Purpose and Requirements

 

At the beginning of each five-year grant cycle the state is required to conduct a comprehensive needs assessment.  The assessment must include both quantitative and qualitative data analysis, with the goal of identifying the health needs of Tennessee women, infants, children, adolescents and their families.  The capacity of the health system to meet the needs identified must also be evaluated.  Then based on all the information gathered the state must choose priorities to focus on for the new grant cycle.  At least one priority must be identified for each population domain, and no more than 10 priorities in total.

 

Population Domains:

• Women’s and Maternal Health
• Perinatal and Infant Health
• Child Health
• Adolescent Health
• Children and Youth with Special Health Care Needs (CYSHCN)
• Cross-Cutting (Optional)

 

Framework

 

For the assessment the main framework used was the Public Health Planning Cycle described in the federal guidance for this grant.  The steps of the process are described below.

 

Public Health Planning Cycle:

1. Engage stakeholders
2. Assess needs and identify desired outcomes and mandates
3. Examine strengths and capacity
4. Select priorities
5. Set performance objectives
6. Develop an action plan
7. Seek and allocate resources
8. Monitor progress for impact on outcomes
9. Report back to stakeholders

 

The state supplemented the Public Health Planning Cycle framework with one from the Needs Assessment in Public Health:  A Practical Guide for Students and Professionals book.  This framework consisted of detailed linear stages that provided a slightly more detailed approach to both planning and implementing the assessment.  The stages in this framework are described below.

 

Stages in Needs Assessment Process

1. Start-up Planning Stage
2. Operational Planning Stage
3. Data Stage
4. Needs Analysis Stage
5. Program and Policy Development Stage
6. Resource Allocation Stage

 

Planning and Implementation

 

Start-up Planning Stage

 

The 2020 comprehensive needs assessment was led by the MCH Block Grant Coordinator, which is a full-time permanent position supervised by the MCH/Title V Director.  The coordinator is responsible for gathering all information needed for the annual grant application and report, which in 2020 included the comprehensive needs assessment.

 

To complete the assessment teams were established for each required population domain.  All staff within FHW was assigned to a domain team.  This was done by appointing each FHW senior leader to the domain that most closely aligned with the programs they lead for the division.  Their program staff and epidemiologists were also assigned to the same domain.  Therefore, each domain team consisted of at least one (but many times multiple) FHW senior leader, program staff, and epidemiologist.  This created multidisciplinary teams where each member contributed specific expertise to fulfill different roles on the team.  The table below shows FHW section assignment by domain.

 

 

All work for this grant is done in partnership with stakeholders.  The formal stakeholder group was established during the 2015 comprehensive needs assessment.  This group has continued to meet in person twice a year since then.  It is open to anyone who has a stake in the health of women, infants, children, adolescents and their families in Tennessee.  Stakeholders were engaged throughout the 2020 comprehensive needs assessment process.  Stakeholder involvement will be described where applicable in the stages below.

 

Operational Planning Stage

 

The assessment formally began in October 2018 with the FHW needs assessment planning meeting.  This meeting was attended by all FHW senior leaders, program staff and epidemiologists.  At the meeting the MCH Block Grant coordinator reviewed the federal requirements, timeline, 2015 comprehensive needs assessment methodology, and roles and expectations of staff for the 2020 assessment.  The group discussed what worked well during the last assessment and which areas needed to change for this assessment.  Based on this conversation it was decided that fewer health topics would be covered in order to take a deeper look at each one.  This would allow the data on each topic to be stratified by geography and racial/ethnic groups.  It was also decided that focus groups would be utilized as a qualitative method because they provided such in-depth insight into areas that are multifaceted and therefore difficult to understand and impact.

 

In January of 2019 epidemiologists from each domain team met to discuss how to analyze and present the quantitative data in a consistent way across all domains.  It was decided that there were three perspectives to cover for each topic.  The first was comparing state level data to national data.  The second was showing the geographic distribution across the state through a map rendering.  The third was to compare race and ethnic groups to check for any disparities.  Then the overall findings from these perspectives would be summarized in a data interpretation section.  A template was created and utilized to gather each of these elements.  However, for some topics the data was not collected in a way that allowed it to be broken down into each of these perspectives.  When this happened, the epidemiologists made substitutions based on what was available.

 

Data Stage

 

Each domain team was asked to develop a list of roughly 10 health topics that most impact the population domain.  These lists were presented to stakeholders on a webinar in February of 2019.  The stakeholders provided feedback on the lists; topics were added based on the feedback.  The final lists included the topics below.

