Summary

 

MCH and OCSHCN conducted the 2020 KY Title V Needs Assessment with support from the Eastern KY University (EKU) Facilitation Center. The goal of this needs assessment was to identify priorities for the Title V Program over the next five years in a way that takes into account maternal and child health data, local and state stakeholder perspectives, and patient perspectives.

 

The needs assessment process was organized by MCH leadership, including Dr. Henrietta Bada, MCH Director; Andrew Waters, Asst. MCH Director; Jan Bright, MCH Title V Authorizing Officer/Coordinator; Branch Managers; and epidemiology team along with leadership from OCSHCN which includes Ivanora Alexander, Executive Director; Jonathan Borden, OCSHCN Title V Coordinator, Dr. Patricia Purcell, Medical Director and Karen Mercer, Director of Clinical & Augmentative Services. Beginning in March of 2018, this team met at various times to develop mechanisms to engage stakeholders, set priorities, and collaborate on program mission, goals, and activities.

 

The Facilitation Center managed the qualitative portion of the needs assessment. MCH and OCSHCN handled the quantitative portion. Many stakeholders were involved throughout the process including local health department staff and patients, OCSHCN staff and patients, and a diverse group of MCH stakeholders.

 

Process: Quantitative and qualitative methods, data resources

To measure progress on current priorities and build evidence to identify new priorities, KY used quantitative and qualitative analysis techniques. The quantitative and qualitative data resources and a brief description of the process is described in detail in the following sections.

 

Quantitative Data Resources

 

MCH Fact Sheets

KDPH MCH produced 120 perinatal fact sheets in 2019, using 2017 Office of Vital Statistics birth and death data. These fact sheets were tailored to each of the 15 Area Development Districts (ADD) and addressed 8 maternal and child health issues including births, breastfeeding, infant mortality, low birth weight, births to Medicaid enrolled mothers, prenatal care, prenatal smoking, and preterm birth. Topics chosen were based on existing knowledge about maternal and child health in KY and findings from birth certificate data. Each fact sheet addressed a specific topic at the local level and allowed regions to compare their findings with statewide outcomes. National benchmarks were included when available. Relationships between topic areas, such as how smoking during pregnancy plays a role in low birth weight, were also included in an effort to better explore maternal and child health in KY. These fact sheets helped identify geographic disparities for various maternal and child health domains, which aided stakeholders in understanding specific health outcomes. Local and state staff utilized this in-depth review to identify health priorities.

These fact sheets are available on the KDPH MCH website, distributed in electronic form to stakeholders, and available in booklet form at the November 2019 KY Maternal and Child Health Conference.

 

For every domain covered, the eastern Appalachian portion of the state consistently had poor outcomes for issues of maternal and child health. This region of the state is rural and faces a great deal of general health issues related to access to care, socioeconomic-related issues that create barriers for proper medical care, and cultural perceptions and beliefs, which hinder cues to actions. This eastern portion of the state had the highest percentage of mothers who smoke during pregnancy, and the most preterm births and the highest percent of births with a low birth weight. They also had some of the lowest percentages for breastfeeding initiation and some of the highest percentages for births to Medicaid-enrolled mothers (as high as 75% in some areas).

 

Not surprisingly, urban areas of the state generally had better outcomes overall and had far fewer births to Medicaid enrolled mothers. While these urban populations contain KY’s highest concentrations of the population, they also have an abundance of resources for a variety of maternal and child health issues. While resources are not the only factor at play, this geographic difference was.

 

OCSHCN Action Plans and Access to Care Plans

OCSHCN tracks its progress each year on its Data Action Plan and its Access to Care Plan. For 2019 the Access to Care plan scored the same as in 2018 as it was already at 94.6%. The Data Action Plan score increased from 76.6% to 86.6% (68 to 78). Both document are included in the material by reference.

 

Consumer/Family Survey

MCH and OCSHN distributed a 21-question consumer survey (English and Spanish) in local health departments, OCSHCN clinics, hospitals, and social media from May 2019 - March 2020. The survey had the following sections: problems affecting population domains (women, babies and children, teenagers, CYSHCN); services for CYSHCN; access to care; and demographics. A total of 395 surveys were returned, representing 58 of KY’s 120 counties (48%). A KDPH MCH epidemiologist analyzed the results.

 

The most common races represented were White (84.8%) and Black or African American (8.7%). Approximately 1% of surveys were taken in Spanish, and 6.9% of participants identified as Hispanic. The median year of birth was 1990. A brief report of survey findings is included in the attachments.

 

Stakeholder Survey

A 47-question stakeholder survey was distributed through professional meetings and social media from September 2019 - March 2020. The survey collected demographic information as well as thoughts on health issues, challenges, and successes for various population domains (women, infants, children, teenagers, CYSHCN). A total of 1198 surveys were returned. A KDPH MCH epidemiologist analyzed the results. Attrition was a serious concern with the results. The demographic questions at the beginning of the survey had about 5% missing values; the missing values rate jumped to 25% for questions in the first population domain and gradually increased to upward of 40% for the last population domain. Rather than limiting this sample to the participants who completed the entire survey or reporting information that is potentially biased due to attrition, KDPH MCH decided to exclude this survey for prioritization purposes, and only use it to provide context. For questions prioritizing issues, the frequencies of each response for each applicable question were added together, and then divided by the total number of responses for all applicable questions to obtain the percent of respondents who selected each choice.

