In addition to population domain specific activities and programs, Arizona's Title V program addressed cross-cutting issues affecting women, infants, children (including children with special health care needs) and adolescents through programs that cross the lifespan (oral health) and programs that strengthen health systems and improve access to care (workforce development program and site development for safety net clinics).

The Office of Oral Health (OOH), housed within BWCH, implements a number of oral health programs and initiatives to improve the oral health of Arizona's children, pregnant women and other high-risk populations. Key programs and initiatives include: School-based Dental Sealant Program, Silver Diamine Fluoride (SDF) Program, Fluoride Varnish Programs, the Healthy Smiles Healthy Bodies Survey, and Mission of Mercy. With the exception of the SDF Program, which is funded through a separate grant from HRSA MCHB, each of these programs receives partial funding from Title V. In 2021, all of these programs experienced major disruption to services due to school closures, workforce shortages, and other challenges related to the COVID-19 pandemic. More information on each program's aims, 2021 results and accomplishments, and the impact of COVID can be found below.

Arizona has continued and enhanced several strategies to improve the oral health of Arizona's MCH populations. The Bureau of Women’s and Children’s Health (BWCH), Office of Oral Health (OOH), initiated the Arizona School-based Sealant Program in 1987, with a grant received from the Flinn Foundation. This evidence-based program was designed to reach high-risk, underserved school-aged children on their school campus using portable dental equipment. Additional funding that same year from the Ronald McDonald Children's Charities allowed OOH to continue the program. In July of 1989, the Sealant Program was incorporated into the OOH State Budget and Maternal and Child Health Block Grant dollars were used for supplies, equipment, and contracting personnel for the Arizona School-based Sealant Program. Since that time, legislative changes have enabled the program to become sustainable through the establishment of the Oral Health Fund and the ability to receive Medicaid reimbursement for oral health services.

The Arizona School-based Sealant Program (AzSBSP) was implemented with the goal of reaching underserved and high-risk populations in efforts to decrease tooth decay in susceptible teeth where topical fluorides are less effective. In order to expand the reach of the program, OOH has been involved in collaborative efforts with other state health agencies and organizations to promote the use of dental sealants and to provide technical and educational assistance in the development of additional resources for dental disease prevention.

The program has been very effective at reaching Arizona’s most vulnerable children by targeting high-risk schools. Both public and charter schools with 50% or higher free and reduced school meal program participation may apply and are eligible to participate in the program. Dental screenings and sealants are provided to children in 2nd and 6th grade with parental consent. Sealants are provided to uninsured children, Medicaid and State Children's Health Insurance Program (SCHIP) beneficiaries, and those covered by Indian Health Service. These two age groups are targeted because they have newly erupted permanent first or second molars that benefit from the placement of dental sealants. The sealant program provides services to children in 6 of the 15 Arizona counties. Services are provided by trained and calibrated dental providers. OOH provides technical assistance and trains local providers to ensure successful sealant placement and retention and makes every effort to connect participating children with a dental home in or near their community.

Program Impacts Related to the COVID Pandemic: The COVID-19 pandemic has created barriers to accessing dental health care that have resulted in severe impacts on oral health. In Spring 2020, because there were shortages in personal protective equipment (PPE) and no COVID-19 vaccines to protect healthcare workers and the public, not only were dental practices limited and preventive dental procedures postponed, but public schools were closed, and school-based dental sealant programs were stopped. Since then, PPE has become more accessible and vaccinations are fully available to children aged 5 and older, teens, and adults. Some restrictions have been lifted since 2020; however, access to preventive dental care has substantially decreased. The significant decrease in dental office visits, combined with the complete pause in school-based programs that are only now beginning to slowly restart, places children at greater risk of not receiving important preventive dental care or treatment for existing oral diseases.

Even before the COVID-19 pandemic, many children in Arizona faced barriers to receiving oral health care. As reports indicate, Arizona children suffer from high rates of tooth decay and lack access to care as compared to the U.S. population. As the pandemic lingers, families have lost jobs and, as a result, have lost dental insurance coverage. In April 2021, the CareQuest Institute for Oral Health released a report that estimated six million people had lost dental coverage because of the pandemic. Families and children are not seeking dental care because of concerns about exposure to COVID and also lack of dental insurance coverage.

