Medicaid, and Public Health shared program priorities and built a crosswalk that identified collaborative opportunities for work to address the strategic plan objective and task. Over the course of this process, it was determined that having a guided approach such as the results-based accountability (RBA) process, would help the task group start to narrow down options and select the three initiatives to focus on. This work will be led by the GHI team, which has completed RBA training, over a series of meetings in spring 2023.
Get Healthy Idaho
The MCH Program is committed to addressing health disparities and improving population health in underserved communities. Get Healthy Idaho (GHI) is a promising initiative modeled on Rhode Island’s Health Equity Zones. With a mission to “create the conditions that ensure all people can achieve optimal health and resiliency,” Get Healthy Idaho is a unique opportunity to invest in innovative solutions that address the root causes of poor health affecting entire communities and, ultimately, individuals, families, and children.
In FY 2020, the MCH Program participated in the development and evaluation of a public solicitation for proposals by communities to receive funding and start the community assessment and action planning process. The Western Idaho Community Health Collaborative (WICHC) was awarded funds to start this process in Elmore County in January 2021. Since then, WICHC has formed a Community Action Team, conducted a qualitative health needs assessment and issued a report highlighting the important personal and community health needs from the viewpoint of Elmore County residents. Through interviews, focus groups, and an online survey, residents painted a clear picture of the advantages and disadvantages of living in rural Idaho. Three common themes emerged from these conversations: mental and behavioral health access, outdoor amenities and physical activity, and local health care access. An additional cross-cutting theme focused on increasing cultural competency was highlighted through qualitative interviews and focus groups with community members. These priority themes were further refined into a countywide action plan which will drive collaborative efforts to address the upstream barriers to good health over the final three years of funding.
In FY 2021, the United Way of Southeastern Idaho was awarded funds and became the second community to join the GHI initiative. High rates of poverty in combination with low rates of healthcare access and other social and geographic inequities have created significant vulnerabilities and disparate health outcomes for residents across the United Way's focus area of Bannock County. For the first year of funding the United Way engaged in a community-led process to organize a multi-sector collaborative. This collaborative used existing data along with collecting lived-experience data directly from community members to better understand the upstream and downstream conditions that are shaping health outcomes in Bannock County. This information was used to develop an evidence-based Community Action Plan to address the social, economic, and environmental drivers of health in subsequent years of the initiative.
In FY 2022, GHI-funded collaboratives in Elmore and Bannock Counties identified opportunities to improve health and wellbeing by increasing access to timely and culturally competent health care services so underserved residents can receive the care they need when they need it. Transportation barriers and timely access to care were the most common root cause of no-show rates and untreated or mis-managed chronic and behavioral health conditions.
Elmore County, like most of Idaho, has a shortage of healthcare providers. The CY 2021 GHI community health assessment found residents overwhelmingly noted the need for affordable health care, insurance, and dental care; improved access to and availability of local providers; and the need for specialty providers – including vision, dental/orthodontia, hearing, and diabetes services. Residents also noted the importance of connectivity to open space and trails as well as alternative transportation options to support their overall health and wellbeing. To address these needs, the collaborative is utilizing GHI funding in the following ways:
- Improving access to health care by bolstering a Community Health Worker (CHW) model of care across the county and establishing a Community Health-EMS (CHEMS) pilot project with local EMS agencies. The CHEMS pilot will address gaps in the behavioral health care landscape and support residents with chronic disease management. The collaborative is working with Desert Sage Health Centers, a federally qualified health center, to hire an additional CHW on staff at their clinic. As a result of listening to the challenges and needs of local care navigators, there are additional plans to hire and co-locate a CHW in the Mountain Home Library in coordination with St. Luke’s Hospital in Mountain Home and with the help of FindHelpIdaho. CHW’s will support community members with diabetes with chronic disease management care and resources to local services. Case studies of clients will be created to better understand how CHW’s impact patient access to care and health outcomes.
- Bringing together federal, state, county, and municipal lands and recreation leaders to identify opportunities for collaboration to improve access to and awareness of trails and open space in the county. The resulting “Elmore County Access to Trails and Open Space” vision plan will ultimately lead to a strategic plan for collaboration and improvement of public lands and trails across the county. The collaborative is also working with county commissioners and local leadership on a Transportation Roadmap, which will lay out a strategy for identifying, funding, and improving safety and access improvements on roadway-adjacent projects across the county.
In FY 2022, the GHI-funded collaborative in Bannock County, led by the United Way, completed a community health assessment. The assessment identified opportunities to improve health and wellbeing by increasing access to timely and culturally competent health care services so residents can receive the care they need when they need it. They identified several census tracts in and around the region of southeastern Idaho where a high percentage of households lack a vehicle. Transportation barriers and timely access to care were noted as the most common root cause of no-show rates and untreated or mis-managed chronic and behavioral health conditions among local health providers and clinics.
The collaborative team developed a community action plan and selected transportation access as their primary intervention. The United Way designed a pilot program and partnered with Shudl to provide free rides to Pocatello Free Clinic clients, all of whom are uninsured and fall below 250% of the federal poverty level. The program, Ride United, launched in December 2022 and aims to reduce no show rates and improve health for uninsured residents. The program also offers food delivery to people in need. Shudl is a family-owned business operated by a former EMS provider who experienced first-hand the complications people face in obtaining holistic healthcare when they lack transportation. Clients in need of this service are identified in the clinical setting. Rides are tracked and reported to the United Way each month.
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