 

Although there were participants from all regions of KY, Western KY was under-represented (8.8% of respondents). The largest response for job role and workplace setting was “Other” (40.4% and 44.9%, respectively), so KDPH MCH could draw few conclusions about the participants’ professional experience or role in MCH. Nearly a third of respondents work in a public health department and over a quarter are nurses. Nearly all participants were White (93.3%) and non-Hispanic (98.9%). A brief report of survey findings is in the attachments for MCH, and selected findings are included below.

 

The volume of survey responses was diminished from previous needs assessments secondary to shifts away from direct patient care services at LHDs and additional planned activities with local primary care offices were cancelled with an onset of increased influenza activity and restrictions that later became part of the now Covid-19 restrictions.

 

Qualitative Data Resources

 

Focus Groups

During November 2019 - February 2020, the EKU Facilitation Center conducted five focus groups across KY. The focus groups were held in four cities, with one city hosting an additional focus group for Spanish-speaking families. Combined, 125 individuals participated, representing a broad variety of MCH stakeholders including families and CYSCHN advocates. The purpose of these meetings was to identify the beliefs, values, and opinions of key representatives throughout the state in regards to health-related programs, successes, or barriers impacting women, infants, children, including those with special health care needs, and adolescents. Participants were asked to develop four lists by the end of each session: maternal and child health initiatives that are working well, community needs by population, barriers to improving the priority needs, and actions to improve the priority needs. The EKU Facilitation Center performed the qualitative analysis and provided a report of findings to KDPH MCH.

 

Informed Stakeholder Interviews

During February - March 2020, the EKU Facilitation Center conducted 18 telephone interviews with MCH professionals across KY. Participants were invited based on knowledge, diverse backgrounds, perspectives, and geographic representation. The purpose of these calls was to identify the beliefs, values, and opinions of key representatives throughout the state in regards to health-related programs, successes, or barriers impacting women, infants, children, including those with special health care needs, and adolescents. Participants were asked to develop four lists by the end of each session: maternal and child health initiatives that are working well, community needs by population, barriers to improving the priority needs, and actions to improve the priority needs. The EKU Facilitation Center performed the qualitative analysis and provided a report of findings to KDPH MCH.

 

Kentucky Hospital Statistics

A review of KY hospital data resources was conducted using data sources/reports available from the KY Hospital Association and hospital searches for their required community health needs assessments. While individual hospital assessments were organized and reported in different ways, maternal and child health needs were identified (Kentucky Hospital Association, 2020).

 

KDPH State Health Assessment

As part of the state health department accreditation process, a detailed state health assessment and update were conducted among all DPH programs. This assessment captured quantitative information for maternal and child health needs.

 

KDPH Workforce Development Survey

In 2019, KDPH conducted a workforce survey based upon the core competencies for public health professionals developed by the Council on Linkages Between Academia and Public Health Practice as well as the Public Health Foundation Tool, "Determining Essential Core Competencies for Public Health Jobs: A Prioritization Process." This survey was conducted in partnership with the University of KY and Northern KY University, and it had state and local health department representation on the planning workgroup. The survey had 897 responses across all divisions of public health. The results were presented at the KY Health Department Association meeting. The presentation included the combined results from LHD’s community health improvement plans. In 2019, there were 49 of 61 jurisdictions that participated. The findings were not surprising as they were in agreement with other MCH surveys and quantitative findings.

 

OCSHCN Parent Survey

In January of 2017, OCSHCN began administering a new clinic survey. The first report based on the survey responses titled “OCSHCN Clinic Survey and National Survey of Children’s Health Data Report” was presented to leadership in June of 2019. The report asks the parents of CYSHCN which were seen in our clinics 37 questions, 35 of which match questions from the NSCH. During the timeframe of the study, over 650 responses were collected. The report is included in the material by reference.

With each domain, stakeholders and MCH/OCSHCN leadership reviewed the quantitative and qualitative information available and ranked priorities for each domain for priority areas for the domains. Some priorities were crosscutting and had impact on multiple domains including substance use, mortality, and access to care, poverty, social, emotional, and behavioral health concerns, health literacy, and transition of care.

 

Women’s and Maternal Health

 

Priority overview

 

The patient survey identified priorities of: overweight/obesity, depression, drug or marijuana use, pregnancy and health problems related to pregnancy, and second hand smoke. These matched the priority results from 2015, although the order changed for some items. The qualitative results identified similar concerns noting some priorities such as obesity, early access to prenatal care, well woman visits, and oral health were overshadowed by the imminent threats of substance use and social determinants of health. Priorities include substance use, including tobacco products; access to care; women’s health preventative care; early prenatal care, early identification and referral for maternal morbidities and treatment options, education and adequate nutrition in pregnancy, behavioral health, and transition of care for identified health conditions after pregnancy; obesity

 

Strengths and Needs

 

Stakeholders felt HANDS, LHD health education, and WIC were the most effective form of service for women. Focus group participants and key informants also found these to be strengths along with other initiatives such as Healing, Empowering, and Actively Recovering Together (HEART), safe sleep education, KY Moms Maternal Assistance toward Recovery (MATR), community health workers, and local substance use treatment options.

