III.C.2.a. Process Description
In 2016, Minnesota embarked on a quality improvement project aimed at creating an inclusive, comprehensive, ongoing needs assessment process for the state’s five-year comprehensive MCH needs assessment. This project lead to the development of a systematic process used by the Title V program, and others in the Child and Family Health Division, to collect information about Minnesota’s public health system and services to pregnant people, mothers, infants, children, adolescents, children and youth with special health needs (CYSHN), and families.
The goal of the statewide needs assessment was to improve maternal and child health (MCH) outcomes by better understanding strengths, gaps in services and needs of target populations; and to strengthen partnerships for effective implementation of strategies addressing the identified needs. The information collected through the needs assessment was used to identify statewide priorities, drive strategic planning, and set criteria for how best to allocate resources.
Minnesota’s Title V Needs Assessment is an ongoing, data-driven, collaborative process that includes families, service providers, and community-based organizations; local public health (LPH) agency staff; policymakers and service funders; staff from the Minnesota Department of Health and other state agencies.
Minnesota established a clear leadership structure in conducting our needs assessment process. The process was guided by a Needs Assessment Leadership Team, which consisted of LPH leaders from urban and rural communities, the University of Minnesota’s School of Public Health and other MCH academia, students, the MCH Advisory Task Force (see Overview of the State for more information about the MCH Advisory Task Force), and an internal needs assessment team composed of MDH staff (see Appendix A for a list of internal members). The responsibilities of the Needs Assessment Leadership Team were to:
- Provide feedback and guidance related to data and process matters throughout the needs assessment process;
- Complete criteria-based ranking during prioritization; and
- Review Minnesota’s 2021-2025 Title V priorities.
Needs Assessment Framework
With the guidance of the Title V Leadership Team and the MCH Advisory Task Force, a mixed methods approach, informed by best practices and evidence-based research, was developed to conduct the needs assessment. Minnesota operated from a trauma-informed, intersectional framework aimed to advance health equity and acknowledge the strengths of our state’s communities. The needs assessment and its activities were rooted in the social ecological model, a systems model in which multiple levels of influence (individual, interpersonal, organizational, community, and policy) impact the health of communities.
The following principles guided the needs assessment:
- MCH Target Population Focus
- Health Equity
- Trauma-Informed
- Quality Improvement
- Community Engagement
- Transparency
- Accountability
- Data-driven Decisions
- Evidence-Based and Informed Practices
- Adaptability
- Collaboration with Systems Partners/Customers
Appendix B includes further information on the guiding principles, including activities for operationalization. For more information on the summary of literature that informed our trauma-informed, intersectional framework see Intersectionality and Trauma-Informed Applications for Maternal and Child Health Research and Evaluation: An Initial Summary of the Literature (health.state.mn.us/docs/communities/titlev/itiappmchresearcheval.pdf).
Stakeholder Involvement and Relationship Building
Throughout the needs assessment process, stakeholders were engaged to provide input, co-create activities and processes, and select priorities. The needs assessment team was intentional in planning for stakeholder engagement throughout the process. Community organizations, family work groups, family-led organizations, and other external stakeholders were involved in the development, review, and approval of the needs assessment plan in early 2018, and the needs assessment team continued to work in partnership with these stakeholders at all stages of the needs assessment process.
During the data collection stage, the Title V needs assessment team engaged 248 people in focus groups, community forums, and key informant interviews. Additionally, there were countless informal interviews with fire department staff, WIC clinic staff, LPH, and other states needs assessment teams. A total of 2,736 people completed a Discovery Survey, and almost 40% of all respondents self-identified as a community member. To maintain engagement with stakeholders, all survey respondents were able to opt in to receive communications about the ongoing process – 784 people chose to provide contact information. Emails were sent to this list when additional engagement activities were occurring, and many continued to participate. A total of 108 people participated in the development of 40 data stories and 40 data placemats. Community forums were held at different community locations in the metro area, as well as all-remote options inclusive of people living in Greater Minnesota.
Finally, after the priorities were identified, over 240 MDH staff, family stakeholders, LPH, and health professionals participated in 11 teams that developed Minnesota’s strategic plan, which is the basis of our Title V action plan.
The needs assessment process was informed by Donna Petersen & Greg Alexander’s book,
“Needs Assessment in Public Health.” Discrete stages of the needs assessment were identified, with evaluation of the process ongoing throughout (see Appendix C for detailed timelines).
Figure 1. 2020 Needs Assessment Process
One of Minnesota’s greatest learnings of the needs assessment is that rigid linear frameworks/models are not appropriate for our cultural communities, namely our Tribal Nation/American Indian community. While we began with a framework in mind, we pivoted and adapted as taught and requested by our partners. This created a much richer process, more robust findings, stronger community partnership, and invaluable learnings.
Data and Capacity Assessment Stage
In 2018, the Title V Data Team (Title V Needs Assessment Coordinator, SSDI Project Director/Title V Data Coordinator, MCHB interns, fellows, and CFH student workers) began the data and capacity assessment stage. While engaging in data activities, the Title V Data Team utilized Petersen’s guidance. As such, data met the following criteria:
- Simple: Well-defined, valid, reliable, understandable to stakeholders
- Stable: Should provide stable estimates
- Available: Timely and readily available
- Logical, Relevant, Important: Should reflect conditions and service patterns thought to correlate with changes in health status outcomes of interest
- Has Broad Representation: Should reflect potential health status concerns of a majority of the target population as well as high-risk groups
- Political Feasibility: Should consider political will, though remember the potential impact of the problem on community health is the most important
The Title V Data Team examined the strengths, needs, and capacity of Minnesota’s target populations and MCH workforce using qualitative and quantitative Minnesota-specific data. The team gathered and reviewed available reports, other needs assessments (including LPH’s community health assessments), existing literature, national benchmarks and goals, and other relevant factors that influence the maternal and child health environment in Minnesota (e.g. agency capacity, political will, etc.).