The COVID-19 pandemic had a devastating impact on all OOH preventive programs. Prior to the pandemic, during the 2018-2019 school year, more than 21,000 children received referrals for urgent and early dental disease and more than 16,000 children received preventive dental care. Since the pandemic began, the number of children who received services in the AzSBSP program has steadily decreased, and the total number of children receiving any preventive service during the 2020-2021 school year decreased by more than 80%. As schools shifted to virtual learning, and later, many to hybrid learning, administrators and school nurses were not allowing outside programs into schools, and parents were reluctant to participate in services.

The COVID-19 pandemic has had a significant negative effect on securing dental providers for OOH programs. The February 2021 Journal of Dental Hygiene reported results of a 30-question web-based survey completed by licensed dental hygienists. One in twelve had dropped out of the workforce citing concerns about being exposed to the novel coronavirus and the infection control measures being taken at dental practices that led them to leave the profession. OOH prevention programs have experienced the most severe shortage in availability of dental providers ever in the history of the program. Maricopa, the largest County contractor, has reported a severe shortage in dental hygienists and dental assistants: some left the profession and the County has not been able to hire since the start of the pandemic. Additionally, other contracted partners have reported issues with retaining and hiring dental providers. OOH currently has no dental providers to cover Santa Cruz, Cochise, and Yuma Counties and has been actively recruiting for the past 12 months. Community health clinics also have reported shortages because dental providers have been reassigned to COVID-related activities. Gila and Pima Counties cannot find dental hygienists or dental assistants. These combined factors associated with the pandemic could result in a surge in oral disease in Arizona’s children.

School-based dental care is a crucial way to reach low-income children who may otherwise have little to no access to care. Nationally, children in low-income families are at higher risk of caries and are less likely to receive sealants than children in higher-income families, at 39% and 46%, respectively. (Griffin et al., 2016) A 2020 report, cited in this CDC Commentary on Oral Health and COVID-19: Increasing the Need for Prevention and Access, asserts that: “The oral health care safety net is expected to cover . . . one-third of the US population, notably those who are low-income, uninsured, and/or members of racial/ethnic minority, immigrant, rural, and other underserved groups.” (Northridge, Kumar, Kaur, 2020).

School-based dental sealants are one of only two evidence-based methods for the prevention of tooth decay and are crucial to reducing decay in children. Untreated tooth decay can cause pain and infection and can affect overall health. Dental screenings help identify serious oral health issues and dental sealants prevent the development of future health-related issues that can require more invasive treatments.

Because COVID-19 created a significant interruption in the delivery of on-site dental services in schools, Arizona’s sealant program responded by revising its policies and procedures so that once schools reopened, providers were adequately prepared to deliver services safely.

The new Arizona School-Based Sealant Program Provisional Policies and Procedures Manual aligns with the most current guidelines and recommendations from the Centers for Disease Control and Prevention (CDC), Organization for Safety Asepsis and Prevention (OSAP), Environmental Protection Agency (EPA), Arizona Department of Education (ADE), and Arizona Department of Health Services (ADHS). As new information is released and the pandemic situation evolves, this document will be updated. It is of utmost importance to keep abreast of new information.

In 2021, there were results and accomplishments that impacted programming. School closures resulted in a significant decrease in the number of children that were served by the program. During the 2020-2021 school year, the Arizona School-based Sealant Program provided dental services at one school, providing screenings and referrals to 13 children, significantly less than the 7,634 children that were screened the previous school year. Of the 13 students that received screenings, 9 (69%) received dental sealants.  Additionally, of the children who participated in the program, approximately 2 children (19%) were identified as children with special health care or educational needs. The program bills Medicaid for its eligible children and Title V funds are used for services to the uninsured. Partnerships with federally qualified health centers (FQHC) and county cooperative extensions have provided outreach to additional counties. When schools fully reopen, OOH will continue working toward reaching the goal of increasing the number of school-based sealant programs and individuals served in rural communities. During the 2020-2021 school year, Arizona School-based Sealant Program could not reach the majority of eligible schools as schools were closed and local program providers were restricted from providing services due to the COVID-19 pandemic.

