METHODOLOGY

CNMI chose a conceptual framework for the needs assessment process that uses a primary prevention and early intervention-based approach with the goal of optimizing health and well‐being among the MCH population, taking into account the many factors that contribute to health outcomes. The CNMI developed this view collaboratively by discussing the overall framework with the MCH Needs Assessment Steering Committee and by subsequently building consensus for this approach with the MCH Advisory Group (both described below in Leadership and Stakeholders).

 

For purposes of assessment and strategic planning, the MCH population was defined as per the domains of women/maternal, perinatal/infant, children, adolescents, children with special health care needs, and cross-cutting/systems building. The overall goal of the process focused on identifying a set of definite priorities that could be acted upon at some depth so that results, even preliminary ones, would be achievable and evident in five years. Strategies employed to achieve results were to be evidence‐based interventions grounded in sound public health theory or research and consistent with the mission and scope of CNMI’s MCH program. A clear MCH public health role needed to exist for an issue to be considered as a potential priority. The process focused on meaningfully involving multiple state and community stakeholders and partners to enhance collaboration, while looking for opportunities to coordinate and integrate MCH efforts externally and internally across the MCH continuum.

 

The needs assessment served as a vital planning process for determining where best to focus CNMI’s MCH efforts to implement programs, policies and systems building efforts that will measurably demonstrate impact within five years. CNMI also employed a strategic planning process to examine how these new priority areas can be incorporated into the existing MCH scope of work. The mixed methods design provided opportunities for a range of input and ensured diverse representation across the CNMI: from youth to adults; parents to providers; and staff to consumers.

Leadership and Stakeholders

CNMI’s needs assessment process was guided by the MCH Needs Assessment Steering Committee. The Steering Committee, which represents the leadership of the MCH program, is responsible for overseeing the development of the needs assessment. With leadership from the Maternal Child Health Bureau Administrator, also MCH Program Coordinator, this group established the overall strategic direction and methodology for the needs assessment while providing the ongoing project management and oversight for the process.

 

Criteria used for selecting stakeholders included their area of expertise and workplace setting (e.g., geographic perspective), training and experience, knowledge of public health, and their ability to conceptualize at the strategic level, while not solely advocating for a single issue. Members solicited feedback from their own constituencies/ stakeholders in between meetings which greatly expanded the reach of this effort.

Data Assessment

CNMI assessed the needs of the MCH population using Title V indicators, performance measures and other quantitative and qualitative data. The consulting advisor reviewed major morbidity, mortality, health problems, gaps and disparities for the MCH population in order to identify specific needs by MCH population domain based on analysis of data trends. The advisor spent time determining data needs and gaps, and reviewing data findings.

 

Specially, the CNMI:

• Reviewed the 2015 Needs Assessment and interim needs assessment findings and noted trends since the last assessment;
• Reviewed recent state, regional and national reports to determine possible issues/problems to be explored in the CNMI;
• Reviewed recommendations made by various task forces;
• Identified major data/indicators (including trends) of health status, access, health needs and health disparities to be included in the assessment for each domain; and
• Determined stakeholder and public input processes.

 

Quantitative methods used for assessing needs for each of the population domains included a review of various the data sources including Vital Statistics Data, U.S. Census Data for the CNMI, Surveillance Systems and Registries, Mortality Reviews, Commonwealth Healthcare Corporation and other CNMI Agency Data and Reports, and Youth Behavior Risk Surveys. Findings were used to guide elements of MCH Public Input Survey.

Public Input Survey

Survey Development

With contribution and approval by the Steering Committee, a survey was developed to gather feedback from stakeholders and service populations on important MCH topics. Beginning in October 2018, MCHB gathered feedback from program staff in their divisions on topics they perceived as the top current or emerging issues among MCH populations. Based on their observations, training opportunities, literature reviews, and interactions with providers and consumers, program staff prepared lists of topics that they perceived as most important to MCH population domains and program implementation.

Survey Dissemination

The electronic survey was directly distributed to 228 contacts in total.  Sixty-six (66) of those contacts were across CHCC programs including family planning, newborn screening, immunization and women, infants and children (WIC); 48 were CHCC clinical providers; and 114 were MCHB partners and consumers.

 

In addition to the direct distribution, the survey was also shared via social media links on What’s App, Facebook and email through an indeterminable number of shares. In addition to the electronic survey, a paper survey was available during home visits with families and caregivers.

 

The survey was open for four weeks in October and November 2018.

 

Upon completion of the original survey results indicated that no adolescents completed the survey.  Therefore, a ten question adolescent-only survey was developed from the original survey asking the adolescent specific questions about health priorities, health beliefs, behavioral health, needs across the lifespan, island of residency, and age group. The survey is included as Appendix 2, Adolescent Public Input Survey, to this report.

Data Analysis

Paper surveys were hand entered electronically for analysis with the online responses. The survey resulted in a large volume of quantitative data. The results were analyzed by focusing on the three topics in each domain the respondents indicated were the highest priority.

 

Demographic information, priorities, issues of parent education and family engagement, and health beliefs were also analyzed. The data analysis process is described below.

  Demographics

The survey asked respondents to identify their role (e.g. parent, health care provider, educator, policy maker, etc.), familiarity with the MCH program and their island of residence. Respondents were also asked to identify their age, race and ethnicity, gender, and education level.

 

Responses were counted and categorized by role, the island of residence and familiarity with the MCH program. The response rates were calculated for these demographic categories and the highest response rates were identified.

  Priorities

There were six questions, one for each domain, that asked respondents to identify their top three priorities. All responses were combined and given equal weight. The ranking of topic chosen within each domain was calculated. The SurveyMonkey-generated data summaries were reviewed and the raw data was cleaned so it did not include any information that did not make sense or appeared to be entered in error. Next, the summaries were reviewed and the top three topics in each domain were identified.

 

The survey asked stakeholders if there are any issues or services that are important that were missing from the survey. Phrases or responses that showed up more than once were highlighted and that information was used to identify themes. Responses were grouped together by theme.