 

Women’s and Maternal Health Topics

• Well Woman Care/Preconception Care
• Cervical Cancer Prevention and Early Detection
• Contraception Access
• Pregnancy Intent
• Prenatal Care
• Maternal Mortality
• Opioid Use
• Teen Pregnancies/Births
• Sexual/Domestic Violence
• Human Trafficking

 

Perinatal and Infant Health Topics

• Infant Mortality
• Safe Sleep
• Birth Defects
• Premature Birth and Low Birth Weight Infants
• Breastfeeding
• Newborn Screening
• Access to Timely Prenatal Care
• Unintended Pregnancy
• Prenatal Smoking
• Perinatal Depression

 

Child Health Topics

• Neonatal Abstinence Syndrome (NAS)
• Adverse Childhood Experiences (ACEs)
• Developmental Screening
• Childhood Obesity and Nutrition
• Dental Care/Dental Home
• Well Child Visits/Medical Home
• Child Injury
• Bullying/Suicide
• Lead Exposure

 

Adolescent Health Topics

• Physical Activity
• Nutrition
• Youth Nicotine Exposure
• Human Papilloma Virus (HPV) vaccination
• Obesity
• Mental Health – Depression, ACEs
• Substance Abuse
• Sexual Behaviors – Unintended Pregnancies
• Intentional Injury – Teen Violence, Human Trafficking, Suicide
• Unintentional Injury – Motor Vehicle Collisions

 

CYSHCN Topics

• Transition from Pediatric to Adult Care
• In Home Assistance and Respite Care
• Birth Defects
• Medical Home
• Access to Care
• Rural Health Challenges
• Decision Making (patient/family/provider partnership)
• Youth Involvement in Care
• Access to Coverage
• Early Intervention and Screening

 

With final lists of topics, the epidemiologists started pulling together data on each one and utilized the template to display the data.  All the quantitative data was then presented at the spring stakeholder meeting in April of 2019, which is held in-person.  The stakeholders where asked to help identify areas that were unclear or gaps that could be filled in with qualitative data.  Based on their feedback each domain team selected a topic(s) to explore with qualitative data.

 

After the meeting the epidemiologists led their teams in choosing which methodology would work best for the topic.  The methods included focus groups, key informant interviews, and open-ended surveys.  Each team worked together to develop the data collection instruments.  The table below depicts all the qualitative topics and methods used.

 

 

During the summer of 2019 four interns were trained to help implement the qualitative methods.  To prepare for data collection the interns created many documents including:  informed consent forms, participant demographic forms, focus group flyers, key informant interview scripts, and participant thank you letters.  To recruit participants, partner organizations were identified based on desired participants.  Partner organizations were asked to help recruit participants, and for focus groups a space to hold meeting.  All key informant interviews were conducted over the phone.  The tables below describe the partner organizations and participants by qualitative method and topic covered.

 

 

 

 

Once all the data was collected the interns and epidemiologist worked together to analyze it.  Data visualizations were created to present the information at the fall stakeholder meeting.  Which was used to inform the prioritization process.

 

Needs Analysis Stage

 

In October of 2019 FHW senior leaders, program staff and epidemiologists met to design a priority setting process.  At this meeting the prioritization process used for the last comprehensive needs assessment in 2015 was reviewed.  Based on the discussion it was decided that a prioritization matrix would be utilized again because of the level of objectivity it brings to the process.  This method allows each potential priority to be considered against multiple criteria.  The criteria are chosen based on what is most important to the group.  To identify criteria for the 2020 assessment the group considered what factors could be evaluated based on the data that had been gathered.  It was decided that severity, prevalence, and level of inequality could be assessed.  The last criteria chosen was readiness.  This was a more subjective criteria that required respondents to give their opinion on the readiness of the state (and community) to address the issue.

 

The matrix was administered at the fall stakeholder meeting.  During this meeting each domain team presented the quantitative, qualitative, and capacity assessment data compiled for that domain.  The teams then facilitated a discussion on the data.  Feedback on each potential priority was then collected by asking everyone (including TDH staff) to fill out the matrix.  The matrix and scores are available in the Supporting Documents section of this grant.

 

In November of 2019 the MCH Block Grant Coordinator analyzed the data collected through the prioritization matrix and shared the results with each team.  Each team then met to discuss the results and identify which potential priority should be recommended as the priority for the new grant cycle.  In January of 2020 all domain teams met as one group to finalize the priorities.  Each domain team recommended a priority and provided an explanation of why it should be chosen based on data gathered and stakeholder feedback.  The MCH Block Grant Coordinator also recommended priorities for the Cross-Cutting domain based on topics that were identified as issues in all the domains.  All recommendations were discussed, and the priorities were finalized at this meeting.