OOH preventive programs also include the Kindergarten Fluoride Varnish Program as part of the same eligibility and infrastructure as the AzSBSP. During the 2020-2021 school year, the number of schools that participated in the program was significantly less than the previous years as most schools were closed due to the pandemic. Services were extremely limited and were provided at three schools in two counties resulting in 25 kindergarteners screened and 23 fluoride varnish treatments provided.

Efforts under a HRSA-funded Oral Health Workforce Grant included implementing the Silver Diamine Fluoride (SDF) Program, a prevention intervention for high-risk children. The SDF Program partnered with existing internal and external community-based dental programs; however, no services were able to be delivered during the 2020-2021 school year. Instead the program focused on training providers to better prepare them to respond to infection prevention needs due to the pandemic. Infection prevention training was provided to 14 school-based and community dental program providers.

The Arizona school-based Fluoride Mouth Rinse (FMR) Program was discontinued in the fall of 2020 due to the lack of availability of the products used to run the program. The one and only national manufacturer of the fluoride mouthrinse product stopped making the products and as a result all fluoride mouthrinse programs nationwide were ceased.

The OOH implements a Fluoride Varnish Program for pregnant women and children ages birth through five. This is in partnership with Arizona’s early childhood agency, First Things First (FTF), through the Arizona Early Childhood Development and Health Board. The Arizona Fluoride Varnish Program began as a pilot with the FTF South Phoenix Regional Partnership Council and Maricopa County. The program is offered at Women, Infants and Children (WIC) Program offices, immunization clinics, and child care centers throughout the county. The application of fluoride varnish, an extremely effective cavity-prevention agent, in combination with dental screenings, referrals, and other educational services, are the core of the primary prevention program. The role of OOH is to provide a sustainable billing system with partner counties. During the 2021 state fiscal year (July 1, 2020–June 30, 2021), the Fluoride Varnish Program served 7,685 children, ages birth through five, in four counties including screenings, oral hygiene education, referrals, and case management as needed. It also included fluoride varnishes for 4,382 children. Due to the COVID-19 pandemic, activities were significantly reduced and 60% fewer children received services in SFY2021 as compared to the previous fiscal year.

The Office of Oral Health began implementing the Healthy Smiles Healthy Bodies (HSHB) Survey during the 2019-2020 school year. This survey is conducted by OOH every five years and tied directly to the Title V MCH Needs Assessment. The goal of the HSHB Survey is to collect oral health and body mass index (BMI) status of population groups (kindergarten and 3rd grade) in Arizona. This surveillance data informs public health programs, monitors progress toward reaching state/national benchmarks, including Healthy People 2030 objectives, and contributes to the CDC National Oral Health Surveillance System. Survey calibration trainings were held for survey teams at three locations (Flagstaff, Maricopa, and Tucson) early in the 2019-2020 school year.  Survey teams completed 33 schools prior to the beginning of the pandemic in March 2020.  When the pandemic hit, the survey was stopped and OOH convened a workgroup of experts to develop policies and procedures for re-entry into schools once they reopened.  As a result, 28 providers were trained again in September 2020 on the new procedures. In addition to a change in implementation procedures, OOH developed communication materials for parents and schools on the safety and need for oral health screenings. While OOH continues effort to reach out to and engage open schools, implementation of the survey has been a challenge. OOH has lost local partners who are either restricted in providing service or have lost dental providers who have left their vocation. OOH continued efforts to engage schools and implement the survey and was able to reach only 3 additional schools during 2021.

The Office of Oral Health continued working in partnership with the Arizona Health Care Cost Containment System (AHCCCS; Arizona's Medicaid program) by collaborating on reimbursement of oral health services for AHCCCS-enrolled children. Reimbursement of program services has built sustainability in the program and increased AHCCCS' preventive services initiatives. One major achievement and outcome of this collaboration was the institution of a policy within the AHCCCS Medicaid Early and Periodic Screening, Diagnostic and Treatment (EPSDT) requirements for health plans to participate with the Cavity Free AZ prevention programs. Collaboration between the two state agencies also included referrals and identifying opportunities to link Medicaid-eligible children to dental homes.