 

The patient survey identified access to services as an area of need. Access issues included wait times for medical/dental care, geographic proximity of medical care, availability of specialist care, and obtaining Medicaid coverage. Access to services (including treatment and other resources) was the most commonly chosen factor that influenced family planning and mental health care. Evaluation of quantitative date from area development districts coincide with areas with highest poverty rates, substance use, premature births, teen births, smoking during pregnancy, and other harmful pregnancy outcomes. These outcomes correlate with adverse outcomes across the life course seen in KY. Per hospital discharge data for women of childbearing age, primary codes are because of vaginal or cesarean deliveries, chemical dependency emergency room visits, psychiatric emergency room visits, or treatment for injuries.

 

The qualitative priorities identified are education and awareness of women’s health issues, access to care for routine, specialty, or substance use, access to providers, overall impact of substance use (including tobacco products), and issues created by poverty such as obesity, nutrition, transportation, and living conditions.

 

MCH Block Grant Efforts

 

Efforts target improving the health of women and mothers in collaborative efforts with other state and local agencies or programs. The goal is to increase comprehensive treatment and improve preconception and interconception health in partnership with stakeholders to identify gaps and barriers and best practice initiatives.

 

Perinatal/Infant Health

 

Priority Overview

 

The patient survey identified the top issues for babies to be exposure to drugs, alcohol, and cigarettes during pregnancy; second hand smoke; NAS; child abuse or neglect; and babies exposed to substances with long-term delays. Although issues related to substance exposure (including tobacco as well as other substances) were present in the priorities for 2015 and 2020, the other priorities from 2015 (preterm birth and breastfeeding) were not chosen as survey priorities in 2020. Please note the 2020 patient survey did not distinguish between infant and child health, but prioritized issues would be applicable for both infancy and childhood. Priorities include premature birth; infant mortality; substance use exposure, including tobacco products, neonatal abstinence syndrome; infant abuse and neglect, sudden unexpected infant death; infant nutrition, growth and development, early interventions.

 

Strengths and Needs

 

Identified areas of strengths were the home visitation program, WIC, LHDs, and social media campaigns. Focus group comments found that community resources with close relationships with families added protective factors and increased likelihood of positive behavior changes. They found HANDS and First Steps Early Intervention are trusted advisors and models of care. The Hispanic group identified free clinics and support groups as best resources. KY Newborn Screening Program is another strength with over 99% of all newborns screened and 100% referred for evaluation and linkage to long-term care. LHDs provide a positive community linkage for education and outreach for a variety of maternal and child health topics.

 

Stakeholders’ concerns about infants’ exposure to tobacco and substances and impact on adverse infant outcomes including preterm birth, child maltreatment, SUID, and growth and development. In order to address infant development, stakeholders suggested focusing on attachment and bonding, a nurturing environment, and early intervention and screening.

 

Focus groups felt there was a gap in knowledge or awareness of perinatal topics, substance exposed infants, overall growth and development, immunizations, and best practices. They felt safe sleep initiatives still lacked parental buy-in. They voiced a need for greater access for well child providers, healthcare coverage, early intervention services for infants, and proper nutrition. For the Hispanic community or others without health care coverage, they felt funding and limited providers left them at highest risk.

 

MCH Block Grant Efforts

 

Approaches include reducing infant mortality with safe sleep education, breastfeeding promotion, early identification and plan of safe care for infants with NAS. KY continues to monitor birth defects, ensure newborn screenings, home visitation, and early intervention services.

 

Child Health

 

Priority Overview

 

The patient survey identified child issues as: in-utero substance exposure; second hand smoke; and child maltreatment. Child maltreatment was a priority in 2015 and 2020, but pediatric obesity and injury prevention were not chosen as patient survey priorities in 2020. However, both topics were heavily weighted by focus groups and key informants.  Priorities include child injury, mortality, abuse and neglect; obesity/ proper nutrition; access to care; behavioral health, adverse childhood experiences (ACEs); parental engagement/support; tobacco use, second hand smoke.

 

Strengths and Needs

 

HANDS, WIC, and First Steps were identified as community respected and best practice initiatives. Stakeholders identified school based resources such as Family Resources and Youth Services Centers (FRYSC), Coordinated School Health (CSH) efforts, nutrition supports for weekend backpack programs (which supply children with non-perishable food for the weekend), and early childhood centers as strength based resources. KY Strengthening Families (KYSF) is a best practice model for development of improving parent/child resilience through parental partnership in Parent Cafés, and social emotional support for families to develop safe and nurturing environments for parents and children. LHDs were identified as a community partner with the schools to address obesity, nutrition, physical activity and tobacco free environments.