  Parent Education and Family Engagement

A question that asked respondents to identify activities to provide parent education as well as a question that asked respondents to identify strategies for family engagement were included. For each question respondents were allowed to choose up to five responses. The ranking of responses chosen within each question was calculated. The top three responses were identified.

  Health Beliefs

There were eight questions that asked respondents to rate their beliefs on the importance and availability of certain health related services within the known domains. The rating of responses chosen for each question within each domain was calculated.

Survey Limitations

Several limitations were identified that potentially had an impact on the methodology and findings.

 

The timeline for stakeholders to submit feedback through the survey was limited. The survey was open for four weeks. If the timeframe for respondents to submit the survey was open for longer than four weeks, more people could have had an opportunity to complete the survey.  In addition, Super Typhoon Yutu, which devastated the islands of Saipan and Tinian, occurred during the survey collection period. Even given these time factors the response rate was ample.

 

The topics respondents could rank were limited to the list provided by the Steering Committee. The topics identified as priorities may not have been identified as such if respondents could have added topics to be ranked. Although, respondents were asked if there were any issues or services that are important to them that were missing from the questionnaire, what those issues or services are and why are they important, few responses to this question were received (25) and most were related to staffing (9) and behavioral health (8).

 

The number of topics respondents were asked to rank varied by domain and may have impacted rating scores. If more topics were available to choose from, there may have been less consensus among the respondents.

 

Unfortunately, Tinian residents were underrepresented, as only two residents of Tinian completed the survey.  Rota had fifteen responses but the percentage of representation is proportional to the population.

SWOT Analysis

A Strengths, Weaknesses, Opportunities and Threats (SWOT) analysis was conducted on each domain by the Core Needs Assessment Workgroup, which represents broad and diverse sectors of the MCH Programs.

 

A SWOT analysis was used to gain insight into MCHB’s current and future impact on the healthcare arena. This allowed the Workgroup to see competitive advantages and positive prospects, as well as existing and potential problems, in order to develop appropriate plans to capitalize on positives and address deficits.  With SWOT factors identified, decision-makers are better able to ascertain if an initiative is able to be influenced and what is required to make it successful. As such, the analysis aims to help MCH match its resources to the environment in which it operates.

Prioritization of Issues

In keeping with the guiding principles of the process, the Needs Assessment Workgroup and public stakeholders completed the final prioritization process and state capacity assessment to determine the MCH priorities. This process focused on the goal of identifying select areas for MCH investment so that a comprehensive set of interventions could be employed at more depth to affect five‐year outcomes.

 

To gauge capacity, public health management and staff, with input from public stakeholders, were asked to assess their organizational capacity to address the potential MCH priority areas. The following four components were utilized to assess capacity for each of the proposed MCH priorities.

• Structural Resources: Financial, human, and material resources; policies and protocols; and other resources needed for the performance of core functions.
• Data/Information Systems: Access to timely program and population data; supportive environment for data sharing; adequate technological resources to support the use of data in decision‐making.
• Competencies/Skills: Knowledge, skills, and abilities of MCH staff.
• Organizational Relationships: Partnerships, communication channels, and other types of interactions and collaborations with public and private entities.

Following these discussions, each issue was ranked, using a grid specifying impact and feasibility along an x and y axis. This, along with the assessment of state capacity, served as key resources for discussion in determining the final set of eight priorities. The ranking tool is included as Appendix 3, Priority Setting Tool, to this report.

 

In addition, the chosen priorities needed to be tied to the MCH scope of influence in order to assure ultimate impact. In order to do so, the Steering Committee was charged with connecting each potential priority to a national or population‐based outcome measure. To this end, the Steering Committee prepared a justification for each priority highlighting the following: public health/MCH role; data to support the need (severity or numbers affected); effective interventions/strategies that exist to address the issue; local capacity score for the issue and specific indicators that could be used to measure success within the five‐year period.

 

Domain: Women/Maternal

Data Assessment

The CNMI has a very large underserved population who are not receiving recommended annual preventive health services within the community. As in many underserved communities with a high percentage of families living below the federal poverty level, these women face many barriers to care, including, unaware of health needs; shame or fear in seeking reproductive health services; access to care issues; uninsured status; transportation issues; and childcare issues.

 

In 2017, data review of visits to the Family Planning Program and the CHCC Women’s Clinic indicate that just 18.2% of women ages 18 through 44 completed a preventive doctor’s visit at CHCC. Screenings are critical in early identification, prevention, and treatment of disease. Diseases of the circulatory system, neoplasms, and diabetes are the top three causes of death for adults, even among women, in the CNMI based on Health and Vital Statistics data for the period of 2008 through 2016. Eighty four percent (84%) of individuals who responded to the 2016 CNMI NCD & Risk Factor Hybrid Survey reported that they avoided medical care due to costs associated with a doctor’s visit[1].

 

The NCD Hybrid Survey indicates that for women ages 21 thru 65 years old, just 43.2% reported being up to date with pap testing as compared to US national average of 69% in 2015 according to the Centers for Disease Control and Prevention National, Center for Health Statistics.

 

Although there appears a decrease in the number of women screened who were at risk for anemia in 2017, a review of nursing log books at the CHCC hospital OB unit indicates an increase in the number of admissions with an anemia diagnosis indicated. Additionally, OB admissions also indicate an increase in the number of admissions that required blood transfusions. Between the years of 2016 and 2017, there had been an increase in admissions with anemia diagnosis by 47% and an increase in admissions with blood transfusions by 56%. A possible factor that may have contributed in these increases was the implementation of a blood transfusion policy in 2016. In response to a sentinel event, the CHCC had implemented a blood transfusion policy to ensure rapid provision of blood components in correct ratios during hemorrhage circumstances and which provides guidance and protocol in identifying and addressing situations that require blood transfusions.                       