In 2012, HRSA’s Maternal and Child Health Bureau, in collaboration with the American College of Obstetricians and Gynecologists and the American Dental Association and coordinated by the National Maternal and Child Oral Health Resource Center, issued the Oral Health Care During Pregnancy: A National Consensus Statement, a document designed to help health professionals, program administrators and staff, policymakers, advocates, and other stakeholders respond to the need for improvements in the provision of oral health services to women during pregnancy. The results of this document spearheaded Arizona’s movement toward improving the oral health of pregnant women and infants. As a result, OOH developed training materials and resources for multiple audiences, including home visitors, childcare providers, health providers, pregnant women and new mothers, to enhance their knowledge and skills on improving oral health for women and young children.  These resources include e-learning modules on oral best practices, which was completed by 62 home visitors in 2021, as well as motivational interviewing, a client-centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence.  The oral health training resources reside on the home visitor portal, Strong Families AZ (strongfamiliesaz.com), and are available to home visitors and partners statewide. As part of the training in 2021, OOH distributed nearly 500 oral hygiene kits to participating home visitors to provide to their clients during oral health conversations.

In addition to the e-learning modules, OOH developed three in-person training sessions to train oral health providers on oral health best practices for pregnant women, infants and toddlers.  In partnership with First Things First, Arizona’s early childhood agency, OOH trained nearly 48 oral health providers across Arizona. Trainings were provided throughout the calendar year and located geographically and virtually to accommodate wide participation from all counties and to address ongoing pandemic issues.

Oral Health is one of the priorities identified in the Arizona Health Improvement Plan (AzHIP).  AzHIP was designed with the participation and commitment from many stakeholders allowing for strategies to be more far reaching than those OOH can implement alone. The oral health strategies include: expand access to childhood oral disease prevention programs; increase utilization of the oral health care system; integrate oral health into whole person health; and expand and maintain community water fluoridation systems. OOH continued partnering with stakeholders to implement and update the AzHIP priorities.  The majority of this work was completed through quarterly scheduled virtual meetings during 2021.

During 2021, OOH worked with a broad array of national, state, and local public and private partners to educate decision-makers on dental public health issues and concerns of state oral health programs. One such partnership included statewide and regional oral health coalitions that were instrumental in addressing access to care issues for our most vulnerable populations.  In 2021, Arizona worked on providing technical assistance to partners regarding the recently signed Dental Therapy bill, which created a new class of dental care providers in Arizona who will be able to provide primary dental care for children and underserved individuals. While employment of this provider type is still in the rules stage of development, partners are eager to move forward with implementation. 

Arizona also looks at ways to reach and serve the oral health needs of the disenfranchised, which started the Arizona Mission of Mercy. This event provides free dental care to those who most need it and is made possible through the work of hundreds of volunteers. A startling 42% of Arizona adults over 65 years have lost six or more teeth due to decay or gum disease. We know that nationally about half of people do not have dental insurance and pay for dental care out-of-pocket. In 2021, the Mission of Mercy event at the Arizona Fairgrounds was once again implemented. The event addressed severe dental needs that resulted during the pandemic and more than 1,500 volunteers provided dental care to more than 1,110 patients.

ADHS implements the Empower Program to support Arizona’s early care and education (ECE) facilities in their endeavors to encourage young children to grow up strong and healthy. By enrolling in the Empower Program, licensed child care facilities voluntarily agree to implement all standards and develop a written policy for each standard that meets the needs of all children served. In turn, the child care facility is provided a fifty percent reduction in licensing fees, partially funded through Title V. Additionally, ECE programs contracted with the Arizona Department of Economic Security (DES) are required to enroll and participate in Empower. The Empower Program requires providers to adopt 10 health standards, two of which impact children's oral health: 'Fruit Juice' and 'Oral Health'. These efforts are welcomed by oral health stakeholders that recognize the link between fruit juice and the oral health of young children. In 2021, the OOH continued support of online e-learning courses on implementing tooth-brushing programs in child care and serving fruit juice. In 2021, ‘Empower Training: Fruit Juice in Child Care Settings’ had 1,001 users and ‘Empower Training: Tooth Brushing in Child Care Settings’ had 688 users.  These training resources are available to all child care staff in Arizona.  AZ Workforce Registry credit is also available, free of charge, to those who enroll.

