New Jersey (NJ) is one of the nation's most urbanized, densely populated, racially and ethnically diverse states. The New Jersey Department of Health (NJDOH) must develop and implement culturally responsive public health interventions to optimize health for the 9 million NJ residents, including the yearly 100,000 newborns the State welcomes. NJ's diversity highlights the importance of addressing disparities in health outcomes and the need to ensure a culturally competent workforce and service delivery system.

The Division of Family Health Services (FHS) within NJDOH works to promote and protect the health of mothers, children, adolescents, and at-risk populations and to reduce disparities in health outcomes by ensuring access to quality comprehensive care. The Maternal and Child Health Block Grant (MCHBG) Application and Annual Report that FHS submits annually to the Maternal Child Health Bureau (MCHB) provides an overview of initiatives, state-supported programs, and other state-based responses. These initiatives and programs are strategically designed to address NJ's maternal and child health (MCH) needs. The needs assessment that we regularly conduct in concert with the NJDOH's strategic plan, the State's Health Improvement Plan, Healthy NJ 2030, and the collaborative process with other MCH partners inform all the activities we implement.

To ensure access to enabling services and population-based preventive services, consistent with the findings of the Five-Year Needs Assessment, the goals and State Priority Needs (SPNs) selected by FHS are built upon the work of prior MCH Block Grant Applications/Annual Reports and in alignment with NJDOH's and FHS' goals and objectives. The State Priority Needs (SPNs) are:

SPN 1-Increasing Equity in Healthy Births,

SPN 2-Reducing Black Maternal and Infant Mortality,

SPN 3-Improving Nutrition & Physical Activity,

SPN 4-Promoting Youth Development Programs,

SPN 5-Improving Access to Quality Care for CYSHCN,

SPN 6-Reducing Teen Pregnancy,

SPN 7-Improving & Integrating Information Systems, and

SPN8- Smoking Prevention.

NJ has selected the following nine of 15 possible National Performance Measures (NPMs) for programmatic emphasis over the next five-year reporting period:

NPM 1-Well Woman Care,

NPM 4-Breastfeeding,

NPM 5-Safe Sleep,

NPM 6-Developmental Screening,

NPM 9-Bullying,

NPM 11-Medical Home,

NPM 12-Transitioning to Adulthood,

NPM 13-Oral Health, and

NPM 14- Household Smoking.

This past year, Title V staff (TVS) has collaborated with sister agencies, insurance companies, and community-based organizations to implement culturally responsive public health interventions to reduce disparities in health outcomes in NJ. These interventions are presented and discussed below.

Maternal/Women's/Reproductive Health & Perinatal/Infant's Health

According to America's Health Rankings, NJ's disparities in maternal health outcomes are known to be among the highest in the US. In 2018, in response to NJ's maternal and infant health crisis, the NJ Title V Program (TVP) funded diverse community-based organizations to support the Healthy Women, Healthy Families initiative (HWHF). Through the HWHF initiative, the NJ TVP has taken a targeted approach to reduce Black infant mortality (BIM) rates. As a result, partners from the Departments of Labor and Workforce Development, Education, Transportation, Children and Families, Human Services, and Community Affairs, as well as community partners, regularly collaborate with NJDOH to address the high BIM rates. One of the most salient aspects of the HWHF initiative is the implementation of specific BIM reduction activities. To better address potential adverse health outcomes post-delivery, the American College of Obstetricians and Gynecologists (ACOG) recently updated the postpartum guideline; instead of a routine checkup that is done 4 to 6 weeks after giving birth, they recommend that the postpartum visit should be ongoing. Considering this novel change to holistically serve the MCH population, in FY24, TVP has drafted an HWHF 2.0 request for proposal that emphasizes the 4th trimester (i.e., postpartum). HWHF 2.0 will focus on implementing breastfeeding support and postpartum doula services.

To date, approximately 250 individuals have been trained to become community doulas, and as of March 2023, 653 births have been attended by doulas. To ensure the sustainability of community doula services, NJ TVP partnered with the NJ Department of Human Services (DHS) to offer doula services to women through Medicaid Benefits. NJ Medicaid benefits have been expanded to cover doula services. Presently, NJ birthing people whom Medicaid covers can receive services from a Medicaid-enrolled community doula.