 

The stakeholder survey identified adverse childhood experiences as a major concern for children and stated it was the biggest factor affecting the standard of living for children. To foster child development, stakeholders recommended focusing on the home environment and parental engagement.

 

In order to improve access to care, stakeholders recommended improving access to: providers, providers who accept Medicaid, public health school nurses, and health literacy.

 

Social determinants such as proper nutrition sources, stable housing, and transportation to meet daily needs and for medical care continued in this domain. The impact of substance use on children with out of home placement in foster care with alternative caregivers, aging grandparents, or great grandparents.Obesity was another concern of stakeholders as they noted children are getting far less exercise, having increased screen time, and have poor nutrition.

 

MCH Block Grant Efforts

 

Methods include conducting local child death reviews and development of prevention plans. HANDS, and KYSF supports the overburdened and stressed families. CSH promotes education of the school, child and community to empower positive health choices, while promoting best practice health polices in the school and community.

 

Adolescent Health

 

Priority Overview

 

The patient survey identified as the top issues: bullying, peer pressure, social media; drug or marijuana use; teen pregnancy; depression; teen smoking. Drug or marijuana use, smoking and pregnancy were identified in 2015. New priorities for 2020 include bullying, peer pressure, and social media and depression. Focus groups voiced concerns about the rise in child/adolescent suicide and suicide attempts, lack of coping skills for adolescents, lack of safe environments for adolescents to play or engage with each other, substance use, sexual health, and obesity. Priorities include mental and behavioral health/suicide; obesity, proper nutrition; substance use; tobacco use/vaping, second hand smoke; parental engagement/support; sexual health/teen pregnancy.

 

Strengths and Needs

 

Similar themes emerged from the stakeholder survey related to mental health and bullying among adolescents. Stakeholders identified the top factors affecting adolescent mental health as: social/emotional supports, social stigma, and access to mental health care providers. In order to prevent bullying, stakeholders felt that anti-bullying education was the most effective, followed by social/emotional supports, and parental involvement. Stakeholders also felt that social/emotional supports was one of the top factors affecting the standard of living for adolescent.

 

A concerted focus continues to evaluate and understand the behaviors and values through the Youth Risk Behavior Survey (YRBS) and from the Kentucky Incentives for Prevention Survey (KIP). The 2018 KIP survey had 128,000 student responses. Data from the 2018 KIP survey found an increase in adolescent smokeless tobacco use that doubled the national rate. Marijuana was the most widely used illegal substance increasing from 11.4% in 2016 to 14% of adolescents reporting use in 2018. School safety, bullying, suicide, self-harm, and emotional harm were other concerns.

 

Stakeholders were concerned that substance use by adolescents could lead to increased school absences and dropouts. Over 100 providers participated in a survey at the KY Youth Health Network in 2019. From this survey, substance use, and youth violence, such as bullying, gun violence, suicide, dating partner violence, and alcohol use were identified as the most common issues youth face in KY. Other concerns noted were risky sexual behavior, obesity, and tobacco use. Participants noted the most important topic to improve adolescent health outcomes would be to address mental health/ACEs and the lack of parental engagement with youth.

 

Obesity, lack of physical activity and poor nutrition choices were priority concerns. School nurses noted a rise in Type II Diabetics in the high school age and lack of health literacy, and a heightened need for transition for students with chronic health issues to adult providers. Teen pregnancies are declining overall, however, geographically rates are higher in areas of most effected by SDoH.

 

MCH Block Grant Efforts

 

Reaching adolescents and effecting change is challenging. Tactics include addressing mental health and gatekeeper assessment in the areas they seek help, such as primary care providers, and school setting. Obesity reduction is part of the tenants of the CSH programs. A concerted focus continues to evaluate and understand the behaviors and values of this population, and finding community level opportunities to engage them where they live, work, and attend school. Child death reviews and prevention efforts and early linkage with regional mental health centers are pivotal to inform local efforts. LHDs are engaged in development/implementation of suicide reduction strategies.

 

Children and Youth with Special Health Care Needs

 

Priority Overview

 

The patient survey identified these as the top issues for adolescents: developmental, social, emotional screening; finding doctors who can provide care; early identification of special health care needs; making sure that families are able to receive needed services; finding insurance to pay for needed services. Many of the 2015 priorities stayed the same in 2020. The 2015 priorities that were not selected again in 2020 were the ability to find insurance to pay for care and training and support for children with behavioral issues. Priorities include access to care transition services for care and education needs; parental health literacy and supports; provider education and awareness for caring and resources for CYSHCN.

 

Strengths and Needs

 

While a lack of providers was a common discussion for this population, the services and clinics provided by the Office for Children with Special Health Care Needs were discussed as a positive statewide resource. First Steps early intervention programs were often cited as the best service for early childhood intervention. The bilingual parent support groups in Lexington and Louisville were named as positive resources for this population.

 

Of individuals who responded to the patient survey, 85 reported having a child in their family with emotional or mental health disorders, 79 had a child in their family with behavioral problems, 72 had a child in their family with chronic health conditions, and 57 had a child in their family with developmental disabilities. Of those individuals who reported having a child in their family with special health care needs, the majority reported that they would use peer support services if available. However, less than half reported that they were aware of OCSHCN.

