New Jersey (NJ) is one of the most urbanized, densely populated, racially and ethnically diverse states in the nation. 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 100,000 newborns that the state welcomes yearly. 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 each year 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 the maternal and child health (MCH) needs in NJ as identified through our continuous needs assessment process and 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.
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 aiming at reducing 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 U.S[1]. In 2018, in response to NJ’s maternal and infant health crisis, the NJDOH FHS funded diverse community-based organizations to support the Healthy Women, Healthy Families initiative (HWHF). Through the HWHF initiative, the NJDOH has taken a targeted approach to reduce black infant mortality (BIM) rates by implementing specific BIM reduction activities include- breastfeeding support, fatherhood support, centering pregnancy, and centering parenting programs, doula services, and more. 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.
Through focus groups, birthing people in NJ echoed the need to have a trusted support person who can advocate on their behalf and help them navigate the complex health system. HWHF facilitates the establishment of a trusted perinatal workforce including Community Doulas and Community Health Workers (CHWs), who are trained to provide culturally competent care.
To date, approximately 150 women were trained to become community doulas, and as of December 2021, 547 births have been attended by doulas from the 3-year Doula Pilot Program. Preliminary results from an evaluation conducted in 2021 indicate that positive birth and/or pregnancy outcomes (e.g., lower rate of cesarean deliveries, increase in breastfeeding rate) are linked to community doula services. To ensure the sustainability of community doula services, NJ’s Title V Program (TVP) partnered with the NJ Department of Human Services to offer doula services to women through Medicaid Benefits. NJ Medicaid benefits have been expanded to cover doula services. Presently, birthing people who are covered by Medicaid are enabled to receive covered services from a Medicaid enrolled community doula.
NJ’s 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 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. To date, the CLG-CHWI successfully trained and integrated 180 CHWs into NJ health systems. Thirty-two percent of our trainees identified as bilingual. They are also trained to respond to diverse public health challenges in areas including COVID-19 response, mental health, and others. Upon course completion, CHWs receive 9 college credits toward an associate degree.
In July 2021, through legislation signed by NJ’s Governor, NJ is now the second state in the nation to establish a universal Home Visiting Program. NJ’s Maternal Infant and Early Childhood Home Visiting Program (MIECHV) is a statewide program with the capacity to serve over 5,000 families of infants and young children. The overall mission of MIECHV is to improve the physical and emotional well-being of infants, children, and their families in NJ by providing community-based education and in-home support to parents, including evidence-based safe sleep strategies. The Central Intake system, which was rebranded in 2022 into a more welcoming and consumer-friendly name, Connecting NJ (CNJ), is a county-based single point of entry system for referrals 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.
Through these public health interventions, NJDOH is leading a pivotal shift toward a sustainable non-traditional, community-based perinatal workforce capable of helping birthing people and their families navigate the healthcare system and get access to individualized care tailored to their needs. NJ’S TVP was invited to develop a Policy Development Handout to be featured on the Association of Maternal & Child Health Programs (AMCHP) MCH Innovations Database[2]. The handout is designed to serve as a resource to help interested teams in replicating NJ’s doulas expansion through Medicaid reimbursement.
This coming year, NJ TVP will continue to reinforce the non-traditional perinatal workforce (NTPW) in NJ, and use $500K that was appropriated from the Governor’s Murphy 2022 budget to further expand the reach of the CLG-CHWI in the community to advance the mission of NJ TVP. Moreover, the team 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 to work with key officials to explore the expansion of Medicaid benefits to cover CHWs services and establish a state registry for both CHWs and community doulas. 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. In 2023, the teams will evaluate and determine the effectiveness of the training on increasing CHW competencies and improving curricula materials and instruction to address gaps in training.
Concurrently, NJ’s TVP designed an evaluation project that will assess the outcome indicators and evaluate the status of current HWHF activities being implemented in the communities. Upon completion of the evaluation project, TVP will synthesize the results into a set of comments, recommendations, and suggestions to inform future programmatic and policy decisions concerning the HWHF initiative. Additionally, NJ’s TVP is investigating novel methodological approaches to standardize the Fetal and Infant Mortality Review (FIRM) case identification process across NJ’s three maternal and child health consortia.
Shortages in mental health and addictions specialists are evident for the general population and especially for maternal child health populations with limited resources. TVP anticipates announcing a competitive Request for Proposals (RFP) to pilot an Alma Program Expansion Project which aims to support pregnant persons who may be experiencing mental health issues and/or substance use issues.
Racial and ethnic disparities continue to 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.