Stakeholders were engaged to collect qualitative data to supplement the quantitative data. Qualitative activities included:
- Holding listening sessions with MDH staff for preliminary understanding of perceived needs, as well as to identify existing partnerships, and data sources (45 staff from 4 divisions attended)
- Completing a stakeholder engagement mapping exercise (see Appendix D)
- Interviewing 9 external experts with expertise in: decision-making science, incarceration and corrections, trauma-informed participation in health research, knowledge translation, father involvement, safety and violence, evaluation and research, American Indian research and evaluation, and adolescent and youth engagement
- Interviewing 20 subject matter experts at MDH
- Conducting the Discovery Survey
- Convening focus groups to further investigate needs of CYSHN and their families
- Conducting key informant interviews related to the candidate priorities
- Engaging the MCH Advisory Task Force and Title V Needs Assessment Leadership Team
Primary Data Collection
Primary data was collected via three methods: a Discovery Survey, key informant interviews, and focus groups for families of CYSHN.
Minnesota used a Discovery Survey to collect the thoughts of interested stakeholders and community members on the greatest unmet needs of women, children, and families in their communities, along with what they need to thrive and live their best lives. The Discovery Survey had two main purposes:
- To hear Community voice
- To use as a tool to evaluate inclusivity
The Discovery Survey was open for six weeks during the summer of 2018. It was web-based, with the exception of a pilot in a county WIC clinic where paper copies were distributed in English, Somali and Spanish.
2,716 surveys were completed and included in our analysis.
Over 780 respondents chose to provide their contact information to be included in updates and future calls to action. Our survey results were representative by geography and race/ethnicity, but not representative by gender (7% of the survey respondents self-reported being male, 85% reported female, and 8% did not respond). Most respondents were between the ages of 25 and 64, with very few adolescents.
Discovery Survey results and methods were shared during two live webinars in late 2018. The webinar recording, slides, and transcript are available on our Needs Assessment website (health.state.mn.us/communities/titlev/assessment.html). Discovery Survey responses informed the selection of the 40 candidate priorities and development of the data stories. We utilized a thematic content analysis via an inductive approach in analyzing the discovery survey responses. More information on this process is in Appendix E.
Key Informant Interviews Corresponding to Priorities
After the 40 candidate priorities were identified, a team of three staff members from CFH formed a work group to conduct key informant interviews on each of the 40 identified needs. Key informants were selected through a frame of geographic diversity and racial equity using results from the Discovery Survey to inform selection. There was a large variety of individuals interviewed ranging from public health professionals, health care workers, business owners, parents/caregivers, and professors. List of key informant interviews by stakeholder organization is in Appendix F. In the spirit of trauma-effective work, ongoing peer support meetings were also scheduled for the three staff meetings conducting the interviews as the content of the conversations could be incredibly difficult with personal stories of suffering and loss.
CYSHN Focus Groups
Nearly 300 Discovery Survey respondents identified as being parents or caregivers of CYSHN. While these responses helped develop some understanding of the needs of families of CYSHN, the CYSHN Program at MDH sought out to dig deeper into the findings of the Discovery Survey to understand specific experiences of families. Therefore, following the Discovery Survey, MDH contracted with Wilder Research to conduct focus groups with families of CYSHN. A total of 44 parents/caregivers attended at least one of the focus groups. Six of the focus groups further explored the top themes identified in the Discovery Survey by parents/caregivers, including:
- Health care accessibility
- Health care affordability
- Flexible employment
- Child care
- Well-being
- Parent support and education
In addition to topic area-specific focus groups, Wilder Research and MDH intended to conduct focus groups with parents and caregivers who belong to specific cultural groups. The study intended to conduct focus groups with Hmong, Somali, Spanish-speaking, and American Indian groups. Because of difficulty in recruitment, we were only able to conduct the focus group with American Indian parents/caregivers of CYSHN.
Secondary Data Collection
County, state, and federal data sources were frequently utilized during the Needs Assessment process to further our understanding of unmet needs, strengths, disparities, and opportunities. Data sources used most frequently include:
- Title V Information System
- Minnesota Vital Records
- Minnesota Student Survey
- Pregnancy Risk Assessment Monitoring System (PRAMS)
- National Survey of Children’s Health (NSCH)
For a complete list of public data sources used during the needs assessment, see Appendix G.
Initial Prioritization Stage
After the collection and review of quantitative data and qualitative data, the team compiled an extensive, inclusive list of all maternal and child health needs reported. Pre-prioritization was needed to reduce the large list of ‘ever-mentioned’ items to a working list of candidate priorities. The methods for this ‘pre-prioritization’ activity are included in Appendix H. Methods were developed, reviewed, agreed upon, and documented prior to the actual prioritization activity to ensure legitimacy of results.
The data and capacity assessment stage resulted in:
- A set of 40 candidate priorities to be considered during the 2019 prioritization rounds;
- Data stories and data placemats for the set of possible priorities outlining impact, prevalence, health equity, and stakeholder input;
- Materials on agency capacity, political will, and stakeholder input; and
- Stakeholder Engagement Tracking Tool.
The data stories are available online on the MDH Title V Needs Assessment website (health.state.mn.us/communities/titlev/datastories.html). Examples of data placemats, brief visualizations of the data stories, are included in Appendix I.
II.C.2.b Findings
III.C.2.b.i MCH Population Health Status
The Minnesota Department of Health’s Title V Needs Assessment team acknowledges that structural (social, economic, political and environmental) inequities can result in poor health outcomes across generations. They have a greater influence on health outcomes than individual choices or a person’s ability to access health care, and not all communities are impacted in the same way.
All people living in Minnesota benefit when we reduce health disparities.
The following section details the findings of Minnesota’s comprehensive needs assessment, by MCH population domain.