 

Program and Policy Development Stage

 

Once the priorities were chosen each FHW senior leader was entrusted to lead one priority.  Their program staff and epidemiologists were also assigned to the same priority.  Therefore, each priority team consists of a FHW senior leader, program staff, and epidemiologist(s).  This again created multidisciplinary teams where each member contributed specific expertise to fulfill different roles on the team.  The table below shows FHW section assignment by domain and priority.

 

 

During the spring and summer of 2020 each priority team developed an action plan.  The plans detailed what will be done to impact the priority in a positive way.  The grant requires that the action plans have a two-tier structure; this consist of grouping activities into broader overarching strategies. The action plan structure is shown below.   There are no maximum number of strategies or activities.

 

Action Plan Structure:

• Strategy 1
  • Activity 1
  • Activity 2
• Strategy 2
  • Activity 1
  • Activity 2

 

Another requirement is that measurements be developed to assess the impact of the action plan.  Therefore, teams developed measures following the 3-tiered measurement framework in the grant guidance.  There are three types of measurements that relate to one another.

 

Types of Measures:

• National Outcome Measures (NOMs) or State Outcome Measures (SOMs)
• National Performance Measures (NPMs) or State Performance Measures (SPMs)
• Evidence-based or –informed Strategy Measures (ESMs)

 

The NPMs and NOMs are listed in the grant guidance.  Each NPM is linked to one or more NOMs; this linkage is also provided in the guidance.  States must choose at least one NPM for each population domain, and by extension the corresponding NOMs.  State may create SPMs to address any priorities that have not been fully addressed through the NPMs.  States may also create SOMs to mirror the national framework.  The state must create at least one ESM for each NPM.  ESMs measure the process of implementing the action plan.  Tennessee chose to create ESMs for each activity planned. The state also chose to create SPMs and SOMs where needed.

 

Relationship Between Measures:

It should be noted that the action plans and measures were developed during the COVID-19 pandemic.  During this time many staff were temporarily reassigned to the pandemic response.  This decreased capacity which caused it to take much longer to create the plans and measures.  Staff also transitioned from working in the office (at least a day a week) to working completely from home.  This new virtual work format required a lot of adjustment to create efficient and effective teams.

 

Due to the COVID-19 pandemic the fall stakeholder meeting was held virtually, typically it is held in person.  Each priority team was given 30 minutes to present their action plan and discuss it with stakeholders.  The stakeholders were also provided with each priority team lead’s contact information so that feedback could be submitted after the meeting.  The teams revised and finalized the action plans based on stakeholder feedback.

 

Resource Allocation Stage

 

Once the priorities were finalized the resource allocation stage could begin.  The goal for this stage was to align funding with the priorities for the new grant cycle.  To do this all currently funded initiatives were categorized by the priorities for the new grant cycle.  If a current initiative didn’t fit into one of the priorities it was set aside.  The initiatives set aside were evaluated as to whether the initiative should continue (with funding from other source) or be discontinued.  Lastly the distribution of funds across the domains was compared to evaluate the spread.

MCH Population Health Status 

 

To assess the population health status for each domain the state used both quantitative and qualitative data.  Both the quantitative and qualitative data can be found as an attachment in the Supporting Documents section of this document.

Tennessee’s MCH/Title V and CSHCN program is housed in the Division of Family Health and Wellness (FHW), within the Tennessee Department of Health (TDH).  This department serves as the state health agency. It is a cabinet level agency within the executive branch of the state government and is led by a commissioner who is appointed by the governor.  The structure of TDH includes a central office, 13 regional offices, and at least one local health department/clinic in each county.  The administration of Tennessee’s MCH/Title V and CSHCN program resides in the central office.  Within this office program staff work closely with regional staff, non-profit partners and other state agencies to implement program activities.

The Tennessee Department of Health's mission is to promote, protect, and improve the health and prosperity of people in Tennessee. The agency accomplishes this through provision of core public health services. Public health services are evolving into gap filling functions providing direct services to those who do not have public or private insurance and into population based, infrastructure and enabling services that support an integrated health care system to meet citizen needs. Services are provided in all counties through local and metropolitan health departments and private nonprofit agencies. These services include medical examinations, screening and treatment for sexually transmitted diseases, preventive health exams, screening for anemia, WIC, EPSDT, dental services, immunizations, education and counseling. Services are provided by nurse practitioners, physicians, certified nurse midwives, public health nurses, licensed practical nurses, nurse aides, educators, and counselors. No charges are made to clients at or below the federal poverty level. TennCare and other insurance are charged as appropriate.