Domain: Perinatal/Infant

Data Assessment

Recent NOMs and NPMs data describe perinatal/infant health in the CNMI, during the previous two years (2016 and 2017), are as follows:

• Slight increases in ever breastfed from 94.1% to 95.6%;
• Slight increases in percent breastfed exclusively through 6 months from 1.7% to 2.5%, although still quite low overall;
• Increases in perinatal mortality rate to 5.8 per 1,000 live birth, plus fetal deaths from 4.9.

Recent SOMs and SPMs data describe perinatal/infant health in the CNMI, during the previous two years (2016 and 2017), are as follows:

• Slight increases in first trimester prenatal care for resident women from 43.4% to 45.8%.

The perinatal mortality rate in the CNMI in 2017 was 5.8 per 1,000 live births, see Table 7 below. According to the National Vital Statistics Reports, the most recent national perinatal mortality rate available was 5.77 per 1,000 live births in 2018 quarter 1.  CNMI has reduced its perinatal mortality in the past five years and is now consistent with the national rate.

Table 7. Perinatal mortality rate per 1,000 live births plus fetal deaths

	2013	2014	2015	2016	2017
Rate:	12.1	14.0	2.7	4.9	5.8
Numerator:	13	15	3	6	7
Denominator:	1,074	1,075	1,107	1,216	1,209

         Source: Health and Vital Records Office

During recent Fetal and Infant Mortality Review, a total of 32 cases were reviewed in which some of the findings included: 41% of the cases had prenatal care initiated during the first trimester of pregnancy; 69% of the prenatal women had a complication or pre-existing health condition; 47% of the cases had three or less prenatal visit and only 6% completed at least ten visits; and almost one-quarter (22%) were uninsured. Recommendations that resulted from the case reviews included: need to include private clinic providers in the review; prenatal records from private clinic providers were lacking; lack of transportation was noted in many of the cases as a barrier to prenatal care; need to focus on engaging women to increase early and adequate care; and a need to focus on Preconception Health (preventive care before and between pregnancies).

 

Accessing early and adequate prenatal care continues to be a need for all CNMI pregnant women. In 2017, just 46% of pregnant resident women received prenatal care during the first trimester of pregnancy. Lack of transportation, not having insurance, and no child care are top three reasons provided for not going to prenatal care appointments. Eighty-four percent (84%) of individuals who responded to the NCD Hybrid Survey reported that they avoided medical care due to costs associated with a doctor’s visit.

Domain: Child

Data Assessment

 Recent NOMs and NPMs data describe child health in the CNMI, during the previous two years (2016 and 2017), are as follows:

• Significant increase in children who complete Ages and Stages Questionnaire screening at a CHCC well-visit from 38.4% to 53.6%
• Slight decrease in children aged 1-17 who had a preventive dental visit from 13.6% to 11.9%;
• Increase in dental caries from 55.6% to 58.4%.

Recent SOMs and SPMs data describe child health in the CNMI, during the previous two years (2016 and 2017), are as follows:

• Slight increases in children age 19-35 months receiving vaccines from 33.8% to 39.2%, although low overall;

Although comparison of the past two years’ NOM shows an increase in dental caries, it has remained steady when including an additional year of data, as seen in Figure 5: School Sealant Program below.  Through a formal partnership with the Public School System, the MCHB Oral Health Program continues to provide school based preventive services to students enrolled in Head Start, and students in 2nd and 6th grade. Students who participate in the Fluoride Varnish or Dental Sealant programs are provided oral health education, oral exams, and fluoride varnish or dental sealant application.

                                  

According to Women, Infants and Children (WIC) 2018 data, 22.9% of child participants aged 2 to 5 years old are overweight as defined by the 85th percentile or above and 10.3% are obese as defined by the 95th percentile or above. This is a steady increase in the same population over the past three years, see Figure 6 below.

Figure 6. Percentage of Overweight and Obese Children Age 2-5

                                    Source: WIC Program

It is known that onset of overweight in childhood accounts for 25% of adult obesity; but overweight that begins before age 8 and persists into adulthood is associated with an even greater degree of adult obesity. Childhood overweight is associated with a variety of adverse consequences, including an increased risk of cardiovascular disease, type 2 diabetes mellitus, asthma, social stigmatization, and low self-esteem.  According to the middle school biennial Youth Risk Behavior Survey, more students describe themselves as overweight, increasing from 26.5% in 2015 to 30.8% in 2017, see Table 9 below.

 Table 9.  Physical Activity Related Youth Risk Behavior Survey Results, Middle School

Question	2013	2015	2017
Percentage of students who describe themselves as slightly or very overweight	26.9	26.5	30.8
Percentage of students who ate breakfast on all seven days before survey	45.0	51.1	48.0
Percentage of students who were physically active at least 60 minutes per day on 5 or more days a week	45.5	45.5	50.9
Percentage of students who watched television 3 or more hours per day (on an average school day)	32.5	29.1	24.3
Percentage of students who played video or computer games or used a computer 3 or more hours per day (on an average school day)	-	46.6	48.2
Percentage of students who played on at least one sports team in the last 12 months	47.9	53.3	50.4

         Source: Source: CNMI Middle School YRBS

Domain: Adolescent

Data Assessment

Recent NOMs and NPMs data describe adolescent health in the CNMI between 2015 and 2017 (based on biennial completion of the Youth Risk Behavior Survey (YRBS) are as follows:

• Slight increase in adolescents aged 12-17 who are bullied from 22.1% in 2015 to 23.3% in 2017.

Recent SOMs and SPMs data describe adolescent health in the CNMI between 2015 and 2017 (based on biennial completion of the YRBS) or during the previous two years (2016 and 2017) are as follows:

• Slight increase in high school students who have thoughts of suicide from 22.8% to 25.0%;
• Steady decrease in pregnancy rates among adolescents aged 15-17 from 16.5 in 2015 and 11 in 2016 to 8.5 in 2017.

Trend analysis for the past three biennial YRBS survey administrations indicate slight increases in the number of high school students that reported being bullied on school property and electronically.