Cross-Cutting/Life Course
Through Minnesota’s needs assessment, the majority of needs identified for MCH populations in the state belong in the cross-cutting domain. Historically, less of Minnesota’s Title V MCH Block Grant efforts addressed the cross-cutting needs of the MCH population. Our work needs to focus more in these areas. Understanding the intersectionality of these needs grounds our work. In order for us to improve outcomes for Minnesota’s MCH populations, cross-cutting/systems changes need to occur. The following issues rose to the top through Minnesota’s needs assessment:
- Housing: Housing is connected to every aspect of people’s lives, critical to financial security, academic success, and health. Minnesota is in the midst of a housing crisis with many unable to own a home, being housing “cost-burdened,” or homeless.
- Accessible and Affordable Health Care: Comprehensive, quality health care services are important for promoting and maintaining health throughout the lifespan. For many in Minnesota, access to health care is impacted by household finances, insurance coverage, geographic availability, timeliness of entry into services, and other factors.
- Mental Well-Being: Mental well-being is about having fulfilling relationships, using strengths, contributing to community and being resilient, which is the ability to bounce back after setbacks. Around 460,000 Minnesotans aged five years and older (8.8% of the population) reported experiencing 14 or more mentally unhealthy days over the course of a month. Subpopulations reporting mentally unhealthy days at a significantly higher rate than that statewide included persons who are on public insurance, the uninsured, Black Minnesotans, those with income levels 200% the federal poverty guidelines, and those with a high school education or less.
- Parent Support and Education: Parents and caregivers need a network of supportive relationships, strategies for coping with stress, resources, knowledge, and an understanding of child development. Unfortunately, a lack of these critical supports can cause undue stress. Many parents in Minnesota report that they don’t feel they are getting the support they need when they feel stressed.
- American Indian Family Health: American Indian women, children, and families experience worse outcomes than other populations in Minnesota. These disparities are caused by historical trauma, racism, and continued colonial practices and policies that are barriers to opportunity and thriving.
- Child care: The cost of child care in Minnesota is a significant barrier for families. Minnesota ranks as the fifth least affordable state in the country for center-based infant care, with an average cost of $15,340 per year, which is higher than in-state tuition for a University of Minnesota freshman. In addition to affordability, simply finding child care can be challenging, with shortages impacting much of the state.
- Financial Security: In 2017, 560,996 people living in Minnesota, including 169,040 children under 18, had family incomes below the official poverty threshold ($24,600 for a family of four). People living in poverty in Minnesota are more likely to experience poor health, be food insecure, have chronic stress, live in unsafe neighborhoods, and experience unstable housing. Those in “near poverty” (up to twice the poverty line) are often one crisis away from falling into poverty.
- Education: Achieving optimal health and well-being is strongly correlated with having access to high quality, well-funded schools. Minnesota’s complex school funding system creates inequities between schools and school districts, affecting students attending these schools. Education inequities seen in Minnesota include differences in graduation rates, achievement levels, early childhood programs, dual credit (high school and college) course offerings, discipline rates, college enrollment, college persistence, college completion, and the diversity of teachers.
- Transportation: Public transport provides critical transportation for transit-dependent people who do not own their own car or do not drive. This population tends to consist of young people without their driver’s license, disabled persons, low-income workers, and a significant proportion of seniors. In 2010, half of transit riders in Greater Minnesota reported not having either a car or a driver’s license.
- Food Access: Minnesota ranks 7th worst in the nation for the share of residents with access to healthy foods. Nearly 1 in 10 households in Minnesota experience food insecurity. When families experience food insecurity they might experience stress about running out of food before they can buy more, eat less healthy meals, and sometimes cut back on the size of meals or skip them entirely.
- Access to Behavioral Health Services: According to the National Survey of Children’s Health, 31 percent of children in Minnesota with a mental or behavioral health condition that needed treatment did not receive services. Access to behavioral health to promote mental well-being and the prevention, early identification, intervention, and treatment of mental health and substance use issues is a large need in Minnesota.
- Culture of Safety: Violence is a public health issue and it is preventable. Lacking a culture of safety negatively impacts the health outcomes of marginalized groups of people through discriminatory practices, violence, and trauma. An example of structural violence is: Black girls are more likely to be suspended or expelled, perceived as being “disruptive” or “loud,” punished for dress code violations, and reprimanded for “defiant” behavior than their classmates. In Minneapolis, 30 people have been killed by police officers from 2000-2018. Nineteen of the victims were Black, five were white.
- Paid Parental Leave: Paid parental leave is critical, as parental involvement during the early years of a child’s life strengthens bonds, helps with forming secure relationships, and decreases chronic stress among families with newborns. Access to paid parental leave is linked to fewer infant deaths, increased breastfeeding duration, and improved birth and developmental outcomes. The United States is one of the only developed countries worldwide that does not offer nationwide paid parental leave. Several states have family-leave laws that support paid parental leave: Minnesota is not one of them.
- Navigating Services and Supports: In Minnesota, 82% of eligible children were not enrolled in Child Care Assistance and 50% of eligible uninsured Minnesotans were not enrolled in MinnesotaCare or Medical Assistance. Coordinated and efficient systems of care for women, children, and families are needed to achieve the best possible health outcomes and to thrive, but do not exist or are out of reach for many.
- Culturally Responsive Care: Culture plays a huge role in how women and families define health and how they interact with the health care system. Over 11% of people living in Minnesota speak a language other than English at home, and in 2016 there were more than 100,000 people in the state who spoke English less than “very well.” Language impacts health literacy. Our health care systems are not easily navigable for people with limited health literacy (e.g., complex forms, needing to identify providers and services).
- Fathers: Approximately 324,000 Minnesotan children, or 1 in every 4, are currently living in homes without a father. Children who grow up in families with an involved father have better performance in school, stronger behavioral skills, and have higher self-esteem.