 

TDH is comprised of local health departments that play a vital role in protecting many aspects of the public’s health including instances of emerging infectious diseases, chronic diseases, bioterrorism, and natural disasters. As threats have increased and become more complex, the local health department role has expanded and demands new and different skills for its workforce. In order to have the capacity to address the roles of local health departments and the consequential workforce challenges to be public health ready, the Department focuses on systems integration, prevention, and access to health care that includes a strong population education and upstream health improvement component.  Ongoing training and support for public health leadership development is provided for the Department’s employees. Accountable baseline federal funding for all local health departments is provided to have the workforce to provide essential services in public health as well as a strategic system-wide effort to increase the production, recruitment, and retention of the public health workforce that is sufficient, competent, and diverse.

Title V-funded MCH and CSHCN staff work in multiple capacities within the Tennessee Department of Health (Central Office, 7 Rural Regional Offices and 6 Metro Offices, and local health departments in all 95 counties).

 

State-level program planning is provided by individual program directors, in consultation with Tennessee’s MCH/Title V Director and senior leadership within FHW. MCH program directors gather monthly for a Program Management meeting, during which staff outline program goals and objectives, map program activities to state priority measures, discuss opportunities for linkages between MCH programs, and work through challenges common across programs. The Program Management meetings also provide an opportunity for ongoing professional development among the Central Office MCH workforce. These monthly meetings also provide an opportunity to familiarize staff with Departmental operations, procedures and policies. FHW staff development is also incorporated into monthly administration meetings and less formal monthly staff lunch and learn sessions. Bi-monthly staff meetings bring all FHW staff together to celebrate successes, share key information, and develop strategy for key division and department priorities. All FHW central office staff are provided opportunities to participate in professional development activities over the course of their annual performance review. All central office FHW staff have participated in ACEs training and health disparities training which include implicit bias training and cultural competencies. ACEs training has been provided statewide to both regional and local staff. A Health Equity Toolkit has been developed that includes resources and education around health disparities, cultural biases in order to provide awareness and education to all FHW staff with plans to distribute the toolkit department wide.

 

FHW has employed 14 epidemiologists (including five doctoral-level epidemiologists). The epidemiologists provide broad support for data analysis and program evaluation across the Division and specialized support in program areas such as home visiting, chronic disease prevention and health promotion, injury prevention and detection, reproductive and women’s health, newborn screening, childhood lead poisoning prevention, and children and youth with special healthcare needs. FHW hosted a CSTE (Council of State and Territorial Epidemiologists) Applied Epidemiology Fellow in 2013-15 (Julie Traylor). Ms. Traylor continues to lead the five-year MCH/Title V Needs Assessment and is now a full-time state employee, serving as Tennessee’s MCH Block Grant and SSDI Grant Coordinator. FHW matched a CDC MCH Epi Assignee in December of 2017 to help build surge capacity for MCH epidemiology-related issues. She has considerably expanded the Division and the Department’s capacity. She has spearheaded data quality initiatives with vital records, provided mentoring structure for division epidemiologists, expanded capacity for analytics in maternal mortality, among many other initiatives. She has also instituted a well-attended journal club as well as publications work group with participants from across the Division.  TDH continues to employ her to assist with MCH related priority areas conducting surveillance and research department wide.

 

Additional data analysis support is provided through a number of collaborative relationships. The SSDI grant (managed by FHW) provides funding support for staff in the Department’s Office of Policy, Planning, and Assessment as well as funding for the MCH block grant coordinator and for the birth defects data infrastructure The SSDI grant also provides funding for Digital Library access to FHW and TDH staff. Initial training was provided to FHW staff in an all staff gathering, and additional training has been initiated to further develop skillsets in literature searches and evidence evaluation. FHW also receives data support through the Department’s Division of Quality Improvement. The Office of Performance Management has also provided support in LEAN process implementation for women's health and CYSHCN.

 

Tennessee’s MCH/Title V Program continues to partner with the University of Tennessee at Knoxville (UTK), a HRSA-MCHB grant recipient, to provide cultural competency training to health department staff. Since March 2012, selected Department of Health staff in all 13 regions continue to participate in the half-day training provided by UTK annually. The workshop takes an in-depth look at individual cultural competence. It is specifically designed to increase awareness, knowledge, and skills in dealing with clients, patients, and co-workers whose world view is different from one’s self. The emphasis is on the health-related professions. The first round of training focused on regional and Central Office Leadership and subsequent sessions (ongoing) have been provided training front-line service delivery staff.