Review of data on the past three years (2015 through 2017) has indicated a steady decline in the rate of teen births, see Table 13: Teen Birth Rates below.  This may be due to the steady increase in family planning visits by adolescents in the past several years, seen in Table 14 below.  Other possible contributing factors are seen in additional measures on adolescent sexual behavior assessed through the biennial high school YRBS. Review of CNMI high school YRBS data indicates a decline in most sexual risk measures and an increase in condom use between 2013 through 2017, as indicated on Table 15 below.           

Table 13. Teen Birth Rates

Teen Birth Rate per 1000	2015	2016	2017
15-17 year olds	16.5	11.0	8.5
15-19 year olds	30.2	26.9	17.1

             Source: CNMI Health and Vital Statistics Office

 Table 14. Adolescent Family Planning Visits

Family Planning Visits	2014	2015	2016	2017
15‐19 year olds	134	109	250	248

                Source: CNMI Family Planning Program

Table 15. Sexual Activity Related Youth Risk Behavior Survey Results, High School

Question	2013	2015	2017
Percentage of students who ever had sexual intercourse	43.0	42.2	33.6
Percentage of students who had first sexual intercourse before age 13	6.9	6.7	4.1
Percentage of students who had four or more sexual partners in lifetime	11.9	10.4	5.9
Percentage of students who had sexual intercourse with 1 or more partners in the last 3 months	29.7	29.0	24.3
Percentage of students who used a condom during last sexual intercourse	45.0	45.8	52.6

Source: Source: CNMI High School YRBS

Domain: Children with Special Health Care Needs

Data Assessment

Recent NOMs and NPMs data describe children with special health care needs in the CNMI, during the previous two years (2016 and 2017), are as follows:

• No change in children with a medical home at 46.8%;
• Slight decrease in children aged 0-17 adequately insured from 59.5% to 57.8%.

MCHB programs have been focused on building a comprehensive and coordinated system of care targeted at ensuring that all children in the CNMI receive appropriate and timely services, including screening, evaluation, diagnosis, early intervention, and family support. Without early identification and intervention, children with special healthcare needs often experience delayed development.

 

The CNMI Part C: Early Intervention Services (EIS) Program is administered under the Public School System and remains a vital partner for ensuring the children with special healthcare needs and their families receive the necessary services and supports. This partnership is formalized through an existing Interagency Agreement. Identification is done through newborn screenings services, developmental screening, working with providers and nurses who identify conditions to refer, and in educating the community and families regarding developmental milestones and available screening services for concerns. Title V funds are used to support these activities. In 2017, the EIS program received a total of 176 referrals, in which 62 infants and toddlers were qualified for enrollment into the program. Most of the referrals, 26.7%, were from the CHCC children’s clinic, 22% from the CHCC nursery, 12.5% from the NICU, and 9% were parent self‐referrals. Referrals were also received from the H.O.M.E. Visiting Program, Kagman Community Health Center, WIC, CHCC Pediatrics Unit, Day Care Centers, and the EHDI program.

 

The CNMI Early Hearing Detection Intervention (EHDI) Program has been improving the EHDI system of care to include partnerships with stakeholders, including: nurses, midwives, physicians, audiologist, public health programs, and the Early Intervention Services program. The program works to achieve the national recommendation of 1‐3‐6: screening all babies by one month of age; completing Diagnostic Testing for babies that require it by three months of age; and ensuring that all babies diagnosed as deaf or hard of hearing are enrolled in Early Intervention Services by six months of age. In 2017, 99% of babies born in the CNMI were screened for hearing loss before one month of age.

 

In 2015, newborn bloodspot screening was reinstated at the Commonwealth Health Center allowing for babies born in the CNMI to be screened for various disorders. In 2017, approximately 50%, or 606, of the babies born in the CNMI received a newborn bloodspot screen. Twenty-seven (27) of those screened had a presumptive positive with three receiving a confirmed diagnosis.

 

In 2017, 90 children ages three to five years enrolled in Part B: Early Childhood services, and 877 children ages six through 21 enrolled in Special Education (SPED). Data from the Public School System indicates that 40% of the children enrolled in Early Childhood and SPED had specific learning disabilities, 16% identified as having a developmental delay, and 14.5% have autism. See Table 20 below.

Table 20. Disability Category and Enrollment in Early Childhood Services and Special Education, 2017

Category	Enrollment Percent
Specific Learning Disability	40.43%
Developmental Delay	16.07%
Autism	14.53%
Other Health Impairment	10.24%
Intellectual Disability	6.45%
Multiple Disability	5.12%
Hearing Impairment	2.56%
Speech or Language Impairment	1.64%
Emotional Disturbance	1.54%
Orthopedic Impairment	0.61%
Visual Impairment	0.41%
Traumatic Brain Injury	0.31%
Deaf-Blindness	0.10%

Source: Public School System, SY 2016-2017

 

The Shriner’s clinic based in Honolulu, Hawaii provides outreach services on the Northern Mariana Islands twice a year for children ages zero through 18 years with musculoskeletal healthcare needs. Referrals to this clinic are made by a primary care provider or anyone in the community who has concerns. Referrals are managed by the Newborn Screener and Family Support Coordinator under the MCHB, who assists families with scheduling and completing all the required paperwork. The outreach clinic comes to Saipan every six months (January and July) and to Tinian once a year, during the summer. Children from the island of Rota are flown to Saipan. Shriner’s provides evaluation and treatment for all children with musculoskeletal conditions in addition to providing orthoses for the torso, upper and lower extremities. If needed, children are referred to the Shriner’s Hospital for Children in Honolulu for orthopedic surgeries. In 2017, Shriner’s providers saw a total of 196 children and eight were referred for surgery in Honolulu. Additionally, the Shriner’s Orthotics provides outreach to Saipan four times a year. A provider comes to Saipan to obtain impressions and then returns after a couple of months to conduct orthotics fittings. Families are provided education on how the orthotic should work, cleaned, and maintained. A total of 38 children were provided orthotics through Shriner’s in 2017.

Domain: Cross-cutting/Systems Building

Data Assessment

Data sources for cross cutting issues are difficult to mine as there is no central depository. All data is collected for individual programmatic purposes and often by defined age groups thereby making it difficult to have a full picture of health across the lifespan of the individual and the whole of the community.