- Safe Neighborhoods: Neighborhoods in Minnesota tend to be segregated based on race, ethnicity, or socioeconomic status, which results in disparities in property values, school funding, grocery stores, and home ownership. Features of neighborhoods have been linked to life expectancy and early death, overall health status, experience of violence, mental health, disability, birth outcomes, chronic diseases, health behaviors, injuries, and other important health indicators.
Women/Maternal Health
Beyond the social determinants of health and needs impacting all populations, there are specific unmet needs women experience. Minnesota’s 2016-2020 women/maternal health priority of promoting routine well-woman visits to support the mental and physical health needs of women and increase the proportion of pregnancies that are intended, saw improvements. There was a 10% increase in routine well-women visits from 68.7% in 2014 to 75.8% in 2018. Despite the improvements, women, especially women of color, still face challenges receiving comprehensive preconception, prenatal, postnatal, and interconception visits. The following needs affecting women and maternal health were identified through Minnesota’s needs assessment:
- Care during Pregnancy and Delivery: Nearly one-fourth of women in Minnesota did not receive prenatal care within their first trimester of pregnancy, with American Indian and African American/Black mothers less likely to have received care. Even if women have access to prenatal care, many are at higher risk of complications during delivery due to shortages in obstetrics care in community hospitals.
- Family Planning: Approximately 20% of women with a recent live birth reported their pregnancy was unplanned. When a pregnancy is unintended, unwanted, or poorly timed, the mother and baby are at higher risk for problems during and after the pregnancy.
- Maternal Morbidity and Mortality: Each year in Minnesota, approximately 20-35 women die and 3,000 experience morbidities during pregnancy, labor/delivery, or postpartum. Many of these morbidities and mortalities could have been prevented by early diagnosis and treatment.
- Postpartum Support and Care: Approximately 1 in 10 women in Minnesota self-report experiencing postpartum depression. Providing postpartum support and care is crucial to ensuring the health of mothers and their babies.
Perinatal/Infant Health
Minnesota’s infant mortality rate has been consistently lower than the United States rate overall; yet, little to no progress has been made in reducing infant mortality in the past decade. There has been progress in Minnesota’s 2016-2020 priority needs related to perinatal and infant health. The proportion of infants ever breastfed increased from 84% in 2012 to 90.4% in 2016. Safe Sleep practices of placing the infant to sleep on her back and on a separate surface have remained rather steady. There was a 5 point increase in those who reported placing infant to sleep without soft objects or loose bedding (from 48.0% to 53.5%). However, the persistent racial disparities in health outcomes in Minnesota infants continues. The main areas of need for infants in Minnesota from the assessment included:
- Infant Mortality: While infant mortality rates for all racial groups in Minnesota has declined overtime (by 29% since 1990), the disparities have remained constant for over 20 years.
- Breastfeeding: Though Minnesota data shows that the rate of breastfeeding initiation has increased overall since 2012, there are significant differences in initiation based on education, age, race, and income of mothers.
- Neonatal Abstinence Syndrome: The rate of NAS in Minnesota has increased drastically in the past decade. In addition to being at risk of premature birth and low birth weight, babies born with NAS can experience withdrawal symptoms, such as breathing problems, diarrhea, seizures, and fever.
- Stillbirths: Roughly 1 out of every 185 pregnancies in Minnesota ended in a stillbirth – a tragic and traumatic event for families.
Child Health
The overall health status of children in Minnesota has remained steady from 2016 to 2018, with approximately 91% of children in excellent or very good health. State-level data using the National Survey of Children’s Health (NSCH) have shown an increase in the percent of children receiving developmental screening using a parent-completed tool within the same time frame. This points toward some effectiveness in Minnesota’s strategies to improve developmental screening rates in the last 2016-2020 Title V cycle. However, even with this increase, families are facing significant challenges in navigating the early childhood system. The following issues were identified for children through Minnesota’s needs assessment:
- Comprehensive Early Childhood Systems: Minnesota faces significant challenges in implementing a coordinated, equitable, and efficient system of care for children and their families. Though statewide data on actual service gaps and barriers is limited, anecdotal evidence from families consistently indicates that services are unavailable, unknown, or hard to access.
- Childhood Trauma: Approximately 37% of children in Minnesota have experienced one or more adverse childhood experiences (NSCH), and many more have experienced other forms of childhood adversity, which can lead to lifelong physical and mental health problems.
- Foster Care: Around 16,600 children and young adults experienced out-of-home care in 2017, with younger children, those from rural counties, and African American and American Indian children disproportionally represented in the foster care system.
- Child and Adolescent Well-Visits: Though well-visits are effective in allowing for early identification of potential health or developmental concerns, some populations of across the state are less likely to receive well-child care, including those who live in rural areas, live in poverty, and are uninsured.
- Oral Health: Though oral health is interconnected with physical health, many children in Minnesota are without access to dental health care.
Adolescent Health
Current efforts to improve the well-being of adolescents in the state have led to reductions in the teen pregnancy rate and higher engagement with youth in programmatic decision-making. However, while Minnesota’s efforts to strengthen the health system to better meet the needs of adolescents have been effective in some areas, we are still struggling on other measures of well-being. For instance, the number of adolescents who had a preventive visit has been hovering steady around 76%. Furthermore, the mental well-being of young adults (especially young men) has been brought forward by community members as an emerging public health issue. The main areas of need for adolescents from the assessment included:
- Adolescent Suicide: Suicide is the second leading cause of death for young people ages 10-24, with American Indian and Alaska Native youth experiencing suicide rates nearly 3 times that of youth of other races.
- Boys and Young Men: Boys and young men in Minnesota have been underserved and are struggling with higher rates of substance use, suicide, mental health struggles, violence, and victimization compared to girls and young women.
- Bullying: Bullying is increasingly recognized as a significant social problem facing our youth with nearly one out of five Minnesota students reported being bullied or harassed weekly.