NJ TVP has also established and expanded a Community Health Worker (CHW) workforce. Through a partnership with the Colette Lamothe-Galette Community Health Worker Institute (CLG-CHWI), multiple state colleges deliver courses and training that equip Community Health Workers (CHWs) with skills to provide equitable care to their clients. Concurrently, TVP is working with key officials to expand Medicaid benefits to cover CHWs' services. Thus far, the CLG-CHWI has successfully trained and integrated over 300 CHWs into NJ health systems. Of those, four have attended the new American Sign Language (ASL) class initiated in 2023. About 32% of our trainees identified as bilingual. They are also trained to respond to diverse public health challenges, including COVID-19 response, mental health, and others. Upon course completion, CHWs receive nine college credits toward an associate degree.

In 2023, the Reproductive and Perinatal Services (RPHS) Team within NJ TVP announced a competitive request for proposals (RFP) to establish the NJ Community Health Worker Hub (CHW Hub). Although NJ TVP will not use MCHBG funding to fund the CHW Hub, TVP staff were involved in designing the RFP and will play an instrumental role in implementing the hub. Once established, the CHW Hub will ensure NJ has a strong CHW workforce by working with organizations across the State to manage training, deploying, and engaging CHWs. The CHW Hub will also actively support and advocate for the integration of CHWs into standard healthcare practice.

Moreover, the TVP will strengthen existing partnerships with state colleges and enhance the current curriculum for CHWs to include additional emerging public health issues (e.g., Long-COVID). NJ TVP will continue working with key officials to explore expanding Medicaid benefits to cover CHWs’ services through the 1115 Waiver. In FY2022, NJ TVP, in collaboration with the Division of Mental Health and Addiction Services (DMHAS), launched a pilot program to facilitate reimbursement for services provided to clients covered by Medicaid. Simultaneously, TVS will solidify a novel partnership with Horizon's Neighbors in Health to give trained CHWs access to numerous employers throughout the State across large health systems.

The NJ Maternal, Infant, and Early Childhood Home Visiting (MIECHV) continues to provide parents with community-based education and in-home support, including evidence-based safe sleep strategies. Additionally, the NJ MIECHV continues to utilize the Connecting NJ (CNJ) referral system to connect New Jerseyans to programs such as HWHF, MIECHV, community resources, medical care, doula programs, social support agencies, and more. Through CNJ, families are connected to care and personalized support.

NJ TVP Epidemiology Team conducted a formative evaluation of the HWHF initiative. The Team synthesized the results into a set of recommendations. These recommendations informed the development of new objectives and the decision to expand evidence-based activities (e.g., lactation education and postpartum doula care) across the State. Moreover, NJ TVP Epidemiology Team conducted a formative evaluation of Fetal Alcohol Syndrome Prevention (FASD) and Postpartum Depression and Mood Disorders (PPD-MD) initiatives. The Team evaluation project informed necessary culturally sensitive programmatic changes and the development of new objectives that seek to improve health outcomes related to FAS and PPD-MD.

Shortages in mental health and addiction specialists are evident for the general population, especially MCH populations with limited resources. In FY23, TVP announced a competitive RFP to pilot an Alma Program Expansion Project, which aims to support pregnant persons who may be experiencing mental health issues and/or substance misuse. Alma is an evidence-based peer specialist program developed by the University of Colorado and expanded in NJ to include substance misuse. It supports new and expectant parents experiencing depression, anxiety, and stress. Developed by a collaborative team of researchers, mental health providers, community members, and parents, Alma gives parents the support and skills they need to navigate this important chapter in their lives.

Racial and ethnic disparities persist in preterm birth rates, necessitating the need to address these disparities and reduce preterm birth rates. TVP has partnered with the Maternal Health Innovation (MHI) Team to implement the Preterm Birth Prevention Program. In FY23, the team undertook multiple activities. One of the key activities is the creation of statewide clinical service best practices standards (one for 17P, one for cerclage, and one for vaginal progesterone cream). While piloting these resources, the team was able to expand the distribution of services to home-visiting residents, Federally Qualified Health Centers (FQHCs), patients in identified healthcare systems, and select providers.