The majority of adults in the CNMI has visited a dentist or dental clinic. However, according to the 2016 CNMI NCD Hybrid Survey, only about one-third of adults reported having a dental visit within the past year. Additionally, about two thirds of adults reported having at least one permanent tooth removed because of tooth decay or gum disease.

            

According to the 2016 CNMI NCD & Risk Factor Hybrid Survey Report, one out of four adults in the CNMI reported to currently smoke cigarettes and one out of five adults reported chewing betel nut. Almost half of CNMI adults report drinking alcohol in the past 30 days, with 3.1% having drunk alcohol every day. In addition, 23% of adults in the CNMI reported binge drinking in the past 30 days (binge drinking is defined as five or more drinks for men and four or more drinks for women in one sitting). Although CNMI adults report smoking cigarettes, the majority (77.8%) report wanting to quit. Among the betel nut chewers, 64.7% report wanting to quit.

 

Betel nut chewers and alcohol drinkers tend to be the younger adult age groups. Adults 25-34 years old have the highest prevalence of smoking. Additionally, the majority of chewers are between the ages 18 to 34 years old. See Figure 12 below.

Figure 12. Percent Age Group of Current Cigarette and Betel Nut Users

       Source: CNMI NCD & Risk Factor Hybrid Survey Report, 2016

According to the 2013 CNMI Behavioral Health Survey very few people report illegal drug use. The highest use is for marijuana with 22.6% reporting use.  For all others the use was below 3%- heroin, crack or cocaine, methamphetamine was 2.6%, inhalants 1.4%, prescription drugs without a physician’s order 1.2% and hallucinogens 0.7%. 

 

Services to address substance use disorders and other mental health issues are very limited in the CNMI. The CNMI has experienced an increase in the number of babies with prenatal exposure to methamphetamine. Illicit drug use, particularly methamphetamine, in the CNMI has increased in the past few years resulting in the establishment of the first Drug Court program in 2016 with the Commissioner for the Department of Public Safety proclaiming a “War on Ice” as a response to increase crime rates related to illicit drugs. Data obtained from the CNMI Office of Attorney General indicates an overall increase in the number of criminal cases filed in 2016 as compared to 2015, with a 39 percent increase in the number of drug related cases. While there are numerous efforts around substance abuse prevention, treatment services are lacking.

 

The 2010 Census reports the CNMI uninsured at 34%; more than double the 15% of the uninsured in the US. Looking specifically at CNMI children, the numbers of uninsured are slightly higher than the overall population, see Table 24 below.

Table 24. Insurance Status of CNMI Children age 1-9 years

Year	Percent Uninsured	Percent with Medicaid
2011	68.4	27.7
2012	60.6	28.5
2013	56.9	38.1
2014	50.0	49.4
2018	35.1	53.3

Source: RPMS, CHCC

As the number of children with Medicaid has almost doubled since 2011, the number of uninsured has decreased by almost half. However, the number uninsured still remains remarkably high at 35% of children. The same improvement in insurance status can be seen in women utilizing the CHCC for medical care, see Table 25 below. However, again the uninsured rate of 40% is well above the national average of 15%.

Table 25. Insurance Status of Women at CHCC

Year	Percent Uninsured	Percent with Medicaid	Percent with Private Insurance
2008	49	27	24
2013	25	55	20
2018	39.9	32.1	28.1

Source: RPMS, CHCC

Medicaid Expansion as part of the Affordable Care Act (ACA) accounts for much of the increase in coverage. However, increases in Medicaid funding to the CNMI under U.S. Public Law 111-148 will currently cease in September 2019 resulting in a 63% reduction in State Medicaid spending. In 2019, the $100.1 million additional funding provided from the PPACA between 2011 and 2019 expires, leaving a funding gap of approximately $11 million annually. This impending resource expiration is a major concern for the CNMI Medicaid Agency and will likely result in increases in uninsured.

 

Little data exists on topics such as health disparities within the community, behavioral health issues, consumer desired use of technology including telehealth, and preferred communication of health messages. 

[1] CNMI Non-Communicable Diseases & Risk Factor Hybrid Survey, 2016 accessed at http://ver1.cnmicommerce.com/wp-content/uploads/2017/04/CNMI-NCD-Survey-Report-FINAL-2017.pdf, on March 11, 2019.

Title V Program Capacity

Organizational Structure

The MCH Program is administered within the Division of Public Health of the Commonwealth Healthcare Corporation (CHCC).  In 2012, Public Law 16-51 dissolved the CNMI Department of Public Health and created the CHCC. The CHCC is a semi-autonomous, quasi-governmental corporation. As such, it has a Governor-appointed Board of Directors and in that way is part of the central government of the CNMI.

The CHCC is the operator of the Commonwealth's healthcare system and the primary provider of healthcare and related public health services in the CNMI, including management of federal health related grants. The Chief Executive Officer of CHCC is the authorized representative for the MCH Program. The Chief Operations Officer provides oversight to the program. The following are senior leadership positions: Ms. Esther Muna, Chief Executive Officer; Mr. Subroto Banerji, Chief Operations Officer; and Mr. Jesse Tudela, Deputy Chief Operations Officer.

The Division of Public Health is responsible for administering the Title V MCH Program. The MCH Program falls under the Maternal Child Health Bureau. The MCH Program is one of the six programs under the Maternal Child Health Bureau along with Family Planning, HRSA and CDC funded Universal Newborn Hearing Screening/Early Hearing Detection and Intervention Programs, Public Health Dental Clinic, H.O.M.E. Visiting, and State System Development Initiative. The Administrator of the MCHB also acts as the MCH Program Coordinator. The development of the MCH Bureau has been a positive asset in that it has improved coordination and collaboration among the programs.  See Attachments: Organizational Chart.

All MCH services are also provided at the Tinian and Rota Health Centers either directly or through rotating visits. A Resident Director oversees services provided in Rota and Tinian. Two H.O.M.E. Visiting staff are placed on these islands.

