Oregon’s Title V framework and leadership role

Oregon’s Title V program relies on shared leadership between the Oregon Health Authority (OHA) Public Health Division’s Maternal and Child Section (MCH), it’s Adolescent and School Health program (ASHP), and the Oregon Center for Children and Youth with Special Health Needs (OCCYSHN) at Oregon Health and Science University. A leadership team makes Title V program and policy decisions and ensures alignment across the programs and agencies. Each Title V priority has a designated state lead who oversees state level program and policy work and provides technical assistance and oversight to the local level Title V grantees (public health and tribal). Title V also has a designated Tribal liaison who supports/oversees the work of the tribal Title V grantees. The state priority leads, Title V Coordinator, Title V MCAH and CYSHCN research analysts and Title V tribal liaison coordinate work across populations/domains.

The five-year needs assessment structure and activities are developed and coordinated by a steering committee with representatives from OHA MCH, Adolescent Health, and OCCYSHN, with input from Title V grantees and other stakeholders. Findings from the needs assessment are presented to a stakeholder group which uses them to recommend state and national Title V priorities, which are finalized by the Title V MCAH and CYSHCN Directors with Title V staff input. Ongoing needs assessment and surveillance activities are conducted in the interim years to support development of evidence based/informed activities, monitor progress, and identify emerging issues.

Title V strategies, activities and measures are developed by Oregon’s Title V staff subject matter experts, in consultation with researchers, MCHB, and state and local partners. Thirty percent of Title V funding to implement and monitor performance related to the developed plans is allocated to OCCYSHN to address the Title V CYSHN priorities at both the state and local levels. The remaining funds are administered through the OHA PHD to implement and monitor state and local level Title V work in the maternal/women, perinatal/infant, child, adolescent, and cross-cutting domains.

MCAH Population Needs, Title V priorities, strategies, and plans

The findings of Oregon’s 2015 Maternal Child and Adolescent Health (MCAH) Title V Needs Assessment identified 8 national priorities and 3 state-specific priorities for 2016-2020. They are: well woman care, breastfeeding, child physical activity, adolescent well care, medical home, and transition to adult health care for children and youth with special health care needs, oral health, smoking, toxic stress/trauma/ACEs, food insecurity, and culturally and linguistically responsive MCAH services (CLAS). An overview of Oregon’s priority MCAH Title V needs, strategies, progress and plans for each domain is outlined below (see map of priority work, Supporting Document 4).

Maternal/Women’s Health

Oregon’s Title V program provides leadership for policy and system development efforts related to maternal/women’s health including: ensuring that health system transformation addresses the need for comprehensive, culturally responsive maternal health services.

Needs/priorities

Based on the 2015 MCAH needs assessment, high quality, culturally responsive preconception, prenatal and inter-conception services are a priority need for this population. This need is being addressed through work on NPM 1 well-woman care (WWC). Improved oral health and reduced tobacco exposure for pregnant women were identified and are being addressed through work on NPM 13 oral health, and NPM 14.

Strategies

Well woman care strategies being implemented at the state level and by 8 grantees include:  case-management and use of the postpartum health care visit to improve utilization of well-woman care; marketing to educate the population and promote well-woman care; training of health care providers, support for access through Family Planning Clinics.

Perinatal/Infant Health

Oregon Title V provides leadership and technical assistance for linkages to prenatal care, oral health, maternal mental health, and other perinatal services; infant mortality reduction; PRAMS and PRAMS2 surveillance systems; early hearing detection and intervention (EHDI); breastfeeding support; and integration of perinatal/infant health into programs and policies across state and local agencies.

Needs /priorities

Based on the 2015 needs assessment, improved nutrition is a priority need for this population which will be addressed through work on NPM 4 breastfeeding, as well as through Oregon’s food insecurity work.