Child Health

One in six children aged 3–17 has a developmental disability. Unfortunately, children with developmental delays are usually not identified until after entering school. Access to adequate coordinated service is paramount. Through the NJ Early Childhood Comprehensive System (ECCS) Health Integration: Prenatal to Three (ECCS P-3) Initiative, the NJ Department of Children and Families (DCF), in partnership with NJ TVP, was able to maintain integrated developmental health promotion and screening as a service of the statewide Connecting NJ system effective in FY19. Through FY20 – FY22, CNJ’s central hubs maintained their outreach through the pandemic and post-pandemic, which enabled thousands of children to receive parent-led developmental screenings. In FY23, we anticipate a sustained reach with a slight increase, with the ability to continue outreach to families in the community during outside community events with the lifting of COVID mandates. DCF, in partnership with TVP, plans to strengthen relationships with pediatric providers in utilizing and referring families to the CNJ system, which can link families to services and programs that support the overall child and family well-being.

Adolescent Health

Adolescents and young adults (AYA) in NJ have continued to experience disruptions to learning and other mental and physical health issues due to COVID-19. AYAs experience school absences due to COVID-19 and increased mental health challenges and bullying rates, which have hit an all-time high with the return to in-person learning. Schools are still experiencing a spike in physical fights with a virtual twist as student witnesses share videos online which exacerbates the impact of the incidents. Currently, one in five students are victims of bullying, with higher rates for adolescents with disabilities and those who identify as lesbian, gay, bisexual, transgender, non-binary, Black, Indigenous, and People of Color (BIPOC). This information, in addition to the Youth Risk Behavioral Surveillance (YRBS), which provides additional insight into youth sexual behavior fueling the rise of STI, has provided significant insight into the needs of adolescents in NJ.

The CAHP plan for the upcoming year strongly focuses on bullying prevention, mental health/suicide prevention, sexual health, and school health. The MCHBG specifically supports adolescent mental health, suicide prevention, and school health, implementing evidence-based models that help reduce bullying and stigma and improve school climate. All CAH programs work together to support adolescents and their health needs holistically. Mental health and suicide prevention activities include training on screening and assessment using the Ask Suicide-Screening Questions (ASQ), Columbia Suicide Severity Rating Scale (CSSRS), SafeSide™ Training for primary care settings, Safety Planning, Adolescent Care and Treatment of Suicide (ACTS Training), and interventions for suicidal teens (Collaborative Assessment Management of Suicide and Attachment-Based Family Therapy). The Garrett Lee Smith Suicide Prevention Project (GLS) and MCHBG support a new learning and resource portal for professionals, parents, caregivers, and a youth named Prevent Suicide NJ (PSNJ) https://preventsuicidenj.org/. PSNJ launched in September of 2022 after the national launch of hotline #988, which will replace the National Suicide Prevention Lifeline number. Since the launch, PSNJ has had over 10,000 hits to the website and has a mailing list of 1,600 people who receive regular updates on trainings, resources, and community events. In addition, NJDOH is implementing Lifelines Trilogy, an evidence-based competent community suicide prevention model for school districts. Other initiatives contributing toward positive outcomes in addressing the State's priority areas of reducing teen pregnancy, promoting youth development, and improving physical activity and nutrition are the Whole School, Whole Community, Whole Child School Health NJ Project, the NJ Personal Responsibility Education Program (PREP), and the NJ Sexual Risk Avoidance Education (SRAE) Program. All CAH programs support evidence-based models rooted in Social and Emotional Learning (SEL) and Positive Youth Development (PYD), proven frameworks to reduce bullying by increasing empathy and self-awareness. In addition to Lifelines Trilogy, these programs include the Teen Outreach Program (TOP®), Love Notes, and Teen PEP.

Professional development for the year will include Mental Health First Aid Training, Mentor/ Advisor Training, Mindfulness/Mental Health for Youth-Serving Professionals, Practical Applications of the Attuned School Approach™ and a week-long Sexual Health Educator Training conducted by ANSWER. Other professional development will be added as needed.