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) Impact Initiative, the NJ Department of Children and Family (DCF) in partnership with NJ TVP was able to integrate developmental health promotion and screening as a service of the statewide Connecting NJ system effective in FY19. Through FY20 and FY21, CNJ’s central hubs maintained their outreach despite the pandemic. This enabled thousands of children to receive parent-led developmental screenings. In FY22, we anticipate a sustained reach with a slight increase, with the ability to 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 been greatly impacted by COVID-19. AYAs have experienced school closures, the hurdles of virtual learning, masking and social distancing from their peers, and missing important milestones and activities such as graduation, sports, and social activities. The COVID-19 pandemic has also impacted bullying, as students shifted from in-person learning to virtual learning and then back to in-person learning. During these shifts, bullying also shifted from in-person to online with a sharp increase in physical fights at the start of the 2021-22 school year that has since quieted. Still, 1 in 5 students are victims of bullying with higher rates for adolescents with disabilities, those who identify as lesbian, gay, bisexual, transgender, and non-binary, and Black, Indigenous, 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 includes a strong focus on mental health/suicide prevention, sexual health, and school health. The MCHBG specifically supports adolescent mental health, suicide prevention, and school health, but all programs work together to holistically support adolescents and their health needs. 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 (Dialectical Behavioral Therapy, 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 youth, named Prevent Suicide NJ (PSNJ). PSNJ will launch in September of 2022 after the national launch of hotline #988 which will replace the National Suicide Prevention Lifeline number[3]. 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.
Professional Development for the year will include Mental Health First Aid training, Building Your Social and Emotional Learning (SEL) Toolkit, Sexual Health 101, Engaging Youth Across Multiple Platforms, Talking with Teens about Sexual Health with Al Vernacchio- Parent Engagement webinar, Working with Youth with Developmental and Intellectual Disabilities, Diversity, Equity and Inclusion training for adults on Race, Trauma and Mental Health and an AYA training series: Bringing Your Voice to the Table™.
NJDOH CAHP will also continue to implement our SEL Bullying Prevention activities including The Teen Outreach Program TOP® and Lifelines Trilogy. TOP® an SEL-based model proven to reduce teen pregnancy will reach at least 1,500 NJ youth and Lifelines Trilogy an SEL-based suicide prevention program will reach at least 4,500 NJ students aged 12-18 (5th – 12th grade).
Children and Youth with Special Health Care Needs (CYSHCN)
In NJ, families of CYSHCN have access to a myriad of services aiming at ensuring that children in need of specific services, get access to services deemed necessary to help them thrive. These services are provided through the following interventions:
- Newborn Screening and Genetic Services (NSGS) ensures 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 in 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
- Birth Defects and Autism Registry (BDAR) ensures that all children 0 through five years old who have a congenital birth defect 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.
- 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.
- 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, and divisions as well as county and municipal agencies. Our FCCS case managers also refer children to NJ Early Intervention Services (NJEIS) to ensure that eligible children receive important services on time, and as children age out of NJEIS and continue to need case management, these children move back to our county-based Case Management Units (CMUs).
- 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, and five Cleft Lip/Palate Craniofacial Anomalies Centers. The goal of the SPS program is 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.
- The NJEIS provides services to children from birth to three years of age who are experiencing developmental delays. At any given time, approximately 15,000 children receive services including Occupational Therapy, Speech Therapy, Physical Therapy, and Developmental Intervention.
NJ’s Title V CYSHCN program diligently 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 remains a priority to ensure that families are adequately supported. Therefore, through the Title V CYSHCN program, staff 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.
Cross-Cutting/Systems Building
The Division of Community Health Services in collaboration with the TVP and other key stakeholders has implemented Fluoride Varnish programs, including those for school-age and HeadStart / Early HeadStart populations. To ensure that the population of focus gets the necessary education to care for their teeth, the Division of Community Health Services has implemented oral health education for doulas and home visitation staff as well as other health care professionals who work directly with families with young children and birthing people. Moreover, to increase awareness of best practices for prescribing pain medications and to combat the opioid epidemic in NJ, the team designed and implemented an opioid education program for dental professionals and dental students.
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 the deep racial inequities, and gaps in public health and health care systems in the U.S. 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[4].
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 aiming at raising awareness, identifying the impact of COVID-19 in high-risk populations, and combating the ill effects of COVID-19 in NJ. As the COVID-19 pandemic continues to rapidly evolve, TVP continues to collaborate with partners and families to deliver services and support.
[1] America Health Rankings. Health of Women and Children. Accessed on April 20, 2022. Explore Health Measures in New Jersey | 2019 Health of Women and Children Report | AHR (americashealthrankings.org)feducation
[2] Association of Maternal & Child Health Programs (AMCHP). Policy Development Expansion of Community-Based Doulas Through Medicaid Reimbursement. Access on April 20, 2022. https://amchp.org/database_entry/expansion-of-community-based-doulas-through-medicaid-reimbursement/
[3] The Lifeline and 988. Access on April 20, 2022. https://suicidepreventionlifeline.org/current-events/the-lifeline-and-988/
[4] McCloskey, L.; Amutah‑Onukagha, N.; Bernstein, J.; Handler, A.; Setting the Agenda for Reproductive and Maternal Health in the Era of COVID‑19: Lessons from a Cruel and Radical Teacher. Maternal and Child Health Journal (2021) 25:181–191. https://doi.org/10.1007/s10995-020-03033-y
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