The mission of the Arizona Department of Health Services (ADHS) is to promote, protect, and improve the health and wellness of individuals and communities in Arizona. To this end, ADHS’ Bureau of Women’s and Children’s Health (BWCH) is honored to implement the Title V Maternal and Child Health (MCH) Block Grant to promote and improve the health and well-being of the Arizona’s mothers, children, including children with special needs, and their families. In 2019, Arizona’s Title V Block Grant proudly served 192,720 individuals.
Overview of the State
Arizona has around 7.3 million residents and is one of the fastest growing and diverse states in the nation. Almost half of Arizona’s population belongs to a racial or ethnic minority group. In addition, Arizona is home to 22 federally recognized tribes and has the largest Native American population of any state.
Geographically, Arizona is the 6th largest state in the nation and shares a 389-mile border with Mexico. Arizona has a shortage of medical providers, and this shortage is particularly acute in sparsely populated, rural areas of the state. There are 587 federally designated Health Professional Shortage Areas (HPSAs); to eliminate these, we would need an additional 560 full-time primary care physicians, 380 dentists, and 181 psychiatrists statewide.
Impact of COVID-19
By August 2020, there had been over 200,000 cases and nearly 5,000 deaths due to COVID-19 in Arizona. That is a rate of 2,791 cases per 100,000 population—currently the third highest rate among all states. The COVID-19 pandemic in Arizona has laid bare long-standing inequities in health outcomes and provision. In particular, there has been a disparate impact of COVID-19 deaths on the Navajo Nation and other tribal lands. We have also seen a disparate burden of COVID-19 incidence and deaths among essential workers (e.g., health care workers, meat packers, prison guards, etc.) and the communities in which they live.
Figure 1 summarizes how Arizona compared to the national average on 46 indicators related to maternal and child health selected by HRSA. The graph shows how much Arizona varies from the national average for each indicator; red bars indicate where Arizona is performing worse than the national average (18 indicators), blue bars indicate where we are performing better than the national average (25 indicators), and grey bars indicate we are performing the same as the national average (3 indicators). A larger image of the Figure 1 can be found in Appendix A.
Figure 1. 2020 Title V MCH Needs Assessment – Arizona Maternal and Child Health Indicators
Structure of the Title V Program
Arizona’s Title V Program is implemented by the Arizona Department of Health Services (ADHS), one of the executive agencies that report to the Governor. Arizona Revised Statute (A.R.S. § 36-691) designated ADHS as Arizona's lead state agency for the administration of Title V. Ms. Patricia Tarango, Bureau Chief, Bureau of Women’s and Children’s Health (BWCH), currently serves as both the Title V MCH Block Grant Director and Title V Children with Special Health Care Needs (CSHCN) Director. Most of the programs funded through Title V are housed within BWCH. BWCH is organized into five (5) offices: Office of Children’s Health (includes Infant Health and Children and Youth with Special Health Care Needs), Women’s Health (includes Adolescent Health), Office of Oral Health, Primary Care Office (PCO), and the Office of Assessment and Evaluation. Where Title V-funded programs and activities occur outside the BWCH, there is a clear coordination of efforts between BWCH and the outside agencies. More information is included in III.E.2.a. State Title V Program Purpose and Design.
Role of the Title V Program
Through Title V funding, we lead, support, implement, and fund activities to reduce mortality and morbidity among women and children, eliminate health disparities in health outcomes and access to services, and increase access to health care. As demonstrated in the 2019 Annual Report, Arizona’s partnership with the Health Resources & Services Administration (HRSA)’s Maternal and Child Health Bureau through the Title V Block Grant has allowed us to leverage federal and non-federal resources to improve the health status of Arizona’s mothers, infants, children and adolescents, including children and youth with special health care needs (CYSHCN) and their families, and we look forward to sustaining these efforts through the strategies and activities proposed in this application. These activities underscore the importance of our numerous public and private partners in fully executing the mandate of Title V. While it is impossible to describe all we do through Title V in this short Executive Summary, we will summarize some of the key activities and strategies below. III.C.2.b.ii.a. Organizational Structure describes all Title V-funded programs implemented through BWCH.