 

Stakeholders felt like these were the factors that most often influenced early intervention: parental understanding of needs and granting consent, lack of providers in the community, and socioeconomic factors.

 

Stakeholders who participated in meetings or calls shared concerns about a need for bilingual therapists and providers. Access to care with concerns about healthcare coverage, as well as lack of specialists and transportation, were commonly discussed. Education of parents to improve understanding of the child’s health care needs, resources, and empowerment of the parent in decision making was a recurring theme in conversations. Transition of the child to adult care providers was considered a strength if the child was part of the OCSHCN services, but lacking in specialty practices. Stakeholders voiced concerns that families of other ethnicities or with language barriers faced discrimination, delay in care, or lack of interpreters to assist with understanding guidance, educational opportunities, or safety factors. Stakeholders voiced concerns about the lack of follow-up for infants with NAS. Mental health supports for both caregivers and children with special health care needs were limited in providers, visits, and insurance coverage. Adequate childcare services for children with special health care needs was viewed as limited.

 

MCH Block Grant Efforts

 

OCSHCN efforts are directed toward reducing barriers with local evaluation and care coordination. Regional office staff assist with access issues, transition, and individualized parent supports to improve outcomes for this population.

 

Cross Cutting/Life Course

 

As discussed in the summary, multiple priorities were crosscutting of all ages or domains. These include mental health/ACEs, behavioral health, health literacy, health outcome education/awareness, substance use, access to preventative and specialty care, equity/inclusion, social determinants of health, communication barriers, and substance use impacts both on health and the family unit. These were emphasized both in surveys and discussions and in review of quantitative health outcomes.

Organizational Structure

 

Governor Andy Beshear assumed the office of governor, December 2019. The KY Executive Branch has 11 Cabinets, with the largest being the Cabinet for Health and Family Services (CHFS). KDPH and OCSHCN are located within CHFS. Other CHFS agencies include the Departments or Offices for Inspector General (OIG), Aging and Independent Living (DAIL), Income Support (DIS), Family Resource Centers and Volunteer Services (DFRCVS), Community Based Services (DCBS), Medicaid Services (DMS), Behavioral Health, Developmental and Intellectual Disabilities (BHDID), Health Data and Analytics (OHDA), and Office of the Secretary.

 

KDPH is the state health agency; with Title V program and funds administrated by the Division of Maternal and Child Health under the leadership of Dr. Henrietta Bada. Kentucky Revised Statute (KRS) 211.180 grants CHFS the responsibility and authority to formulate, promote, establish, and execute policies, plans, and programs relating to all matters of public health. The majority of Title V funding allows LHDs to implement MCH Evidence Informed Strategies based upon the priority needs of the MCH population. Other programs supported with Title V funds include maternal mortality, regionalized perinatal care, access to specialty care (Genetics, Developmental Evaluations) and infrastructure for the MCH effort including IT systems, university based trainings, MCH workforce, and pediatric injury prevention technical assistance.

 

As per the mandates and authorizations in state statute (KRS 200.460-200.499), services provided by OCSHCN include:

1. Direct care gap-filling clinics for those children with a diagnosis on the agency’s eligibility list. Services include direct patient care clinics and care coordination by nurses, therapists and specialty providers using a multidisciplinary team approach. Telehealth services are utilized to reach underserved populations and to improve local access to quality care.
2. Audiology direct care services. OCSHCN administrates the Early Hearing Detection and Intervention (EHDI) newborn hearing screening surveillance program.
3. Foster care support program and home visitation supports for children with special needs placed in child protective services in collaboration with DCBS.
4. Autism Spectrum Disorder (ASD) developmental screening is provided by OCSHCN in several locations throughout the state.
5. Family-to-Family Health Information Center to assist families and professionals in navigating health care systems; information, education, training, support, and referral services. This center provides outreach to underserved and underrepresented populations, guides health program and policy, and collaborates with F2F HICs, family groups, and community and state agencies to improve CYSHCN services.
6. Complex medical care clinics where OCSHCN uses funding from a Title V grant award administered through Boston University to provide care to children with medical complexities.
7. First Steps Early Intervention and Point of Entry Services for the KIPDA region of the state which covers 6 KY counties and includes the states most populous county.

Title V provides supports for population health promotion, prevention, or gap filling services for the MCH population, inclusive of children with special health care needs in all 120 counties in KY. These services are in collaboration and agreement with statewide partnerships with LHDs and other community agencies.

 

Women’s/Maternal Health

 

MCH assures population health services for prenatal, postpartum, and interception plans of care through collaboration with multiple agencies to promote best practice initiatives. Each LHD assures linkage to care, presumptive Medicaid Eligibility, and provides consultation and education for pregnant women seeking assistance at the LHD. MCH collaborates with the Division of Women’s Services (DWH) for family planning and teen pregnancy prevention, and preconception/interconception care efforts.  In the past 3 years, KY has developed a quality Maternal Mortality Review Committee and launched the KY Perinatal Quality Collaborative.