 

Several professional development have been provided and were made available in multiple sites across the state. These trainings include health equity, ACEs, Implicit Bias, reproductive life plan, maternal depression, and breastfeeding promotion and support. Tobacco Cessation including addressing tobacco use with families, strategies for engaging the family and connecting families with local resources is provided throughout the state. Professional development resources that align with both requirements for Infant Mental Health Endorsement and the National Family Support Competency Framework are available on line through the Institute for the Advancement of Family Support Professionals and Achieve on Demand. The Department of Health has taken a leadership role in the Building Strong Brains through Tennessee’s ACEs Initiative and has increased the knowledge of ACEs throughout the state. Staff members in each region have been trained in the standardized ACEs curriculum that shares key information about the brain science behind ACEs, the importance of safe and nurturing relationships during early childhood, and strategies for reducing the impact of ACEs. Knowledge dissemination is the first step in ensuring that all health department services are ACEs informed. The Department of Health continues to expand understanding of ACEs and further explore how we can ensure that ACEs are considered as we make program, policy, and procedure decisions.

 

FHW staff are also encouraged to take advantage of external workforce development activities. Tennessee has successfully trained staff on CHANT with programmatic rollout in all Regions of the State.  Navigating the complex system of health and social services can be challenging for many individuals and families, and depending on individual needs and medical diagnoses, care may involve a number of programs, providers, and personnel.  To overcome these challenges, the Tennessee Department of Health streamlined three public health programs, Help Us Grow Successfully (HUGS), Children’s Special Services (CSS) and Tenncare Kids Community Outreach into one integrated model of care coordination, the Community Health Access and Navigation in Tennessee (CHANT). CHANT teams provide enhanced patient-centered engagement, navigation of medical and social services referrals, and impact pregnancy, child and maternal health outcomes.  Some staff participate in LEAD Tennessee, a statewide, 12-month development initiative which includes six one-day summits of intense, personally tailored, high impact learning focused on twelve core leadership competencies. The goal of LEAD Tennessee is to increase the state’s leadership bench strength by providing agencies with a continuous pipeline of motivated and prepared leaders that share a common language and mindset about great leadership. Julie Traylor, MCH Block Grant Coordinator is participating in this program which promotes valuable components for both new and experienced directors.

 

MCH/Title V funding is used to support ongoing training of local and regional health department staff who provide services to the MCH population. Examples include an annual professional development conference for CYSHCN care coordination staff and an annual “Spring Update” training session for women’s health and family planning staff. MCH staff have also been instrumental in planning the annual in-person conference for state public health educators to develop capacity in the health department priorities of tobacco prevention, physical activity promotion, obesity reduction, and prevention of opioid use. Tennessee has also utilized MCH/Title V funding to support the broader MCH workforce outside of public health. For example, Title V/MCH funding supports an mPINC technical assistance web site for hospitals and pays for 20 hours of lactation continuing education for interested members of the care team. FHW also supports CLC training and certification for staff across the state who work in breastfeeding.

 

FHW routinely hosts student interns from a variety of training levels (undergraduate, graduate, and post-graduate). Products of recent or current trainees include: Investigation of pediatric opioid overdose with publication of relevant infographics for key stakeholders. Development of an online overview of health equity approaches in all fifty states. Literature synthesis for statewide provider, payer, and advocate groups which have developed to address the recurrent prematurity prevention initiatives of17-OHP utilization and access to immediate post-partum long acting contraception Educational materials on preventing unintended pregnancy for adolescents and adolescent health care providers Development of "one key question" outreach to providers encouraging them to act to reduce unintended pregnancy Mapping of tobacco retailers in relation to school and engaging youth in tobacco prevention activities Focus groups to gain understanding of decision making of minority fathers regarding breastfeeding initiation

Maternal and Child Health and Women's Health (part of the Division of Family Health and Wellness) staff at the central office, regional offices, and local health department levels are involved in numerous collaborative efforts within the Department with various programs, other governmental departments and agencies, and organizations and agencies outside government (universities, school systems, city/county government, hospitals, and nonprofit agencies such as March of Dimes, American Cancer Society, American Heart Association, Arthritis Foundation, Tennessee Suicide Prevention Network, State Minority Health Task Force, Family Voices, The Tennessee Disability Coalition, and the Council for Developmental Disabilities). MCH has always had a strong collaborative relationship with metropolitan health departments in the state. Since these entities have separate boards of health, the state's role is to provide needed service, focused funding, training and continuing education and participation as a partner in all planning and system change initiated to improve the public's health. The six designated metro health departments receive funds through the state's contractual system. Staff in Metro Health Departments who provide MCH services are regularly included in conference calls, quarterly meetings, in-service training and planning meetings about MCH programs and services. The MCH Director holds monthly conference calls with all regional MCH Coordinators; the agenda includes updates from the central office, regional updates, topical presentations on MCH programs, and information on specific MCH performance and priority measures. Metro Regional Directors participate as active partners with rural Regional Directors in public health planning and new initiatives. The primary difference between these two entities is that metros report to boards of health and the mayor, while rural regional directors report to the Department.