- Physical Activity: Fewer children and youth are meeting physical exercise guidelines, which may be impacted by access to safe, adequate, and affordable recreational activities.
- Teen Pregnancy and Childbirth: In 2017, 2,113 babies in Minnesota were born to mothers under age 20. Teen childbirth is a strong risk factor for poor outcomes for both infants and their mothers.
Children and Youth with Special Health Needs
Approximately 17.7% of Minnesota children 0-17 years old have special health need, which includes a range of chronic physical, developmental, behavioral, and emotional conditions. CYSHN and their families often need a wide variety of medical, psychosocial, educational, and support services. Minnesota’s 2016-2020 priority needs related to CYSHN aimed to help promote a comprehensive, coordinated, and integrated system of services/supports and ensure adequate health insurance coverage. However, NSCH state-level data shows downward trends related to key measures of a well-functioning system, including medical home, care coordination, transition, and adequate insurance. Though block grant efforts worked to improve systems for CYSHN and their families through promotion of medical home, transition, and insurance best practices, families still report difficulty navigating the state’s complex system and gaining access to needed services. The main areas of need from the assessment included:
- Access to Services and Supports: Families often have to forgo care due to long waiting lists, problems getting appointments, troubles with eligibility criteria, complex systems to navigate, child care issues, language and cultural barriers, transportation issues, and lack of financing.
- Coordinated Care: Systems and services are difficult and confusing to navigate because there is a lack of effective care coordination occurring in the state. When care is not coordinated, children and families can receive fragmented or duplicative services – or may not end up receiving needed services at all.
- Autism Spectrum Disorders: There are significant gaps in being able to receive a timely evaluation and diagnosis for conditions such as Autism Spectrum Disorder, causing families to have to wait to receive vital early intervention services.
- Deaf/Deafblind/Hard of Hearing: Without early identification and early opportunities to learn language, some children will fall behind their hearing peers in communication, cognition, reading, and social-emotional development.
- Transition: Significant gaps exist in accessing the needed supports to transition from pediatric to adult health care, especially for youth with more complex medical needs.
Needs assessment findings were the drivers of the finalization of priority needs, as stakeholders used community voting and criteria-based ranking to evaluate candidate priorities that arose from the needs assessment process. The state action plan was developed in partnership with stakeholders during a highly collaborative, inclusive process.
III.C.2.b.ii. Title V Program Capacity
III.C.2.b.ii.a. Organizational Structure
Minnesota Department of Health
The Minnesota Department of Health (MDH) is one of the major administrative agencies of state government in Minnesota. Commissioner of Health Jan Malcolm is responsible for directing the work of MDH. The Commissioner reports directly to the Governor and is a member of the Governor’s Cabinet.
The mission of MDH is to protect, maintain and improve the health of all Minnesotans. The work of the department is carried out by four bureaus: Health Protection, Health Systems, Health Operations, and Health Improvement. The department has approximately 1,500 employees and an annual budget of approximately $500 million in state, federal, and fee-based funds.
Division of Child and Family Health
The Child and Family Health (CFH) Division within the MDH Health Improvement Bureau provides collaborative public health leadership that supports and strengthens systems to ensure healthy families and communities. The CFH Division employs approximately 120 staff and manages over $200 million in state and federal funds annually, the majority of which is distributed to LPH and community-based organizations. The CFH Division is comprised of the Director’s Office and four sections: Maternal and Child Health (MCH), Children and Youth with Special Health Needs (CYSHN), Minnesota Women, Infants, and Children Program and the Commodity Supplemental Food Program (WIC/SNP), and Family Home Visiting (FHV). Organizational charts of MDH and the CFH Division are included in Appendix J.
Our Annual Report and Application Year Plan describes key efforts of the Division supported by the Title V MCH Block Grant. In addition to the programs described throughout this narrative, Title V funds have supported Minnesota’s Health Equity and Children’s Cabinet efforts.
- Health Equity: Title V MCH Block Grant funding supported the development of the 2014 Advancing Health Equity report, which significantly changed how we do our work. The CFH Division is committed to operating from a “health in all policies” approach, using an equity lens in the distribution of grant funding, and identifying how the CFH culture can be more inclusive. CFH is dedicated to exploring how housing, education, and the environment intersect with the health and well-being of people, families and communities.
- Children’s Cabinet: Title V MCH Block Grant funding supports the work of Minnesota’s Children’s Cabinet, an interagency partnership charged by the Governor to make Minnesota the best place for children to grow (see Overview of the State for more information about Children’s Cabinet).
Partnership with Local Public Health
Minnesota’s Title V efforts are carried out in partnership with our state’s LPH agencies. The Local Public Health Act in Minnesota – Minnesota Statute § 145A (revisor.mn.gov/statutes/cite/145A) – outlines the shared public health responsibilities of the state and local public health agencies. Community Health Boards are the legally recognized governing body for LPH in Minnesota.
By statute (Minnesota Statute § 145.88 – 145.883 (revisor.mn.gov/statutes/cite/145.88), two-thirds of Minnesota’s Title V funds are distributed by formula to the state’s 51 Community Health Boards (CHBs). This statute directs the use of Title V funds to CHBs to fund programs that address needs or issues faced by MCH populations. CHBs are required to meet all federal Title V requirements and to report annually to MDH on the use of funds. They also must conduct a needs assessment and planning process every five years.
III.C.2.b.ii.b. Agency Capacity
While Minnesota’s needs assessment process did not include a formal assessment of program capacity, discussions occurred internally within the CFH Division related to the agency’s capacity to carry out the responsibilities of the block grant.
MDH has a longstanding history of collaborating with statewide partners to ensure the health and well-being of all mothers and children, including children with special health needs, are protected and promoted. The CFH Division takes steps to assure that a statewide system of services exists, which reflects the principles of comprehensive, community-based, family-centered care. This is done in partnership with LPH agencies as well as through collaboration with other state agencies.