 

Perinatal/Infant Health

 

Perinatal and infant health relies upon preventative service, promotion of nutrition/breastfeeding, safe sleep practices, and growth and development education to assure a strong and healthy start for infants. KY newborn screening identifies and links infants who screen positive to specialty care for evaluation, diagnosis and long-term care. HANDS home visitation provides support for at-risk families promoting healthy birth outcomes. First Steps early intervention program provides resources for education, health, and social services to meet the special needs of children and families.

 

Child Health

 

Child health programs promote well child assessments and physical, emotional, and oral health in children. KY has a robust relationship with injury prevention partners and the KY Department of Education to improve child health outcomes.

 

Adolescent Health

 

Adolescents receive gap-filling services for immunizations. MCH’s focus has been on community level engagement and promotion to address ongoing mental health initiatives to reduce bullying and suicide, reduce obesity, and promote positive behavior and choices. MCH partners with the DWH for teen pregnancy initiatives.

 

CYSHCN

 

Through contractual agreement, or otherwise, OCSHCN provides services necessary to diagnose and treat CYSHCN.  OCSHCN holds contracts with state universities, pediatric specialists, and other providers serving the CYSHCN population.  OCSHCN staffs nurse care coordinators, service coordinators, social workers, therapists, and parent consultants who work along with families to implement their plan of care.

MCH employs 95 public health staff focused on improving the well-being of all KY women, infants, children, adolescents, and their families. With 149 employees statewide, OCSHCN strengths include organizational structure, collaborative history, financial management, and affiliation with hospitals and universities.

 

The foundational statute KRS 211.180, gives CHFS the responsibility and authority to formulate, promote, establish, and execute policies, plans, and programs relating to all matters of public health. This allows MCH to collaborate with LHDs to fund Title V evidence-informed strategies based upon the priority needs. MCH administers many programs, regulatory services, and health promotion initiatives, which include:

• Nutrition Services
  • Federal funded Special Supplemental Nutrition Program For Women, Infants And Children (WIC) including vendor enrollment
  • Nutrition education, breast feeding, and surveillance
  • Medical nutrition therapy
  • Engagement with local farmer’s markets
• Early Childhood Development
  • Health Access Nurturing Development Services (HANDS), home visitation
    program
  • Child Care Health Consultation Program for technical support for health, safety, and nutrition in childcare
  • IDEA Part C, Early Intervention Services
  • Early Childhood Mental Health addresses social, emotional, and behavioral issues for children and pilot programs for Help Me Grow
  • Birth Surveillance Registry (KBSR) provides surveillance for possible causes of birth defects through age 5
  • Kentucky Strengthening Families (KYSF) focuses on enhancing the protective factors of the family
  • Healing, Empowering, Actively Recovering Together (HEART)
• Child and Family Health Improvement
  • Perinatal program provides technical assistance on reduction of early elective deliveries, presumptive eligibility, and linkage to resources
  • Maternal mortality reviews all deaths of pregnant women, within one year of the end of the pregnancy
  • Pediatric programs include
    • Child Fatality Review and Injury Prevention
    • Coordinated School Health
    • School Health Nursing
    • Childhood Lead and Poisoning Prevention
  • Oral health programs provide education and technical assistance to LHDs utilizing public health nurses to screen children and provide fluoride varnish in childcare settings and school settings.
• MCH Supportive Services provide epidemiologic support for
  • NAS Surveillance Registry
  • SUID case registry
  • Pregnancy Risk Assessment Monitoring Survey
  • Kentucky Birth Surveillance Registry with linkage to genetic clinics and IDEA Part C services
  • MCH Budget and Expenditure monitoring

 

CHFS leadership changed in the fall of 2019 with the change of governorship. Eric Friedlander was appointed as the new Cabinet secretary. Mr. Friedlander has 35 years of public service with most of that time served in CHFS leading KY through successful implementation of the Affordable Care Act and transformation of KY’s healthcare delivery system. He returned to this position after serving as the Chief Resilience Officer for Jefferson County with targeted work on infrastructure, poverty, homelessness, and SDoH factors influencing outcomes in that area. His previous positions include Executive Director for the Office for Children with Special Health Care Needs, and Manager of KY’s Early Intervention Program.

 

In February of 2020, Dr. Steven Stack was appointed as the DPH Commissioner. He brings to DPH over 20 years of expertise in emergency department and hospital management, health system reform, physician licensure and regulation, and healthcare anti-trust issues. Dr. Stack has extensive experience in policymaking and advocacy at federal, state, and county levels and before legislative bodies and executive branch regulatory agencies. He also is a skilled public spokesperson and longtime advocate for universal access to affordable and high quality healthcare.