Strategies

Breastfeeding strategies being implemented at the state level and by 17 grantees include:  education of non‐nursing partners and family members about the importance of breastfeeding; filling unmet needs for peer support of breastfeeding; education of pregnant women about breastfeeding; workforce support for breastfeeding; access to workplace breastfeeding support; and support for breastfeeding at child care settings.

Child Health

Title V’s work in child health focuses on increasing community and caregiver capacity to promote the foundations of health: stable responsive relationships, safe supportive environments, and nutrition and healthy behaviors. A major focus is integration of child health into programs and policies across state and local agencies, including the early learning and education systems.

Needs/priorities

Based on the 2015 needs assessment, enhancing physical activity is a priority need for this population, which will be addressed through work on NPM 8 physical activity, as well as through Oregon’s cross-cutting/systems work. Improved oral health for children; and reduced tobacco exposure for pregnant women and children were also identified and are being addressed through work on NPM 13 oral health, and NPM 14.

Strategies

Physical activity strategies being implemented at the state level and by 4 grantees include: physical activity in child care settings; physical activity before, during and after school; improving the physical environment for physical activity; expanding safe and active transportation options; policies and programs for healthy worksites; and partnerships with clinical care providers to support anticipatory guidance for physical activity.

Adolescent Health

Title V strengthens policies and systems that support adolescent health in school-based health centers, schools, health systems, and communities. The program engages youth to develop policies and programs that reflect their needs through youth action research.

Needs/priorities

Based on the 2015 needs assessment, high quality, confidential preventive health services for adolescents is a priority need for this population. Title V will address this need through continued work on adolescent well-visit (NPM 10) and through Oregon’s cross-cutting/systems work.

Strategies

Adolescent well care strategies being implemented at the state level and by 7 grantees include: outreach to key populations; promoting the practice of going beyond sports physicals to wellness exams; partnerships with public and private entities invested in adolescent health; policies and practices to make health care more youth-friendly; investigating barriers to adolescent well visits; and strengthening health care privacy and confidentiality policies and practices.

Children and Youth with Special Health Needs (CYSHCN)

Title V CYSHCN program provides leadership and support for the development of comprehensive, coordinated, and integrated systems of care that are culturally responsive for CYSHCN and their families. It leads efforts that support access to care for CYSHCN, and partners with families and communities in policy and program development.

Needs/priorities

Medical home (MH) and youth health care transition (HCT) are Oregon’s current state Title V CYSHCN priorities. Additionally, culturally and linguistically responsive services are a state CYSHCN priority. Findings from the needs assessment showed that high quality, family-centered coordinated systems of care are required to meet CYSHCN’s complex needs. The National Standards for Systems of Care for CYSHCN include MH and HCT as 2 of its 10 domains of standards. The priorities will be addressed through work on NPM 11 and 12.

Strategies

Medical Home (MH) strategies focus on increasing cross-systems care coordination (CSCC) for CYSHCN and their families through public health nurse home visiting; supporting local public health in convening cross-sector child health teams to develop family-centered shared care planning; promoting family health literacy and family engagement in healthcare settings; promoting regional and state level infrastructure development to support CSCC; and building an evidence base to describe the effectiveness of these strategies.

Health Care Transition (HCT) strategies are integrated with those of MH given the interrelationship of these 2 priorities. Led by local public health entities, child health teams identify youth with special health care needs and build capacity to provide Shared Plan of Care services. Professional development for both pediatric and adult providers increases the capacity for provide necessary HCT services. Families receive HCT education, and we are exploring alternative payment models to support facilitated transition of care between pediatric and adult providers.

Life course and Cross-cutting/systems

Oregon’s Title V program uses a life course focus and equity lens to maximize investment in policies, systems and programs that support lifelong health. Cross-cutting/systems work includes work on upstream state-specific priorities and investment in foundational capabilities such as epidemiology, communications, and leadership. Life course priorities of oral health and smoking priorities are also reported here.