In 2020, a work group of the Empower Advisory Committee (EAC) began a review of all the standards.  Under review is Standard 7: Oral Health (Provide monthly oral health education or implement a toothbrushing program) and its components:

• Provides monthly oral health education and/or implements a daily tooth brushing program
• Does not allow children to carry a bottle or sippy cup during the day unless it is water
• Educates parent(s) on the importance of a dental visit by their child’s first birthday
• Does not put children to sleep with a bottle
• Limits serving of meals and snacks to scheduled times
• Educates parents about cleaning teeth and oral hygiene at home
• Provides information on tooth decay to families at least annually

Also, under review is Standard 5: Fruit Juice (Limit serving fruit juice to no more than two times per week) and its components:

• Provides water throughout the day both inside and outside
• Offers water as the first choice for thirst
• Does not serve fruit juice more than twice per week for children 1 year and older
• Limits serving more than 4-6 ounces of fruit juice at one time
• Serves only 100% fruit juice with no added sugar
• Serves fruit juice only at meal or snack times
• Provides information about limiting fruit juice to families at least annually

Work groups will review existing standards and components, compare to best practices, and recommend changes for consideration.  The EAC and ADHS leadership anticipates a final report in December, 2022 with anticipated implementation in July. 

Additionally, through the work of the Nemours grant, Go NAPSACC is currently being implemented into the statewide early care and education system, with full implementation beginning in early 2022.  Of the seven modules addressed in Go NAPSACC, there is a module on Oral Health.  This online system includes self assessments, tips and materials and online training. More information on the Empower Program can be found in the Children’s Health sections of this application.

In addition, the Primary Care Office (PCO) within BWCH leads statewide efforts to improve access to care to all health services in Arizona’s rural and underserved communities. The PCO continues to lead the data evaluation and coordination of submitting for Health Professional Shortage (HPSA) or Medically Underserved Areas or Populations (MUA/P) to HRSA in order to inform where resources can be leveraged to create the greatest impact for improving access to health care. As of December 2021, Arizona had 661 HPSAs: 238 primary care, 211 dental, and 212 mental health. These include facility HPSAs for Federally Qualified Health Centers and Indian Health Service sites. Arizona needed 653 primary care physicians, 398 dentists, and 183 psychiatrists to eliminate these HPSA-designated areas, which is a higher need when compared to earlier in 2021. There were also 37 MUAs and 10 MUPs in the State. Residents residing in these underserved areas are less likely to receive preventative health services.

The work conducted through the PCO is primarily funded through the State Primary Care Office Grant (federal), State Loan Repayment Program funds (includes federal funding and state match), Arizona State General Funds, and private donations. Title V provides supplemental funding to support the development of infrastructure to support the workforce programs, access to care activities, and professional development of health professional staff throughout the state. 

The State Loan Repayment Program (SLRP) and the National Health Service Corps Loan Repayment Program (NHSC) help recruit and retain health care professionals into HPSAs by providing loan repayment incentives to providers in exchange for an initial two-year commitment to practice medicine in the HPSAs. In 2021,153 providers were obligated through SLRP and 503 through NHSC.

The PCO partnered with the Arizona Alliance for Community Health Centers, Arizona’s Primary Care Association (PCA), to implement activities that educate communities about programs and resources that can help recruit healthcare professionals in areas with significant challenges with recruitment. The aim of the partnership is also to support the development of health professionals from diverse backgrounds and expose them to service in rural and underserved communities.

In 2021, Title V funded activities that directly assisted in increasing recruitment of health professionals in Arizona was the support of clinical rotations for students and preceptors in Federally Qualified Health Centers (FQHC). Due to the workload of the current healthcare workforce, it is difficult to recruit providers to take on additional responsibilities of being a preceptor for medical and dental students. Through this activity the PCO, together with the PCA, supported preceptors by creating incentive opportunities, assisting with technology and licensing fees, materials, and other costs related to student clinical rotations. In 2021, this activity supported the clinical rotations of 70 students rotating in FQHCs.                                      