 

 

 

Agency Capacity

Women/Maternal Health

Prenatal and Postpartum care, Family Planning services, and comprehensive women’s health and gynecological services are provided at the Women's Clinic located at the CHCC, and Rota and Tinian Health Center. There are midlevel providers as well as four obstetricians/gynecologists at the Women's Clinic for referrals of high risk cases such as diabetes and hypertension. Increasing the percentage of women receiving adequate prenatal care visits, especially during first trimester, continues to be a focus for the Division.

The HIV/STD Resource and Treatment Center provides counseling, partner identification and notification, treatment, and case management. Some goals of the program include community testing and mass media campaigns emphasizing behavioral change.

Breast cancer and cervical cancer screening exams such as pap smears, clinical breast exams, and mammograms are provided at no cost to women that meet the Breast and Cervical Cancer Screening Program's criteria.

Perinatal/Infant Health and Child Health

Perinatal health is also described above in Women/Maternal Health prenatal care.

Newborn assessments, well baby/child exams, and adolescent health visits are provided at the Children’s Clinic and at the Rota and Tinian health centers. Breastfeeding is also discussed and education for proper technique or identified issues is completed.

Providers at the Children’s clinic make referrals to MCHB programs for dental care, hearing screening, early intervention services, specialty clinics, and home visits are made based on assessment findings. The promotion of breastfeeding is actively done during these visits.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Program serves to safeguard the health of low-income women, infants, and children up to age five who are at nutritional risk by providing nutritious foods to supplement diets, information on healthy eating, and referrals to health care. MCH Program partners with WIC on many initiatives including breastfeeding support and encouraging prenatal care.

Newborn Hearing Screening has successfully screened 98% of newborns before hospital discharge. Quality improvement activities are focused on reducing loss to follow-up.

The Immunization Program ensures availability and accessibility of vaccination services. The Immunization Program was transitioned under the MCHB in May of 2020. The Public Health Clinic is open for walk-ins, improving accessibility. The implementation and strengthening of the Web IZ immunization surveillance system, will help improve tracking and case management of children in need of immunizations.

The School Health Program fulfills the local school health certificate requirement for all children entering school for the first time in the CNMI. A school health certificate is issued after a physical examination, including hearing and vision screening, is performed as well as completing the required immunization series for that age group.

The School Dental Program has proven to be one of the most successful collaborations between the Division of Public Health and the school system, both public and private. A dental assistant provides a full mouth examination, fluoride varnish and sealant application, and education at each Head Start facility. In addition to the Head Start Program, every school year children in second and sixth grades in the public and private schools, including Rota and Tinian, are bussed to the Dental Clinic to receive dental services. Services provided include a full mouth examination in which they are assessed for caries and periodontal diseases, sealant application, and education. The children are given report cards on their dental assessments so parents can make necessary appointments for further dental treatment and procedures.

Outside of the School Dental Program, the Dental Clinic provides services that include general dentistry such as sealant application, fluoride tablets, education/counseling, community outreach activities, cleaning, extraction, and fillings. Public Health, along with four private dental clinic, accepts children enrolled in the Medicaid Program for their restorative treatment needs. The Dental Clinic includes the private clinic information on all brochures to promote access to oral health.

Adolescent Health

Preventive and primary health care services for adolescents: Services provided at Women's Clinic, Children's Clinic, and HIV/STD Resource Center as described above.

The adolescent health focus is on the avoidance of risky health behaviors such as drugs, alcohol, and unsafe sex. The MCH Programs works closely with the HIV/STD Program. In addition, much work for this population is done in collaboration with the Public School System (PSS). Mental health and social services are provided through the Community Guidance Center (CGC).

The CGC promotes positive youth behaviors. The CGC leads underage drinking prevention efforts. It also addresses injury and suicide, violence prevention and has strong ties to the federal, state and community agencies and programs that carry out risky behavior reduction activities. The CGC Garrett Lee Smith Youth Suicide Prevention Program focuses on ages 10 to 24 years old to promote awareness that suicidal and self-destructive behavior is a public mental health problem in order to reduce stigma associated with being a consumer of suicide prevention, increase system-wide capacity to deliver effective suicide prevention and intervention, develop collaborations and networks that support common goals in suicide prevention and improve the usefulness of  data surveillance systems to effectively inform suicide prevention and intervention efforts.  The CGC Systems of Care focuses on ages 5 to 21 years old to promote the improvement of care and opportunity for youth with and youth at risk of severe emotional disturbances through improved collaboration between youth and family serving groups.

Children with Special Health Care Needs

Services are set up to promote an integrated service delivery system for CSHCN from birth to 21 years of age and their families. The Program works collaboratively and cooperatively with other agencies and departments to provide appropriate education and support services needed to meet their social, emotional, physical, and medical needs. The CSHCN Program has been developed as an interagency effort among the MCH Program, the Hospital, the Special Education Program, and the Early Intervention Services Program.

 

One priority of the program is to identify these children at the earliest age possible, preferably right after birth. The entry point into care is through referral to Child Development Assistance Center (C*DAC). C*DAC employs special education teachers, social workers, and occupational, physical, and speech therapists for 0-3 year olds. MCH Program employs care coordinators who oversee the coordination of specialty care that the children need.

The program provides transportation, eligibility assistance, and activities such as parent events, health forums, and trainings, to support CSHCN and their families. Challenges for the program include: lack of qualified professionals on-island for specialized services; clients who do not qualify for SSI, Medicaid, etc., because of citizenship status; and limited respite care facilities for families of CSHCN.

 

Contractual services, such as the audiologist, provide services that are not available otherwise. Specialty teams from Shriner Children Hospital in Honolulu visit CNMI twice a year. These specialized groups provide services in Cardiology, EENT, Orthopedics, and select surgeries. With limited or practically no state-of-the-art medical equipment, compounded with the lack of physicians with specialized skills, CNMI heavily relies on overseas contractors and medical referrals, both of which are very expensive. MCH collaborates with health care providers and the Medical Referral Program to ensure children needing extended care are treated off-island.