Children and Youth with Special Health Care Needs (CYSHCN)

In NJ, families of CYSHCN have access to a myriad of services to ensure that children in need of specific services get access to necessary services to help them thrive. These services are provided through the following interventions:

1. Newborn Screening and Genetic Services (NSGS) ensure that all newborns and families affected by an out-of-range screening result receive timely and appropriate follow-up services. NJ remains among the leading states offering the most screenings, with 60 disorders on the current screening panel. NJ’s newborns are also screened with pulse oximetry through the Critical Congenital Heart Defects (CCHD) screening program.
2. Birth Defects and Autism Registry (BDAR) ensures that all children 0 through five years old who have a congenital disability and all children 0 through 21 years old who have an Autism Spectrum Disorder (ASD) are registered. In 2020, staff took on the monitoring of COVID pregnancies and infant outcomes through a CDC- funded project to review maternal charts for all births to COVID positive persons in 2020 and 2021.
3. Early Hearing Detection and Intervention (EHDI) program ensures that children who did not pass their initial screening receive timely and appropriate follow-up remains an area for continued efforts.
4. Family-Centered Care Services (FCCS) addresses families' medical and social conditions by providing, in addition to quality health care, referrals to support accessible services within state departments, divisions, and county and municipal agencies. Our FCCS case managers also refer children to NJ Early Intervention Services (NJEIS) to ensure eligible children receive important services on time. As children age out of NJEIS and continue to need case management, these children move back to our county-based Case Management Units (CMUs).
5. Specialized Pediatric Services (SPS) consist of eight Child Evaluation Centers (CECs), of which four house Fetal Alcohol Syndrome/Fetal Alcohol Spectrum Disorder Centers and three provide newborn hearing screening follow-up, three Pediatric Tertiary Centers, five Cleft Lip/Palate Craniofacial Anomalies Centers. The SPS program aims to provide access to comprehensive, coordinated, culturally competent pediatric specialty and sub-specialty services to families with CYSHCN that are 21 years old or younger. With support from the State and Title V funds, health service grants are distributed to multiple agencies throughout NJ.
6. The NJ Early Intervention Services provides services to children from birth to three years of age who are experiencing developmental delays. Approximately 18,000 children receive services at any given time, including Occupational Therapy, Speech Therapy, Physical Therapy, and Developmental Intervention.

NJ's Title V CYSHCN program collaborates with intergovernmental and community-based partners to ensure that care through these multiple systems is coordinated, family-centered, community-based, and culturally competent. Communication across State agencies and timely training for State staff, community-based organizations, and families with CYSHCN remain a priority to ensure that families are adequately supported. Therefore, through the Title V CYSHCN program, staff provide access to comprehensive, coordinated, culturally competent pediatric specialty and sub-specialty services to families with CYSHCN that are 21 years old or younger.

Cross-Cutting/Systems Building

The Oral Health Services Unit (OHSU) continues to educate the public about the importance of preventive oral health services and good oral health, with programs predominately targeted to school-aged children and pregnant women. Other preventative services include dental screening, nutrition counseling, and placement of sealants and fluoride varnish for underserved, uninsured, and underinsured children across New Jersey. During 2021 – 2022, OHSU is proud to report the completion of the first NJ third-grade oral health Basic Screening Survey (BSS), a national standard for establishing key oral health baseline data. The survey results will be reported to the Centers for Disease Control and Prevention by Mid-2023.

In 2022-2023, OHSU will initiate the next phase of the Oral Health Basic Screening survey, concentrating on children enrolled in Head Start and Early Head Start. Additionally, leveraging our experience, collaborations, and close partnerships with other agencies, OHSU aims to continue expanding our oral health outreach services to cover more children at schools and pregnant women across New Jersey.

COVID-19

The impact of COVID-19 on all areas of maternal, child, and adolescent health has been and continues to be significant. Published studies confirm the pre-pandemic persistent racial/ethnic health disparities and their exacerbation during the COVID-19 pandemic. These results illuminated deep racial inequities and gaps in US public health and healthcare systems. Per the literature, the discontinuation and/or scaling back of lifeline services during the pandemic is believed to have exacerbated preexisting socioeconomic, health, and emotional challenges.

NJ TVS continues to support the work and mission of Title V and actively works on developing innovative ways to improve the health and well-being of NJ women, children, and families. For instance, TVP partnered with Rutgers Project ECHO to develop a CHW COVID-19-specific curriculum to raise awareness, identify the impact of COVID-19 in high-risk populations and combat the ill effects of COVID-19 in NJ. As the impact of the COVID-19 pandemic continues to linger and evolve, TVP continues collaborating with partners and families to deliver services and support.