Another activity that was funded by Title V was the Street Medicine Phoenix (SMP) program. This is a student-driven, interprofessional healthcare team consisting of students and licensed health professions faculty from the University of Arizona College of Medicine – Phoenix. The SMP program supports interprofessional learning by collaborating with other health professions programs within Arizona State University, Midwestern University, and Northern Arizona University, along with community stakeholders. The mission of the SMP program is to ensure access to health care for Phoenix’s homeless populations. The project’s purpose is to develop and train the next generation of health care professionals and prepare them to be aware of and address the health inequities that exist in Arizona. During these services, the student shadows licensed providers and their care to homeless individuals. These students from the health professions and volunteers in SMP gain hands-on experience in caring for underserved and vulnerable populations. The project provides the exposure and service learning for students rotating in SMP as volunteers or in fulfillment of academic requirements for the UA Certificate of Underserved Program (CUP) Distinction. From July to September of 2021, there were approximately 900 total patient interactions and 180 student volunteers experienced hands-on training and exposure to service in underserved communities.

In 2021, Title V partnered to support and expand community-based service learning opportunities for health professions students focused on maternal and child health. This project was completed in partnership with the University of Arizona College of Medicine – Phoenix and the Halle Empowerment Affirmation Legacy (HEAL) at Banner – University Medical Center Phoenix. The funds were used to enhance the Street Medicine Phoenix Program and therefore focused on exposing students to pregnant or parenting women with a substance use disorder diagnosis and possibly, homeless or about to be homeless.

The services include building and maintaining physical, mental and relational health, through trauma-informed and integrative, interdisciplinary services, which include prenatal through postpartum care, child development, wellness and parenting support, and substance abuse recovery treatment. Pregnant women with a diagnosis of opioid use disorder (OUD) who are or need to be on medications for addiction treatment (MAT) are referred to and enrolled in the HEAL program for continuity and coordination of obstetrics and behavioral health care services. The core team included: student learners and staff consisting of clinical social workers and nurses. There was also a support team from Banner's Departments of Obstetrics and Gynecology, Family Medicine, Behavioral Health and Addiction Medicine and the University of Arizona College of Medicine – Phoenix that included developmental pediatricians, nurse practitioners, nutritionists and other health care specialists.

In 2021, the program provided services to 15 women enrolled in this project. For the future health care workforce, student learners developed interprofessional training to provide critical services, such as mental health promotion, access to healthy nutrition, education and support, and developed a resources database to help build a community medical home. They also gained experience in approaches to screening for social determinants of health and identifying and understanding adverse childhood experiences (ACEs) in a manner that can help prevent intergenerational trauma. They gained unique real-world experiences in positive psychology approaches to addiction care to promote recognition of inherent and learned resilience, values, virtues of patients and built capacity for cultural humility and bias mitigation that will benefit future care of diverse patient populations.

Early September 2021, we were able to host the Arizona Health Professions and Workforce Summit that convened partners from academic programs, clinical placement sites, and community health center human resources and executive leadership to discuss and strategize on ways to support and expand clinical rotation and health professions education in Arizona.  The meeting included facilitated group discussions on current gaps and opportunities related to workforce and workforce development, strategies, and strategic planning on how we might address healthcare workforce shortages by supporting the expansion of health professions education.

In an effort to support professional development and the diverse workforce, Title V funding supported Community Health Workers (CHWs) in attending a translating course. CHWs are often the frontline staff that coordinate care and provide translation between Spanish-speaking patients and English-speaking healthcare professionals. The funding supported CHWs in accessing and receiving professional credits to attend a 40-hour online course to provide formal professional training for Spanish to English translation. The course training modules included: Medical Interpreter Ethics and Protocol, Consecutive Interpreting and Sight Translation, Medical Terminology, Anatomy and Physiology, Patient Medical History, Major Disease: Depression, Major Disease: Diabetes and Infectious Diseases, and Cultural Intelligence and Mediation. In 2021, 13 Community Health Workers completed the courses and now have a Certificate from the University of Arizona for Medical Spanish Interpretation. Not only does this increase their skills for future employment, but it ensures that patients who are Spanish speaking or have limited English proficiency can receive quality care and translation. These Community Health Workers will also be volunteering as Medical Interpreters and will help train medical students participating in Spanish language courses.