We provide leadership to and participate in a number of workgroups that bring together key stakeholders around specific topics of importance to our Title V populations. These groups, which include the Adolescent Well Visits Stakeholder Workgroup, the Safe Sleep Task Force, the People of Color Infant Mortality Workgroup, Arizona Prevention Leadership Cohort (domestic violence), the Preconception Health Alliance, Collective Impact for Child Safety and Well Being workgroup, and the Telehealth Task Force, serve to identify needs and challenges and set agendas to address these.
An important role of the Title V program is to increase education and awareness of issues that affect our populations. For example, BWCH has developed media assets to encourage and teach parents, teachers, and youth how to intervene when they witness acts of bullying and plans to promote the importance of childhood immunizations using messages and graphics from the “Catch-up to Get Ahead” Toolkit. We support the Arizona Partnership for Immunization (TAPI), which has 400 members from 200 organizations, to distribute educational materials to schools, child care facilities, health care providers, county health departments, and WIC sites.
We also provide workforce and professional development training programs to strengthen the skills and knowledge of Arizona’s medical and public health providers. For example, the Office of Oral Health (OOH) provides professional development opportunities for dental providers and program administrators on dental health issues, in partnership with the Arizona Alliance for Community Health Centers, the Inter Tribal Council of Arizona, and the Greater Valley Area Health Education Center, and the Child Fatality Review partnered with the Maricopa Medical Examiner’s Office to provide training on Sudden Unexpected Infant Death to law enforcement and first responders around the state.
Through Title V funding, we also implement direct services, such as hearing and vision screening, oral health screening and care, the Children’s Information Helpline, and home visiting programs, and we fund public and private organizations to implement Title V programming. Most notably, we provide around two million dollars in funding to county health departments to implement programs that address our state priority needs and selected National Performance Measures (NPMs). We also provide both monetary and non-monetary support, such as technical assistance and coordination, to a number of non-governmental and community-based organizations, academic institutions, professional associations, hospitals, clinics, and other private entities that are furthering the aims of the Title V Program.
We also collaborate with other State agencies, local governmental organizations, and private entities to promote and implement activities that address our priority needs. For example, within ADHS, we collaborate with the Bureau of Nutrition and Physical Activity (BNPA) to implement the Empower Program (which promotes health and wellness in state-licensed childcare facilities), promote breastfeeding, and maintain the Title V Toll-free Helplines; with the Bureau of Chronic Disease and Health Promotion on childhood injury prevention programs, like car seats, safe sleep, and tobacco cessation; with the State Laboratory Services on newborn screening; and with Public Health Statistics on the Arizona Birth Defects Monitoring Program. We also collaborate with other state agencies involved in child welfare, such as the Department of Education and the Department of Child Safety (DCS).
Another key role Arizona’s Title V Program plays is to provide referrals, linkages, and access to care. A principal means of doing this is through the various home visiting programs we implement and support (e.g., MIECHV, HRPP, Health Start). In addition, we participate in the state-wide, inter-agency Comprehensive System to Meet the Developmental Needs of Arizona's Children Initiative to ensure that each child’s needs are identified, referrals are made and completed, services are not duplicated, and the messages that families hear are clear, aligned, and consistently reinforced. BWCH is also an active and involved member of the Arizona Transition Leadership Team (ATLT) for the Arizona Community of Practice on Transition, which supports collaboration among twenty-five (25) community and state agencies or organizations, including ADHS, the Arizona Department of Education (ADE), Rehabilitation Services Administration, Division of Developmental Disabilities, AHCCCS, Raising Special Kids, and Tribal Vocational Rehabilitation Services. The CYSHCN team is also, as part of the Mountain States Regional Genetics Network, working with partners in Newborn Screening, Arizona Early Intervention Program (AzEIP), Arizona American Academy of Pediatrics (AzAAP) and Phoenix Children’s Hospital to increase use by pediatricians of the Developmental Delay Algorithm for genetic referrals.