 

Dr. Henrietta Bada, a neonatologist with the University of KY, has served as the Director for the Division of Maternal and Child Health as well as KY’s Title V Director since 2017. Dr. Bada serves as the Mary Florence Jones Professor and Vice Chair of Academic Affairs of the Department of Pediatrics at the University of Kentucky, where she practices clinical neonatology and is an attending physician for the neonatal abstinence care unit. Dr. Bada, a graduate of the University of Santo Tomas, Manila, Philippines, earned a Masters of Public Health from the University of South Florida. She is Board Certified by the American Board of Pediatrics in General Pediatrics and Neonatal-Perinatal Medicine. She has been involved in clinical and basic science research for several years. Her areas of research include newborn brain disorders, perinatal addiction, and developmental follow-up. She served as Principal Investigator (PI) of the Maternal Lifestyle Study (MLS) in collaboration with other PIs from the University of Miami, Wayne State University, and Brown University. The MLS is a longitudinal follow-up of children exposed to cocaine and or opiates in utero until the children reach 16 years of age. Dr. Bada has numerous publications with recent ones related to the findings on follow-up of children and adolescents who had prenatal drug exposure.

 

Ivanora “Ivy” Alexander was appointed OCSHCN Executive Director in April of 2020. Ivy has worked at OCSHCN since 2007, most recently as Assistant Director of Support Services. Prior to working at OCSHCN, Ivy held positions dealing with vocational rehabilitation and therapy services. Ivy is published in the peer reviewed journal Technology and Disability regarding rehabilitation in rural areas. She has won awards from the University of Miami Mailman Center for Child Development related to assistive technology as well as a distinguished service award in the field of vocational rehabilitation services. Ivy holds a B.S. in Biomedical Engineering (BSE) from Wright State University.

 

MCH and OCSHCN Leadership Staff:

• Connie White, MD, MS, FACOG is the Senior Deputy Commissioner for Clinical Affairs, and is Board Certified in OB/GYN with emphasis on patient education and preventive medical care
• Henrietta Bada, MD, MPH, is the MCH Division and Title V Director and is Board Certified in pediatrics and neonatal-perinatal medicine and directs all MCH programming
• Andrew Waters, MPH, is the Assistant MCH Division Director and manages day-to-day MCH operations, budget planning and administration, and functions as the MCH legislative liaison
• Jan Bright, RN, BSN, Manager of the Child and Family Health Improvement Branch and Title V Block Grant Administrator, has 30 years of pediatric nursing experience
• Tracey Jewell, MPH, Manager of the Program Support Branch, MCH Epidemiologist with over 21 years of experience in DPH and Title V
• Nicole Nicholas, MS, RD, LD; Manager of the Nutrition Services Branch has over 22 years of experience as a registered dietician Kentucky WIC programs
• Paula Goff, MS; Manager of the Early Childhood Development (ECD) Branch has over 32 years of experience in ECD programs and IDEA Part C
• Julie McKee, DMD; State Dental Director: KY Oral Health Program
• Karen McCracken, MCH Family Consultant: Early Childhood Mental Health, KY Strengthening Families, and family informed workgroups
• Vivian Lasley-Bibbs, MPH, directs the Office of Health Equity and is a Health Disparities Epidemiologist and Healthy People 2020 State Coordinator
• Ivanora Alexander, BSN, OCSHCN Executive Director, 13 years working at OCSHCN as both a branch manager and assistant director of support services and over a decade more experience in related fields.
• Patricia Purcell MD, MBA, FAAP, OCSHCN Medical Director, has over 20 years’ experience as a pediatrician. Dr. Purcell is the immediate Past President of the KY AAP, is currently the KY AAP District IV Vice Chair, and is an associate professor at UofL’s School of Medicine.
• Freida Winkfield Shaw, MBA, CPA, Director of the Division of Administrative & Financial Services, has over 20 years of accounting, budgeting, and finance experience, and 15 years in grant writing.
• Karen Mercer, RN, BSN, Interim Director of Clinical & Augmentative Services has over 20 years of state government service, with over 17 years at OCSHCN and three with the Department of Juvenile Justice.
• Jonathan Borden, MBA, Ed.D. Procedures Development Specialist II, OCSHCN Title V MCH block grant coordinator, has over 15 years of experience dealing with policy analysis and reporting in both the public and private sectors.
• Sondra Gilbert, Co-Director, F2F, works with the Am. Acad. of Pediatrics Section on Home Care, Midwest Genetic Network, CMC CollN, Family Voices, and Parent to Parent of KY.

 

In the past 5 years, the workforce for MCH and OCSHCN has transitioned across the state from direct service provision to population health. Staffing positions have adapted to be less nurse, clinician focused to public health educators or other specialties. Tenure of staff has decreased as pension changes resulted in retirements, attrition, and delay in hiring for positions occurred. MCH has approximately a 25-27% vacancy rate at any time resulting in about 30 vacant positions. Approximately 10% of staff have been in their current role for less than one year. This has resulted in intensive need to for MCH development at all levels of the division. LHDs likewise have had similar impact resulting in multiple education and technical support opportunities between the state MCH programs and local MCH endeavors.