 

Examples of collaborative efforts: TennCare/Medicaid: The Childhood Lead Poisoning Prevention Program has a cost-sharing protocol with TennCare for cases when an environmental investigation is conducted for a lead poisoned child on Medicaid. CSS requires that all children applying for the CSS program apply for TennCare; assists families in locating a medical home, specialists and related service providers within the managed care organizations' (MCO) provider networks; keeps TennCare informed of underserved areas and works with the MCOs to identify out-of-network providers for CSHCN. CSS participates in TennCare advocates' meetings to keep informed of changes and uses the network of state, regional, and local CSS staff for disseminating information. This route also allows direct interaction between CSS staff and parents to ensure parental understanding of the changes and improve transition of services. CSS also helps families file appeals for denied medically necessary services.

 

All local health departments are providing outreach, advocacy, and EPSDT screenings for TennCare enrollees and referring patients to their medical home as applicable. The clinics refer patients who may be eligible to TennCare. The family planning program informs patients who test positive for pregnancy about TennCare's presumptive eligibility benefit and refers eligible patients to the agency for application. Department of Children's Services (DCS) is responsible for the children in state custody. The Department of Health is providing the EPSDT screenings for all these children. MCH gets referrals from DCS for home visits. DCS staff are involved on teams reviewing cases for the Child Fatality Review program. MCH staff is invited to attend the multidisciplinary teams to case manage clients. CSS regional coordinators work with the DCS Regional Health Unit nurses to coordinate health services for CSHCN in state custody.

 

Collaborations are occurring between the Child Fatality Review Program (housed in MCH) and DCS. The MCH Director meets regularly with senior leadership from DCS to discuss opportunities for primary prevention of child maltreatment. Local DCS staff have for many years participated on the local child fatality review teams, and state DCS leadership has participated on the state team. MCH staff are members of the Children's Justice Task Force and the Child Sex Abuse Task Force, whose members are from many state government departments and community organizations. The Children's Justice Task Force focuses on the welfare of children reported to have been abused or neglected and is charged with identifying existing problems and recommending solutions. The Child Sex Abuse Task Force is responsible for assisting DCS in developing a plan for better coordination and integration of the goals, activities and funding for detection, intervention, prevention and treatment of child sexual abuse. MCH has a staff member who is an associate member of the TN Child Abuse Prevention Advisory Committee. The committee focuses on statewide efforts to prevent child abuse. The Family Planning Director represents the Department of Health in a collaborative effort with the Tennessee Bureau of Investigation and the Departments of Human Services, Children's Services, Intellectual and Developmental Disabilities, and Mental Health to establish a system of identification and service delivery for human trafficking victims.

 

Department of Human Services (DHS): DHS houses the Division of Vocational Rehabilitation, TN Services for the Blind and Visually Impaired and the TN Technology Access Project. These programs work in collaboration with the CSS program. The Deaf/Blind Coordinator has participated on the Newborn Hearing Screening (NHS) Task Force since 1997. DHS offices serve as the place of application for Medicaid and TennCare. DHS provides CSS proof that CSS applicants have applied to TennCare. MCH has collaborated with DHS since 1996 to build a statewide network of child care resource centers which include a child care health consultant. Services provided include: technical assistance and consultation, training, and lending resource library materials and are available to all child care providers in the State. MCH through its Early Childhood Comprehensive Systems Program and its Child Care Resource Centers assists DHS in providing technical assistance for state regulated day care centers.

Department of Education (DOE): Central Office MCH staff collaborate routinely with the Office of Coordinated School Health (OCSH), which is housed within the Department of Education. There is also increasing collaboration between regional TDH staff and regional CSH staff. In early 2012, TDH Regional MCH Directors provided an overview of MCH-related services at regional CSH meetings. Feedback from both MCH and CSH staff indicated that the meetings were useful for sharing program information and building local connections. MCH staff in collaboration with CSH recently organized an Adolescent Institute for Adolescent Health and Adolescent Pregnancy Prevention Coordinators, CSH Professionals, Health Educators, and Abstinence Education Grant Program Staff. Institute workshops addressed: childhood obesity, asthma, the importance of breakfast, physical activity, vision, aggression and violence, ADHD and teen pregnancy and parenting. The Department of Education, Division of Special Education, is the lead agency for the IDEA Part C TN Early Intervention System (TEIS) for infants and toddlers birth to 3 identified with or having a potential for a developmental delay. TEIS has been an active collaborator with the CSS program since 1990 and with Newborn Hearing Screening (NHS) since 1996. The programs coordinate referral and care coordination activities on infants and children requiring services from both agencies. An MCH staff person serves on the State IDEA Interagency Coordinating Council. TEIS staff serve on the NHS Task Force. TEIS works closely with the NHS program to provide tracking, follow-up and intervention services for infants referred for or identified with a hearing loss after hospital hearing screening. An MCH staff member serves on the Part C (Early Intervention) Monitoring Review Committee. CSS central office and regional office staff participate in Early Intervention Administrators' Forums which include various agencies and promote interagency linkages at the program administrators' level. Local CSS staff participate in meetings for individual CSHCN with DOE Part C and Part B personnel in developing coordinated care plans to insure the coordination of services.