Needs/priorities

Based on the 2015 needs assessment, improved oral health for pregnant women and children; reduced tobacco use/exposure among pregnant women and children; nutrition; safe and nurturing relationships/stable, attached families; and improved health equity are all high priority cross-cutting needs for Oregon’s MCAH population. These are addressed through work on NPM 13 oral health, NPM 14 smoking, as well as Oregon’s state-specific priorities/performance measures of toxic stress/ACEs/resilience, food insecurity, and culturally and linguistically responsive services (CLAS).

Strategies

Oral health strategies being implemented at the state level and by 18 grantees include: oral health preventive services through Oregon's Home Visiting System and during well-child visits; collaboration with primary care providers on oral health guidelines for pregnant women; oral health preventive services for adolescents through schools; education about oral health & the importance of dental visits; and promotion of community water fluoridation.

Smoking strategies being implemented at the state level and by 5 grantees include: policy agenda to decreases youth exposure; 5As Intervention and Quit Line Referral within MCH Programs; collaboration with health systems and providers on screening and intervention processes and workforce training; promotion of health insurance coverage benefits for pregnant and postpartum women.

Toxic stress, ACEs and resilience strategies being implemented at the state level and by 7 grantees include: family friendly policies that decrease stress and adversity; outreach and education to increase understanding of NEAR science (neurobiology, epigenetics, ACEs and resilience) and the impact of childhood adversity;  engaging partners to build capacity for safe, connected, equitable and resilient communities; assessment, surveillance, and epidemiological research; development of trauma-informed workforce, workplaces, systems, and services;  support for programs that build protective factors.

Culturally and linguistically responsive services strategies being implemented at the state level and by 5 grantees include: effective, equitable, understandable, and culturally responsive services; organizational policy, practices, and leadership to promote CLAS and health equity; assessments of organization’s CLAS-related activities and integration of CLAS-related measures into continuous quality improvement.

Food insecurity strategies being implemented at the state level and by 7 grantees include: screen clients for food insecurity & provide referrals for food assistance; food security education; access to healthy, affordable food; economic stability for individuals and families

Progress on State and National Performance measures 

Title V MCAH and OCCYSHN staff monitor progress on state and national performance measures (SPMs and NPMs). Oregon’s NPMs have shown mixed results during the past year. The NPMs that have improved moderately include NPM 8: Child physical activity, NPM 10: Adolescent well visit, NPM 13 B: Dental care among children, and NPM 14 A: Smoking during pregnancy. The NPMs that have worsened slightly are NPM 1: Well woman care, NPM 4 A & B: Breastfeeding initiation and exclusivity at 6 months, and NPM 13 A: Dental visit during pregnancy. Although the rates of breastfeeding and dental visits during pregnancy have both worsened slightly, Oregon consistently performs better in these areas than the national average. Both the increases and decreases in NPMs are small should be interpreted with caution. 

According to the 2016-17 National Survey of Children’s Health (NSCH), 39% of CYSHCN have a medical home (NPM 11) and 17% of YSHCN received services necessary to make transitions to adult health care (NPM 12). These data are not comparable to previous NSCH/NS-CSHCN estimates because of significant sampling and administration changes, but will be comparable to future data. 

All SPMs either show improvement since last year’s report or have remained stable. For SPM 2 B: Food insecurity among households with children, no new data is available to compare to data included in the previous report.”

Title V partnerships and stakeholder engagement

Stakeholder engagement and partnerships are central to all phases of Oregon’s Title V work. The Title V Director, CYSHCN Director, Adolescent Health Director, and Title V staff all work with external and internal stakeholders to provide MCAH leadership and ensure that Title V work is represented and integrated within and across agencies. These partnerships – including with the Governor’s Children’s Cabinet, Coordinated Care Organizations, the Early Learning Division, Local Health Authorities, and Tribes - provide critical opportunities to leverage Title V’s work and develop collaborations which benefit the MCAH population and maximize use of funds.  This work - especially with families and communities - also informs ongoing needs assessment, strategy implementation, evaluation, and modification of strategies/activities throughout the 5-year cycle.