 

Cross-cutting

The Dental Program described above provides services for all MCH populations.

 

In addition to those mental health activities listed above, MCH works closely with the Community Guidance Center (CGC) for all cross-cutting mental health needs. The CGC’s Recovery Clinic, a substance use disorder treatment program, offers services to support individuals and families affected with substance use disorders with essential information and coping skills to pursue health, wellness, and recovery.  In 2017, the Recovery Clinic launched Intensive Outpatient (IOP) Treatment Services for individuals affected by moderate to severe substance abuse disorder. Through the Matrix Model, participants and their families are provided structured, evidenced-based treatment for 16 weeks and 36 weeks of continuing care.  Alongside the Matrix Model, CGC offers peer support and 12 Step facilitation which builds and empowers participants and their families in the ongoing recovery process.

 

The CGC’s Victims of Crime Advocacy (VOCA) Program’s purpose is to support the provision of services to all victims of crime, whether reported or not, in the CNMI. Services include response to the emotional and physical needs of crime victims, help for primary and secondary victims of crime stabilize their lives after victimization, assistance of victims to understand and participate in the criminal justice system, and to provide victims of crime with a measure of safety and security. Counselling services available to victims of crime include counselling for secondary trauma, domestic violence, depression, panic disorders, suicide ideation, and physical, emotional and/or sexual abuse.

 

MCH works closely with the Medicaid office to promote eligibility and enrollment. A designated MCH staff member provides assistance in filling out Medicaid applications, assists with expediting application processing, and also provides translation assistance for those with limited English.

 

MCHB continues to improve data capacity. The CNMI MCH State Systems Development Initiative (SSDI) Project continues to focus grant resources to improve data capacity for the CNMI Title V MCH Block Grant program including: the 5 year comprehensive needs assessment, development and tracking mechanisms for ESMs, and data gathering and analysis on NPMs, SPMs, and NOMs. Additional information available in section III.E.2.b.iii. States Systems Development Initiative and Other MCH Data Capacity Efforts of this report.

 

 

Workforce Capacity

The MCHB management and team are committed to promote the strategic mission and values of the organization by developing a culturally competent and diverse workforce. To address the shifting demographic trends in the population served, each program within the Bureau works closely with key stakeholders and consumers to understand and manage the social and cultural differences of target groups.

 

The MCH Bureau is administered under the leadership and direction of the Chief Executive Officer, Esther L. Muna. Direct oversight is provided by the Chief Operations Officer, Subroto Banerji. The following key personnel provide support and coordination:

 

MCH Program Coordinator/MCH Bureau Administrator: Heather Santos Pangelinan, MS.

SSDI Project Coordinator: Richard Sablan, BS.

MCHB Fiscal Specialist: Maxine Pangelinan, MBA.

MCH Services Coordinator: Mr. Yarobwemal, MS.

Children with Special Health Care Needs Coordinator: Danielle Youn Jung Su, MS, CRC.

 

The following is a listing senior level management and key staff involved in the Title V needs assessment and application processes although not directly supported by Title V funds.

 

Department Chair of Pediatrics: Elizabeth Triche, MD, MPH.

CHCC Dental Clinic Dentist: Dr. Angelica C. Sabino, DDS.

OB/GYN Physician/Family Planning Program Medical Director: Michael Deary, MD.

 

The MCH Programs continue to provide coordination and provision of outreach clinic services, education and awareness, data collection and reporting, and other services aimed at improving the quality of life for our MCH population. The programs administered under the CNMI MCHB continue to meet major milestones and objectives. The following are key MCHB staff:

 

Family Planning Program Manager: Crystal Pangelinan, MS.

H.O.M.E. Visiting Project Coordinator: Yuline C. Fitial, BS.

Newborn Screener and Family Support Coordinator: Shiella Marie Perez, ASN.

 

 

 

KEY Partnerships

The MCH Program has been instrumental in forging strong partnerships to enhance disease prevention and public awareness activities. Other strategies to strengthen the MCH Program’s capacity to promote and protect the health of the target population are: 1) work with schools to ensure children enrolled are up to date with their immunization and on nutrition and physical fitness activities; 2) work with partners during island-wide community events which will strongly emphasize lifestyle behavioral changes especially with health care practices, diet, and physical fitness; 3) develop partnership with other agencies to ensure continuity of care; and 4) support partnerships with internal clinical providers/partners to enhance the public health- clinical collaboration for the provision of population based and enabling services and programs. The strength of MCH Program’s work is through collaboration with partners.

Below is a list of partnerships along with corresponding MCH population groups supported:

Priorities and Linkage to National Performance Measures

Feedback received in response to the needs assessment and priority survey was helpful in identifying issues impacting MCH populations in the CNMI that stakeholders consider a priority. The state priorities that emerged are summarized below. A comparison of the 2015 priorities and new priorities is also provided in this section as well as the linkage to National Performance Measures.

 

Several themes arose from the findings, including access to direct health services, prevention, access to social and support services and awareness of community resources.  Access to direct health services is seen in the well-woman, prenatal care and well-adolescent visits.  Prevention is apparent in prevention of obesity through physical activity and nutrition, prevention of infant mortality through adequate prenatal care, and prevention of suicide through coping skills.  Findings indicated healthy coping skills are also a protective factor that can reduce the likelihood of youth developing addictions and increase their chances of becoming healthy, functioning adults. Social and support services are important to support transition to healthy adulthood, breastfeeding, and navigation of coordinated care systems. Another key finding was stakeholders identified the community as critical in impacting the health status of MCH populations and viewed awareness of community resources as a priority. Community resources was a topic that was identified by stakeholders to be one of the top priorities across all domains. Identification and use of community resources can be seen in the navigation of care in the CSHCN domain and in home visiting in the maternal, infant and child domains. Supporting individuals, families and communities to make changes that would make it more likely for youth to be healthy and successful in both the adolescent and CSHCN domains.