MCH has many partnerships at the federal, state, and community level to expand the influence and reach to improve outcomes for the MCH population. The primary partnership with OCSHCN allows Kentucky to align agency goals and address priority needs for children with special health care needs. To assure priority goals and program initiatives locally, collaboration occurs at the local level with the LHDs that are able to build work groups within the community. These are often the local school districts, community leaders, private organizations, health care providers, local hospitals, and federally funded health care systems. KY collaborates federally with the CDC, Department for Medicaid Services, Behavioral Health, Perinatal Quality Collaboratives, and others to align KY goals with those of other states through work completed for CFR, MMR, SUID, PRAMS, SSDI, MIECHV, ECCS, WIC, CoIINs, KY Strengthening Families, and more.

 

OCSHCN continues to play a critical role in coordinating partnerships with various boards and councils where vision and work is specific to children with special health care needs. For over 95 years, OCSHCN has developed formal and working relationships with a variety of programs and contracts with a network of direct providers for the clients. OCSHCN strives to remain connected with outside organizations that are resources to families of OCSHCN. With Family to Family programming, CoIIN work, and other opportunities, OCSHN is coordinate efforts to serve this population from the local to the federal level.

 

A more extensive discussion of partnership is addressed specific to each population throughout the narrative sections of this report.

 

 

Needs Assessment Plan

 

The needs assessment process was developed using a logic model identifying primary inputs inclusive of statewide workforce, collaborative agencies, stakeholders, data sources, and consumers as informants of KY MCH needs. MCH goals were for the data to address population-based indicator data, survey data, structured group data, and program-based data. Both quantitative and qualitative input was necessary to understand and inform current and ongoing program activities and to be reflective at the depth of the community level for targeted intervention. With multiple quantitative and qualitative data sets, MCH used multiple methodologies to prioritize data for identification for each population domain and for those that were crosscutting for all domains. Key guiding principles were targeted to focus on the MCH population, health equity and implicit bias, community input/engagement, data driven decisions, evidence-informed practices, collaborative effort with agencies, stakeholders and systems, and accountability.

 

Activities

 

Activities included stakeholder and consumer surveys and field testing during the 2018 MCH conference with over 400 stakeholders in attendance. With public health transformation, MCH recognized LHDs and OCSCHN clinic responses would most likely not be at the same volume as with previous needs assessment years. A data distribution plan was completed and included use of multiple formats comprised of presentations at regional meetings and partnership conferences, reports, and use of electronic distribution. To gain stakeholder input, MCH utilized the resources of the EKU Facilitation Center to lead community stakeholder focus groups through vital tabletop discussions of the driving needs for each population, ending with evaluation and ranking priority needs for each. This process of scoring priorities was used with key informant interviews.

 

Quantitative and qualitative final data reports were posted for a 30-day public comment period with none received.

 

Prioritization and Linkage to National Performance Measures

 

During the final prioritization stage, MCH hosted a facilitated meeting with MCH and OCSHCN leadership with review of all data sources and rankings. Discussion included who or what informed the reports, methodology, outcomes, and planning for development of the state action plan. This meeting scored the various topics based upon trend, health and racial equity, impact/severity, preventability, agency capacity, public perception/political will, and stakeholder engagement/capacity. Once prioritization was complete, EKU facilitated multiple small group meetings with this leadership team to link these priorities to the national performance measures and develop the detailed state action plan evidence-informed strategies and measures.

 

From this process, Kentucky priorities emerged as the following:

1. Infant mortality with specific concerns related to prematurity, substance use exposure (NAS), SUID, abuse and neglect, nutrition, and growth and development
2. Improving women’s health with specific concerns around access to care, resource and referral, substance use disorder, maternal mortality, maternal morbidities, and obesity
3. Child injury prevention and mortality with focus on preventable causes of death and improved well child assessment/immunizations
4. Child growth and development with specific focus on behavioral health and ACEs and parental engagement/support, improved physical activity, reduced obesity rates, and substance use exposure
5. Adolescent mental health and suicide prevention
6. Adolescent behavior risk with focus on healthy lifestyle to reduce obesity, prevent  substance use including tobacco products, reduce teen pregnancy, and building social and emotional resilience
7. Children with special health care needs’ ability to transition to adult care and education services, ongoing community access to care, addressing health literacy, and parental supports

 

With an informed list of priorities and drivers for these, KY was able to link each population domain to a National Performance measure that allowed the state to continue ongoing targeted best practice interventions, develop new action measures, or adapt other measures to better fit the priority needs. This meant a change in the chosen NPM for women’s health, and it intensified the previous surveillance model actions to population health evidence-informed strategies.

 

Emerging Issues

 

Issues discussed did not identify large or unknown issues. Rather, the discussions provided valuable insight on the depth of the concerns, limitations of program or community level interventions, or highlighted strengths and positive community constructs that were valuable for continuation. Throughout the various activities these two factors overshadowed all topic areas, the ongoing substance use crisis, and behavioral health needs for all populations.

 

2015 to 2020 Priority Changes

 

The priority list from five years ago is relatively unchanged. Instead, the current priority list is inclusive of a deeper depth of detail for informing systems level change and improving quality efforts. In the past 5 years, KY has made informed and targeted changes at many operational levels to improve MCH outcomes. It is anticipated these efforts will continue with ongoing program level strategic planning and adaptation utilizing best practice interventions.