Within the CFH Division, the CYSHN and MCH Sections are primarily responsible for the Title V MCH Block Grant Program with support from the Directors Office, WIC, and FHV Sections.
Maternal and Child Health Section
The MCH Section provides statewide leadership and public health information essential for promoting, improving, and maintaining the health and well-being of women, children and families throughout the state. The MCH Section provides leadership and program management for the Women/Maternal Health, Perinatal/Infant Health, Child Health, and Adolescent Health domains. The MCH Section works to carry out the following activities:
- Preconception, Maternal and Infant Health: Leading improvement of maternal and infant outcomes and reducing racial/ethnic and socioeconomic disparities with efforts such as the perinatal quality collaborative, robust safe sleep activities, and the maternal mortality review committee.
- Child and Teen Check-Ups (C&TC): Providing technical assistance on the best practices of early periodic screening, diagnosis, and treatment in children and adolescents.
- School Health Nursing Program: Providing consultation to School Nurses across the state, as well as recommendations for policy and procedure support for medication administration, health assessment and delivery of other school health services.
- Adolescent Health - Teen Pregnancy Reduction: Addressing overarching adolescent health and well-being through the Minnesota Partnership for Adolescent Health and high quality, medically-accurate programs to target populations experiencing the greatest disparities in teen births, HIV/AIDS, and sexually-transmitted infections.
- PRAMS Program: Collecting and analyzing data and trends on MCH populations with the Minnesota PRAMS survey.
- Family Planning Special Projects (FPSP) Program: Providing low-income, high-risk people pre-pregnancy family planning services through state-funded grants to counties, Tribal governments, or nonprofit organizations.
- Positive Alternatives Program: Promoting healthy pregnancy outcomes and assisting pregnant and parenting people in developing and maintaining family stability and self-sufficiency through state-funded grants to non-profit organizations.
Children and Youth with Special Health Needs Section
The CYSHN Section provides statewide leadership, in partnership with families and other stakeholders, toward a future of well-functioning systems for CYSHN and their families. The CYSHN Section primarily provides leadership and program management for the CYSHN domain; however, it also provides consultation/collaboration with all other block grant domains. The CYSHN Section carries out the following activities:
- Education: Providing information about specialized services to families of children with or at risk for chronic illnesses and disabilities; promoting evidence-based interventions for CYSHN.
- Early Identification and Connection to Services: Improving early identification and assuring linkage of families of children with special health needs to resources and services.
- Community Partnerships: Providing technical assistance to primary care providers, specialty care providers, LPH nurses, and other community agencies who provide services to CYSHN.
- Public Policy: Engaging in the development, coordination, and support of state and local systems for children with special health needs. Serving in an advisory capacity to policy-making bodies to assure the interests of CYSHN are considered.
- Surveillance: Monitoring and analyzing data to identify trends and underlying causes of birth defects and other conditions; assessing the adequacy and availability of services and supports; and monitoring the effectiveness of interventions and programs.
Minnesota’s Title XIX program provides broad coverage and a comprehensive array of services including rehabilitation services. The CYSHN program instead ensures that the ongoing needs of children and youth receiving Supplemental Security Income are met, and does not directly cover services for blind and disabled people under the age of 16 receiving benefits under Title XVI.
III.C.2.b.ii.c. MCH Workforce Capacity
Minnesota’s Title V efforts are carried out via a partnership between MDH and LPH agencies. Therefore, our workforce is composed of both staff at the local and state levels. Approximately one-third of the state’s Title V MCH Block Grant funding supports state-level activities, salaries, and indirect costs. Within the CFH Division, Title V funding is used to support approximately 23 full-time equivalents (FTEs) of staff, who are primarily located in Saint Paul, MN. This includes approximately 10 FTEs within the MCH Section, 6 FTEs in the CYSHN Section, and 7 FTEs in the CFH Director’s Office.
Strength in Title V Leadership
An exceptional strength in Minnesota’s MCH workforce is their dedication toward improving outcomes for women, children (including those with special health needs), and families. Not only are staff passionate about their work, but they are also highly qualified. A team of well-experienced leaders in the field of maternal and child health lead Minnesota’s Title V efforts. Senior level leadership and program staff are listed below and their biographies are included in Appendix K.
- Joan Brandt, PhD, MPH, CFH Division Director (Current Title V MCH Director)
- Kathy Wick, MPA, CFH Division Assistant Director
- Karen Fogg, MPH, MCH Section Manager
- Nicole Brown, MSN, PHN, CPNP-PC, Interim CYSHN Section Manager
- Mira Sheff, PhD, MS, State MCH Epidemiologist
- Judy Edwards, BS, MCH Assistant Section Manager, MCH Title V Coordinator
- Sarah Dunne, MSW, MPH, CYSHN Title V Coordinator
- Molly Meyer, MPH, Senior Research Scientist, SSDI Project Director
- Blair Harrison, MPH, Senior Research Scientist, Title V Needs Assessment Coordinator
Many paid staff members within the CFH Division identify as parent or caregiver of a child with special health needs. The Family Engagement Coordinator within CYSHN is Sarah MapelLentz, JD, MPH. The part-time position provides leadership for the inclusion of the family and community perspective in all CYSHN Section efforts.
III.C.2.b.iii. Title V Program Partnerships, Collaboration, and Coordination
Minnesota partners with federal, state and local entities to bolster state agency capacity in meeting the needs of its MCH population.
Coordination with Federal Investments
Minnesota’s Title V program partners closely with the state’s WIC Program, which is funded by the United States Department of Agriculture. Both the Title V and WIC programs work with LPH agencies to implement the programs and ensure our performance measures are met. Many WIC staff participated in our five-year needs assessment and strategic planning efforts.