In order to further support the growth of Arizona’s health professions, ADHS, through the PCO/PCA partnerships, conducted a Teaching Health Center Feasibility Study. During this study, 12 FQHCs participated, where each center's readiness to become a Teaching Health Center was assessed through key informant interviews.  The study concluded that while 100% of participants were interested in becoming a Teaching Health Center, many of them were concerned about the costs of administering a residency program and sustainability of the program beyond initial funding. For smaller FQHCs, the absence of infrastructure, capacity and patient volume to qualify for residency accreditation was a major concern. All FQHCs expressed interest in follow up conversations and support in establishing a Teaching Health Center.  We found that many of the FQHCs, especially the smaller and rural centers, could benefit from participating in a State-based Consortium Residency Program. This study will guide the development of future programs to support building Teaching Health Centers in underserved communities.

The PCO partnered with the Arizona Alliance for Community Health Centers on the health professional and student engagement activities above to aim to build partnerships with academic training programs, employers, local and state partners, tribal entities, and providers to collectively address workforce shortages in Arizona.  Examples of activities implemented this year include: education and technical assistance to students and residents attending medical, dental, or behavioral health training; local and national presentations; partnering with the PCA to help students receive rotation placements in community health centers; assisting providers with finding job placements; and working on improving the coordination efforts between the PCO, PCA, and the State Office of Rural Health to recruit providers in underserved rural areas of the state.

In terms of expanding access to care via telemedicine, the PCO launched the Rural Prenatal Telemedicine Program (RPTP) in State Fiscal Year (FY) 2020 (July 2019 – June 2020) through a Request for Proposal (RFP) process. The RPTP aims to improve the health outcomes of women in rural areas before, during, and after pregnancy by improving access to prenatal care services through telemedicine. Through legislation, the RPTP is required to contract with rural hospitals in federally designated HPSAs to create or expand telemedicine infrastructure for the provision of prenatal care. The RFP was released three times to solicit contractors to operate the RPTP.  Unfortunately, no qualifying organization responded to the RFP and no awards were made.

The PCO received a one-time state funding for State FY 2020 in the amount of $700,000 to implement the Community-Based Primary Care Program which concluded in June 2021.  This funding is intended to support the provision of primary health care services in geographically isolated areas of the State.  Required services include primary and preventative medical, dental, behavioral health, pharmacy, labs, referral, transportation, 24-hour triage, and other medically necessary services provided on-site or through a referral process to an outside entity.  Through an RFP process, the PCO awarded the funds to a new HRSA-designated federally qualified health center, Creek Valley Clinic, serving Colorado City, a geographically isolated area in Mohave County, Arizona. Colorado City is on the border of Utah and Arizona and residents in this community frequently travel into Utah to access needed health care. The community experienced historical trauma related to family separation, restricted child play and toys for appropriate social development, child labor, child abuse as well as issues of malnutrition, lack of primary education, and low literacy levels.  Other cultural barriers include fear of asking for assistance from people outside the community and an aversion to evidence-based public health practices, such as immunizations and fluoride treatment. Creek Valley Clinic was able to leverage these state funds to provide services while applying for and successfully obtaining HRSA federally qualified health center funding and status.

This section describes the cross-cutting ways in which Arizona’s Title V Program supported the state’s COVID-19 response in 2021.

On March 25, 2020, Governor Doug Ducey issued Executive Order 2020-15, Expansion of Telemedicine, to help ensure continuity of health services via telemedicine during the COVID-19 public health emergency. ADHS created a Telehealth Task Force to facilitate the expansion of telemedicine services by helping to identify barriers to adopting or fully implementing telemedicine (through stakeholders’ engagement and based on stakeholders’ feedback) and develop short-term and long-term solutions to address those barriers.  The Telehealth Task Force identified a number of clinician- and patient-related barriers, which include an overall lack or limited knowledge of telemedicine technology, limited understanding of telehealth requirements and regulations (i.e., reimbursements, coding, HIPAA regulations, etc.), lack of awareness of where telemedicine services could be accessed in Arizona, and broadband and connectivity issues. It was led by Ms. Patricia Tarango, BWCH Bureau Chief; Mr. Martín Celaya, BWCH Office Chief for Assessment and Evaluation; and Ms. Alison Lucas, Block Grants Program Manager.