 

Head Start: A staff person representing Head Start and Early Head Start is an active member of the TEIS State Interagency Coordinating Council; MCH works through this committee with Head Start. The DOE Head Start Collaboration Officer is a member of the Childhood Lead Poisoning Prevention Program and the Early Childhood Comprehensive Systems Advisory Committees. These committees include state agency staff and advocates for children and who meet regularly. The Newborn Hearing Screening Program, in collaboration with the National Center on Hearing Assessment and Management (NCHAM), works with 3 Early Head Start agencies across the state to implement the Early Childhood Hearing Outreach (ECHO) initiative to provide training on hearing screening, follow-up and reporting. The MCH Director also liaisons with the Director of the State Head Start Collaboration on an as-needed basis. For example, the two collaborated to clarify policies related to EPSDT screening and worked with Head Start staff and community health care providers to promote better understanding and compliance with policies.

 

Mental Health/Developmental Disabilities: Staff are active members of the Child Fatality Review program at both local and state levels. MCH staff work collaboratively with the Department of Mental Health/Developmental Disabilities (TDMHDD) to assure that appropriate mental health services are accessed for children with special health care needs. CSS includes an assessment of a child's psychosocial development and refers CSHCN and family members to local mental health centers or other local mental health providers if appropriate. Mental health and socialemotional development are one of the five critical areas being addressed in the Early Childhood Comprehensive Systems, and TDMHDD staff participate on the Advisory Committee. The TDH Injury Prevention and Detection Director serves as a member of the Tennessee Suicide Prevention Network and works with a state intradepartmental committee and the state suicide prevention advisory committee. The committee has developed a state plan to address youth suicide prevention.

 

Social Security Administration (SSA): MCH staff provide information on MCH programs to parents of CSHCN who have applied for SSI. The CSS program coordinates referral of children whose names are received from the SSA. The parent or guardian is sent information about possible services available to their child from state programs (CSS, Mental Health, Mental Retardation, TEIS, and the regional genetics centers, HUGS, Traumatic Brain Injury, Hematology/Sickle Cell Centers, Department of Mental Health and Developmental Disabilities, Department of Intellectual Disabilities, TEIS, and Special Education).

 

Tennessee Bureau of Investigation (TBI): TBI staff are active members of the Child Fatality Review program at both local and state levels. CSS staff work with Corrections staff to get wheelchair ramps and custom made furniture for CSHCN constructed at no cost to families.

 

Child Fatality Review: The Child Fatality Review process is a statewide network of multidisciplinary, multi-agency teams in the 31 judicial districts to review all deaths of children 18 and younger. Members of each local team include: Department of Health regional health officer; Department of Human Services social services supervisor; Medical Examiner; prosecuting attorney appointed by the District Attorney General; local law enforcement officer; mental health professional; pediatrician or family practice physician; emergency medical services provider or firefighter; juvenile court representative; and representatives of other community agencies serving children. Members of the State Child Fatality team include: Department of Health commissioner; Attorney General; Department of Human Services commissioner; Tennessee Bureau of Investigation director; physician (nominated by Tennessee Medical Association); physician credentialed in forensic pathology; Department of Mental Health and Developmental Disabilities commissioner; Department of Education commissioner; judiciary member nominated by the Supreme Court Chief Justice; Tennessee Commission on Children and Youth chairperson; two members of the Senate; and two members of the House of Representatives. The state child fatality team is collaborating with several agencies to implement prevention initiatives.

 

The Injury Prevention Program is collaborating with the Tennessee Department of Education and the trauma centers to implement the Battle of the Belt Program, an educational intervention to increase seatbelt usage among high school students. The Department of Health is collaborating with the Department of Children's Services, the Tennessee Commission on Children and Youth, the Department of Human Services, UT Extension, the Department of Education and Prevent Child Abuse Tennessee to distribute safe sleep materials.