Minnesota’s Preschool Development Birth through Five Grant focuses on supporting families with young children who experience racial, geographic, and economic inequities, so they can be born healthy and thrive. Minnesota was recently awarded this three-year $26.7 million federal grant by the United States Department of Education’s Office of Early Learning. The grant is a partnership of the Minnesota Departments of Education, Health, Human Services, and the Children’s Cabinet. MDH aims to align the work of the Preschool Development Grant with our five-year action plan for the Child Health and CYSHN Domains.
HRSA/MCHB Investments
Minnesota’s Title V efforts partner specifically with multiple initiatives that are run out of the Maternal and Child Health Bureau of the Health Resources and Services Administration, including:
- State Systems Development Initiative (SSDI) Grant: Minnesota receives a SSDI grant from MCHB to build data capacity around MCH efforts. This grant funds a Senior Research Scientist who is primarily responsible for evaluating MCH efforts and maintaining performance measures for Title V.
- Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Grants: Minnesota is a recipient of the federal MIECHV grant, which is administered by the Family Home Visiting Section in the CFH Division. Like the state’s WIC Program, staff from the Family Home Visiting Section participated actively in our five-year needs assessment and strategic planning efforts to ensure alignment across programs.
- Family-to-Family (F2F) Health Information Centers: Minnesota’s F2F Health Information Center is a partnership of two family-led organizations, PACER Center and Family Voices of Minnesota. MDH partners with both organizations on an informal basis – consulting with family leaders from both organizations on planning, implementing, and evaluating our programs/initiatives. Staff from both organizations also sit on the State’s MCH Advisory Task Force as ex-officio members.
- Early Hearing Detection and Intervention (EHDI) Program: The state’s EHDI program, supported by HRSA, enables Minnesota to develop a coordinated system of care so that newborns, infants and young children who are deaf or hard of hearing are identified early and receive needed supports.
Coordination with State and Local Government Partners
Partnerships within MDH
The Title V Program partners with other programs within MDH. This has particularly occurred these last few years as a part of our five-year needs assessment and strategic planning efforts. Some of the most impactful internal partnerships have included:
- Immunizations, Refugee Health: This partnership was instrumental in responding to a measles outbreak that occurred in the state’s Somali community in 2018. Work continues to monitor and respond to immunization rates in the Somali community, which have decreased due to community-wide misperceptions on Autism Spectrum Disorders and the Measles, Mumps, and Rubella vaccination.
- Health Care Homes: A longstanding partnership aimed at improving access to comprehensive, coordinated primary care via a medical home.
- Public Health Lab/Newborn Screening: This partnership has helped to create long-term follow-up for children identified with newborn screening conditions
- Center for Health Equity: This partnership coordinates and aligns maternal and newborn health activities with communities disproportionately impacted by poor maternal and infant outcomes, including birth outcomes in African American communities and children born into homelessness.
Partnerships with Other State Agencies
Minnesota’s Title V program has a long history of collaboration with the Department of Human Services (DHS), the state’s designated Medicaid agency. In addition to having a Memorandum of Understanding in place to promote partnership related to Title V, some additional examples of collaborative efforts with DHS include:
- Child and Teen Check-Ups Program (Minnesota’s Early and Periodic Screening, Diagnostic, and Treatment program): MDH partners with DHS to provide training and guidance on best practices for developmental screening through an Interagency Agreement.
- Safe sleep: MDH partners with DHS to provide guidance on best practices for safe sleep in child care programs and foster care families.
Title V also collaborates with the Minnesota Department of Education on many projects and programs, including:
- Program for Infants and Toddlers with Disabilities (Part C of the Individuals with Disabilities Education Act (IDEA)): An Interagency Agreement is in place to improve access to screening for young children. This agreement provides funding to MDH, which is used to support the Follow-Along Program (described in the Child Health Domain).
- Services for School-Aged Children (Part B of IDEA): An Interagency Agreement is in place related to coordination of services for school-aged children. This agreement provides funding to support a portion of the salary of a Public Health Nurse Advisor who works to integrate health into the Individualized Education Plans process, especially for youth who are transitioning from adolescence to adulthood.
Interagency partnerships are also in place related to early childhood systems, developmental and social emotional screening, autism spectrum disorders, transitioning from childhood to adulthood, and other systems efforts.
Partnerships with Local Public Health
As stated earlier, Minnesota’s Title V efforts are carried out in partnership with our state’s LPH agencies. State level Title V staff collaborate closely with LPH agencies as they implement MCH programs at the local level. Title V provides administrative oversight of the grant funding awarded to CHBs; and is also responsible for providing technical assistance, consultation, and best practices related to home visiting, infant mortality, developmental screening, family planning, and follow-up for children with special health needs.
Partnerships with Tribal Nations
The Minnesota Department of Health addresses disparities by working closely with Tribal Nations to embed healing strategies into our work, improve family home visiting programs, promote breastfeeding, adapt evaluation methodologies, and learn more about native ways of knowing. This partnership has enhanced our programming by integrating indigenous knowledge to provide culturally appropriate services. Other partners in this work include Johns Hopkins Center for American Indian Health, the Minnesota Indigenous Breastfeeding Coalition, indigenous birth workers, and Bemidji State University.
Partnerships with University of Minnesota
Title V partners with multiple programs at the University of Minnesota. One such partnership is with the MCH Program at the School of Public Health. Two representatives from the MCH Program hold an Ex-Officio and alternate position on the state’s MCH Advisory Task Force. In addition, MDH hires students as interns or paid student workers for Title V programs. Students helped with our five-year needs assessment and strategy development. MDH also partners with the University’s Adolescent Health Resource Center, Healthy Youth Development - Prevention Research Center, Institute on Community Integration (includes Minnesota’s Autism Developmental Disabilities Monitoring Network study and the Minnesota Leadership Education in Neurodevelopmental Disabilities program), and the Center for Children with Special Health Care Needs.