Another key activity of the Title V program is the collection, analysis, and dissemination of MCH data. The data helps us identify areas of need and emerging issues, assess program effectiveness, measure improvement, and channel federal and state funding where it can be most impactful. An area of particular importance within data collection and analysis is the identification and designation of Health Professional Shortage Areas (HPSAs) and Medically Underserved Areas/Populations (MUA/Ps). Title V programs work with the PCO to complete the statewide assessment of areas for HPSA designation.
Family engagement and health equity are two guiding principles that are interwoven through all the work we do. In fact, we believe that family engagement is one of the best tools we have to identify and understand health inequities, and to help us address those inequities.
Title V Population Needs and Priorities
We employed seven data collection approaches during the 2020 Needs Assessment to better understand the primary and preventative health service needs of Arizona’s Title V populations (Figure 2). In addition to collecting and analyzing quantitative MCH data from national and state data sources, Arizona’s 2020 Title V Needs Assessment was designed to engage families and the public through a public survey, focus groups, and community forums to capture qualitative and quantitative data that draws on the experience and knowledge of the communities we serve.
Surveillance data allowed us to identify both desirable and undesirable trends in key health indicators using readily available data from state and national datasets. The public survey, available in English and Spanish, solicited information from 1078 participants statewide on specific programmatic needs and included an assessment of 20 social determinants of health. The focus groups identified 13 hard-to-reach communities to hear their perspectives on health issues, services, and sources of information in their communities. In total, we held 23 focus groups: 15 with adults, 8 with youth. Community forums collected information on service needs at the local regional level and solicited feedback on how difficult participants felt it would be to address those needs. A total of 7 community forums were held in rural and urban counties, including one was in Spanish (open to Spanish-speaking community members across the state), in which 135 community members participated.
We also engaged Arizona’s 22 federally recognized tribes to assess the MCH needs of Native American/indigenous communities through a contract with Diné College to conduct a Needs Assessment for the Navajo Nation and the Inter Tribal Council of Arizona (ITCA) to conduct the Needs Assessment for the other 21 tribes. These assessments leverage BWCH’s ongoing relationship with Arizona’s tribal partners to identify and support efforts to address their unique MCH needs.
To guide the Needs Assessment process and set priorities, we established a Steering Committee, with 68 members from 27 organizations. They provided feedback on data collection approaches and tools, recommended groups of interest and local individuals for community forums, leveraged existing partnerships for participation in assessment activities, promoted assessment methodologies, participated in the prioritization process, and guided the selection of our priorities and NPMs.
Figure 2. Data Collection Approaches in Arizona’s 2020 Title V Needs Assessment
Based on findings from the 2020 Needs Assessment, and in coordination with the Steering Committee, we developed the priorities listed in Figure 3. In many ways, these priorities are a continuation of interventions and strategies that have been at the focus of our work for some time, yet we wanted to put a renewed and explicit emphasis on healthy equity and quality of service provision; for this reason, we included “equitable and optimal” in many of the priorities. Family engagement is also at the core of the new priorities as a mechanism through which health equity can be achieved. In coordination with Title V program managers, the Steering Committee, and local County Health Departments, we selected NPMs and State Performance Measures (SPMs) to measure and track progress on our priority needs (Figure 3).
Figure 3. 2021-2025 Statewide Maternal and Child Health Priorities and National Performance Measures (NPMs)
Our SPM measures access to a healthcare provider—percent of adults that have a personal doctor or healthcare provider—and will be drawn from Behavioral Risk Factor Surveillance System data.
More information on the Needs Assessment can be found in III.C. Five-Year Needs Assessment Summary. A state action plan, with strategies for the 2021-2025 cycle of the Title V Block Grant and associated Evidence-based or -informed Strategy Measures (ESMs), can be found in III.E.1. Five-Year State Action Plan Table and III.E.2. State Action Plan Narrative Overview.
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