PRIORITIES

 

Access to health services -ability to find and see a doctor when needed

Domain: Women/Maternal

Priority 1 reflects MCHB’s commitment to the MCH guiding principles and current work by addressing the clinic processes as the best way to reach positive outcomes. Throughout the needs assessment process, women’s health consistently was voiced as a priority and it became apparent that the recurring themes in this domain reflected the overall needs of the state. MCHB already has successful partnerships, resources and services yet is now in a better position to provide more and engage community partners, build on existing programs, and address the needs of the state’s woman/maternal population. The following actions are addressed in this priority: uniform screening, coordinated care, increased access to care through extended hours and additional locations, increased well woman visits, and understanding of preventive health coverage.

 

Education and support to help with breastfeeding

Domain: Perinatal/Infant

MCHB remains committed to the current work of promoting breastfeeding as a means of impacting infant health and throughout the life course. By strengthening existing successes of partnerships with WIC program, MCHB can continue to strengthen the guiding principle of collaboration and creating community change. The following actions are addressed in this priority: collaboration with partners, community education, and increased access to private breastfeeding spaces for the working mother.

 

Prevention of premature births and infant mortality and prevention of alcohol and drug exposure and related developmental delays through prenatal care

Domain: Perinatal/Infant

Priority 3 reflects MCHB’s commitment to current work by addressing the clinic processes as the best way to reach positive outcomes. The following actions are addressed in this priority: uniform screening, coordinated care, increased access to care through extended hours and additional locations, increased prenatal visits, and access to transportation. Taken together, these needs can be addressed through existing programs as well as new initiatives and contribute to the whole health of the child beginning prenatally and throughout the life course.

 

Obesity related issues including nutrition/food security and safe school and neighborhood programs to promote physical activity

Domain: Child

Discussions during the needs assessment regularly focused on the need to address obesity across population domains but beginning at an early age. While there was targeted discussion about children, specifically related to obesity, there was a shift to a broader view of the systemic nature of nutrition and physical activity. Specifically, a change in terminology and definition began to emerge and the priority was reframed. Providing access to healthy food choices and safe physical activity was an issue of both availability and knowledge. The need to educate parents and children on what constitutes a healthy food choice was clearly reflected in the data. At the same time, the real challenge caused by affordable and healthy food deserts in CNMI was discussed. Some families rely on a small convenience stores due to transportation barriers and/or locale, thus connecting other daily issues (poverty, work schedules, children home alone) to unhealthy food choices. Physical activity is impacted by community issues related to neighborhood planning and development and transportation barriers to organized sports. Participants and staff suggested the importance of aligning with existing programs, including home visiting programs, sporting events, schools, and community campaigns, to promote nutrition education and physical activity.

 

Coping skills and suicide prevention

Domain: Adolescent

Life skills development such as budgeting, cooking, job training and healthy recreation are also important objectives under this priority. The need to promote positive coping mechanisms can be accomplished with yearly mental health screenings that can lead to suicide prevention and addressing bullying/bullies. Preventative health well visits for adolescents which are fully covered under insurance can promote overall physical health (immunizations, healthy eating, and oral health) as well as social emotional health. Social emotional health can also be enhanced by trained adults and mentors to help adolescents navigate life skills and set goals (high school completion, employment, youth development). Given that adolescents have a natural desire to become active agents in society and community, this priority can be promoted through community partnerships and engagement, and can reinforce protective factors and promote prevention of risky behaviors. MCHB can support schools and faith based organizations to provide the whole family with education and public awareness campaigns, and implementation of policy and procedures can be explored to address bullying and promote suicide prevention.

 

Helping parents/caregivers navigate the health care system for coordinated care

Domain: Children with Special Health Care Needs

This priority is specific to the needs of children and youth with special health care needs, though not exclusive, as it addresses all children in the way that MCHB strives; comprehensively and inclusively. One of the main goals of the Special Health Care Needs program is care coordination, so that children and their families can navigate systems to gain optimal health in a consistent and comprehensive way. During the needs assessment process, it became apparent that family support was emerging as a high need and that those supports include understanding available resources. Understanding the resources and how to navigate them can reduce caregiver stress. This priority exemplifies the collaboration and partnership building principles that MCHB promotes and is willing to sustain so that all children with health care needs are children first.

 

Support individuals, families and communities to make changes that will make it more likely for youth to be healthy and successful

Domain: Adolescent and Children with Special Health Care Needs

Priority 7 was identified to address the overall needs related to transition in the territory.  Empowering individuals to coordinate their own health care was approached as a priority for both adolescents and children with special health care needs so that every youth can understand and practice self-care as well as have a continued awareness into adulthood. Participants stated that understanding the importance of personal health, seeking services, and navigating the health care system promotes lifelong habits for well-being. In addition, empowering youth to enter to adult life with the skills and resources for success throughout life and contributing to the community promotes lasting achievement. Data on this priority is lacking and current resources unknown, therefore assessment of current status will be of primary importance.

 

Professionals have the knowledge and skills to address the needs of maternal and child health populations

Domain: Cross-cutting

The needs assessment process indicated that lack of resources were contributing to stressors across all population domains. Lack of services were an issue, but the bigger issue was lack of knowledge of services. This systemic issue suggests the need for trained, qualified professionals to deliver services across the MCH population domains.  Seeking the appropriate care for the maternal and child health care population is critical to ensure that the population needs are being met. For quality care to be delivered it’s important that the professionals interfacing with this population are properly trained to provide this care. Ensuring professionals that serve the MCH populations have adequate training impacts individuals from birth and continues throughout adulthood.

Comparison to Previous Priorities

The comparison to prior priorities identified in 2015 is slightly different. The MCH program took a more detailed view of the priorities to improve overall health through specific actions.  Below is a table of the old priorities compared to the new with notations of changes.

 

Table 30. Comparison of Current and Previous Priorities

 

 

 

Linkage to National Performance Measures

The CNMI selected the following six National Performance Measures and two State Performance Measures in relation to the identified priority areas.

Table 31. Priority Linkage to National and State Performance Measure