III.C.2.c. Identifying Priority Needs and Linking to Performance Measures
Minnesota’s Priority Needs
Ten Title V 2020-2025 priority areas were identified during Minnesota’s prioritization process. The priorities reflect a continuation of one priority, two modified priorities, and eight new priorities from the previous five year reporting cycle (2010-2015). Many of Minnesota’s priority needs are related to priority needs in the previous five-year reporting cycle, but overall we heard loud and clear the need to focus our efforts towards health equity and the social determinants of health. Half of the priority needs identified are cross-cutting and will require continued collaboration with stakeholders to develop and implement effective strategies.
The final ten priorities are:
- Access to Services and Supports for Children and Youth with Special Health Needs and their Families
- Accessible and Affordable Health Care
- Adolescent Suicide
- American Indian Family Health
- Care during Pregnancy and Delivery
- Comprehensive Early Childhood Systems
- Housing
- Infant Mortality
- Mental Well-Being
- Parent and Caregiver Support
It is important to acknowledge the intersectionality of the priority needs. These needs do not exist in isolation, which is important to remember as we approach solutions. In addition to the topics themselves being intersectional, there are also intersecting processes and systems through which power and oppression are produced, reproduced, and actively resisted. Figure 2 is a visualization of how the priorities relate to one another through intersecting pathways.
Figure 2. Causal-Loop Diagram of 2020 Title V MCH Block Grant Priority Needs
Methodologies Used to Select Minnesota’s Final Ten Priorities
Minnesota used a criteria-based ranking approach and community voting process through three rounds of prioritization (see Figure 3).
Figure 3. Prioritization Activities
Community Voting Process
Minnesota was very inclusive in their priority-setting process with community voting events, remote options for Greater Minnesota residents, and community input being weighted in the determination of final priorities.
Four community forums were held in-person during July and August 2019 (with four corresponding remote events). Stakeholders viewed data stories/placemats and voted for their top 3 priorities by domain. The stakeholder scores were used to prepopulate the stakeholder input score for the criteria-based prioritization.
Criteria-Based Ranking Approach
The MCH Advisory Task Force and Needs Assessment Leadership Team scored each candidate priority area from 1 (low priority) to 5 (high priority) based on the provided data stories. Reviewers were also encourage to do their own research and consider information beyond what is provided by the Title V Data Team.
Criteria-Based Ranking Prioritization Criteria included:
- Magnitude
- Trend
- Health and racial equity
- Impact/severity
- Perceived preventability
- Effective Interventions
- Agency capacity
- Political will
- Stakeholder Input
See Appendix L for the spreadsheet used during these rounds of prioritization. This method was employed during round 1 and round 3. In round 1, the needs assessment leadership team evaluated the list of cross-cutting priorities for final selection by the community. In round 3, they selected the final domain-specific priorities.
One exception was made to our process. American Indian Family Health did not rise to the top of priorities identified through prioritization activities. However, due to the severity of disparities experienced among American Indian families in Minnesota, the Title V Leadership Team made the decision to include this important area in the final list of priorities.
Performance Measure Framework
Minnesota utilized an inclusive priority-setting process to determine our strategies and performance measures to track our progress on these strategies. Minnesota’s state selected priorities along with the corresponding performance measures are located in Appendix M. We plan on continuing to work with stakeholders to improve and add to our performance measure framework. To learn more about the proposed strategies for addressing Minnesota’s new priorities and how our selected national and state performance measures help drive improvement, see the Application Year Plans (section II.F.1).
Emerging Issues
COVID-19 Pandemic
Beginning in early 2020, MDH responded through its Emergency Preparedness Incident Command Structure to the growing number of COVID-19 cases within the state. Beginning in March, and with no foreseeable end, staff from across the department were reassigned to assist with the response in a variety of roles. Much of the work of the Child and Family Health division was put on hold, as over 75% of the staff were assigned to support the response. It is anticipated that with the peaks and valleys of the pandemic, the impact on our workforce will continue through the end of 2020 and beyond. Given the anticipated effect of the pandemic on both state and local budgets, we expect that we will need to plan for budget reductions. The impact of the pandemic will likely be felt for years to come, and will have a lasting impact on the well-being of our workforce and community.
As the pandemic has continued, several issues have emerged that will clearly impact the work of our Division as we move into the future:
- The pandemic has exacerbated the disparities that exist within the state. Health outcomes for those with COVID-19 have been poorest for those communities most impacted by housing instability, food insecurity, and health care access.
- Well-child and well-women visits and immunization rates have declined as families delay routine health care out of fear of contracting COVID-19 if they visit their health care provider.
- CYSHN may be at increased risk for complications from COVID-19. In addition, school and other closings affect the availability of important therapies and supports for CYSHN.
- Pregnant women might have a greater risk for severe illness when they contract COVID-19.
Anti-Racism and Racial Justice Movement
The murder of George Floyd at the hands of Minneapolis police, and the resulting demonstrations and riots amplified attention to inherent racism in our systems and policies. Dr. Martin Luther King, Jr. asserted, “A riot is the language of the unheard.” As a public health institution, MDH acknowledges that systemic failure has endured far too long, and we have an urgent obligation to take concrete steps toward equity. To achieve positive change and an end to racism, we must collaborate with the Black, Brown, and Indigenous communities boldly, swiftly, and thoughtfully. We must work to disrupt and dismantle racism in all its manifestations and structures in our policies, systems, programs, and practices that are designed to improve but instead maintain health inequities and injustices in our Black, Indigenous, and communities of color. MDH aims to support future initiatives for collaboration and conversation on issues regarding race and justice and to proactively engage more in advocacy work in the communities most impacted by inequities.
The historical trauma for Black, Indigenous, and people of color, along with the disproportionate impact of the COVID-19 pandemic and the murder of George Floyd on these same communities, calls for organizational response to and understanding of the impact of trauma on these communities. Additionally, it is imperative to develop ways to support community healing, and well-being, as well as recognize the resilience inherent in these communities.
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