In response to the needs identified by the Telehealth Task Force, in 2021, ADHS provided $150,000 in Title V funding to the University of Arizona’s Arizona Telemedicine Program (ATP) to provide training, technical assistance and resources related to telemedicine and telehealth to facilitate increased adoption and use of telemedicine services among providers, employers and patients in Arizona. With Title V funding, the ATP conducted a number of webinars on federal and state telehealth policies and legislation (including HB 2454, new legislation that expands telemedicine in Arizona); information on telehealth/telemedicine billing and medical coding; and monthly virtual office hours. In 2021, ATP hosted, promoted, and co-branded 11 webinars with ADHS that were advertised to over 8000 healthcare and public healthcare workers and had over 6000 registrants (in total). Under this contract, ATP also expanded their Telemedicine & Telehealth Service Provider Directory to include an opt-in Arizona directory of Direct-to-Consumer telemedicine and telehealth clinical service providers and built out the resources and information within their existing websites for the Arizona Telemedicine Program (telemedicine.arizona.edu) and the Southwest Telehealth Resource Center (southwesttrc.org).

Ms. Angie Lorenzo, Chief for the Office of Women’s Health, provided support in the Schools Reopening Task Force. She was brought in to assist with a Schools Support pilot project that was being implemented with 14 school districts across the state and included a myriad of options schools could select from to help support them during COVID. The main component offered was saliva-based testing and surveillance for school teachers and staff to help schools identify their infection rates within the school staffing community. Several lessons learned arose from the pilot project that helped inform the start of a pool testing in classrooms project. Aside from the projects, her role included participation in weekly check-in meetings with the Arizona Department of Education, the local county health departments, and the pool testing vendor to ensure all agencies were kept informed of the work being conducted with schools around COVID.

On July 1, 2020, ADHS entered into a new five-year intergovernmental agreement with local county health departments to leverage the partnerships between state and local health departments in Arizona by providing Title V funding to counties to promote and implement evidence-based or evidence-informed strategies that will improve the health and wellbeing of Title V populations in their communities. Through the MCH Healthy Arizona Families Intergovernmental Agreement (MCH HAF IGA), counties are encouraged to address needs identified through the 2020 Title V Needs Assessment and the Arizona State Health Assessment (SHA) (completed in 2019 and updated annually) and to align their efforts with the 2021-2025 MCH health priorities and Arizona Health Improvement Plan (AzHIP) strategies; however, they are provided with the flexibility to design their strategies and activities in a way that meets the needs of their local context. Fourteen (14) out of Arizona’s 15 counties have elected to participate in the MCH HAF IGA; only Santa Cruz County does not because its health department is too small to conduct prevention and health promotion work. Through this mechanism, $2,017,415.00 is invested each fiscal year to serve Title V populations across Arizona. In 2021, local county health departments directly served 31,876 clients (compared to 34,128 clients in 2020; 7% reduction) through their MCH Programs and 1,789 (compared to 2,084 in 2020; 14% reduction) through their Family Planning Programs (see the Women’s Health narrative for more information on the Title V Family Planning Program).

Local health departments (LHDs) develop Action Plans for each state fiscal year (July 1 to June 30). Between July 1, 2021, and December 31, 2021, LHDs worked on a diverse set of strategies and activities to serve MCH populations. Ten (10) counties used funds for family planning and reproductive health services, including cancer screenings (pap, mammograms) and STD/STI screening and treatment (see the Women’s Health 2021 Annual Report for more information on the Title V Family Planning Program). Two (2) counties promoted breastfeeding with their Title V funds, six (6) worked on safe sleep education and support (i.e., provision of pack n’ plays), six (6) worked on injury prevention strategies (including car seat distribution and training, teen safe driving initiatives, household safety, etc.), and six (6) worked on bullying prevention (often linked to work on Adverse Childhood Experiences [ACEs], resiliency, and trauma-informed approaches). Please see Appendix M for a full crosswalk of the county strategies across the 15 NPMs.

Unfortunately, the ongoing COVID-19 pandemic, and the response it required from local county health departments, slowed the progress of many of these identified strategies in 2021. In particular, county health departments found it difficult to get into schools during the 2021-2022 school year to conduct health programming, as schools were hesitant to have additional people on campus and were overwhelmed by other priorities. We observed that schools were more willing to let programs they considered flagship health programming, such as sexual health, back in before they were willing to move forward with smaller initiatives, like Battle of the Belt (teen safe driving).