 

Childhood Lead Poisoning Prevention Program: Collaborating agencies include: a) University of Tennessee Extension Service which provides social marketing to develop and distribute information on childhood lead poisoning to health departments and extension agents, and surveillance system assistance to analyze child blood lead level data and assist staff, partners and health care providers regarding medical case-management of children with elevated levels; and b) Tennessee Department of Environment and Conservation to conduct environmental investigations.

 

Adolescent and Young Adult Health: The adolescent health director provides educational presentations and resources to adolescent health coordinators and the advisory committee through quarterly teleconferences. The director serves on several committees designed to improve the quality of life for youth and provide educational opportunities for youth and adults including the intra-departmental committee of the Tennessee Suicide Prevention Network; the local and state Disproportionate Minority Contact and Confinement (DMCC) committees; the Tennessee Commission for Children and Youth (TCCY)/Mid-Cumberland committee; and the Tennessee Alliance for Drug Endangered Children (TADEC). The Adolescent & Young Adult Health director assists in coordinating activities of the Department's annual Child Health Week with Mental Health and Developmental Disabilities, the TENNderCare program, and community partners. Additional collaborations for the Adolescent & Young Adult Health director include coordinating a committee from throughout the Family Health and Wellness Division (FHW).

 

Asthma Management: State of Tennessee Asthma Task Force (STAT) members, in conjunction with Early Childhood Comprehensive Systems, the TennCare Bureau and the Department of Education, developed and are implementing a comprehensive state plan to reduce the burden of asthma among Tennesseans. The plan includes surveillance and epidemiology; public awareness and education; medical management; and environmental management components. The program director currently collaborates with STAT nurses to make educational presentations across the state to medical providers, educators, parents, and youth. STAT plans to target preschool children, school-aged children, and adults 30 and older. MCH also sponsors children to attend summer asthma and diabetes camps. The 10 Child Care Resource and Referral (CCR&R) Centers were provided with asthma tool kits for use with parents and child care providers. A nurse consultant was funded to provide training and technical assistance to the staff at CCR&Rs on health related issues of young children in group care including asthma management. Print material on prevention of tobacco/smoking exposure was developed and circulated to child health related programs across the state.

 

Federally Qualified Health Centers: Community Health Centers are located in medically underserved areas of the state. These community health centers provided primary health care, dental and mental health services to more than 280,400 patients. Referral systems exist between those community health centers and health departments located within the same county. Community Health Centers in TN are community-based public and private nonprofit corporations that provide comprehensive primary health care services to all people regardless of the patient's ability to pay for those services. They are located in medically underserved areas of the state, both rural and urban. These sites provide primary health care, mental health care and dental services to over 361,000 people per year.

 

Early Periodic Screening, Diagnosis, and Treatment Program (EPSDT): Since July 2001, local health department clinics have assisted TennCare by providing EPSDT screenings to TennCare enrollees. The TennCare Program previously had difficulty in achieving desired EPSDT screening rates and partnered with the Department to improve these rates.

 

Autism Spectrum Disorders and Other Neurodevelopmental Disorders: TDH actively participates on the TN Autism Summit Team (led by the Tennessee Disability Coalition) and has been actively involved in the development of the Autism State Plan. TDH has also partnered with staff from the TN Chapter of the AAP and the CDC Act Early Champion to develop a pilot protocol for autism spectrum disorder (ASD) screening in local health departments. The Early Childhood Initiatives section of MCH successfully applied for funding from AMCHP to co-brand CDC materials on ASDs and developmental screening. These materials will be distributed through a number of venues including early childhood home visits. Developmental screening (using the PEDS and Ages and Stages tools) is conducted in all local health departments as part of EPSDT screenings. Staff in all thirteen regions were trained on the appropriate administration and scoring of these tools; staff also received guidance on making appropriate referrals and talking for families about suspected delays.

 

Folic Acid Education Campaign: Women's Health and Nutrition staff (central and regional offices) are partnering with the March of Dimes, Girl Scouts, and members of the state folic acid council to educate the citizens of TN on the need for folic acid. Staff developed and implemented many of the statewide activities. The Women's Health director serves on the state council. The family planning program provides vitamins with folic acid to patients of reproductive age who receive program services. MCH staff are currently partnering with the March of Dimes and a health education consultant on a grant to use text messaging and web technology to educate college women on important lifestyle issues.

 

HIV/AIDS/STD (Communicable Diseases Section/Department of Health): There is strong collaboration between the staff of the Women's Health and HIV/AIDS/STD sections. Family planning staff make referrals for HIV counseling and testing and educate clients regarding all STDs including HIV/AIDS. With the integration of services at the local levels and the multiple functions performed by staff in the clinics, staff are very familiar with these programs. The Infertility Prevention Program (screening for chlamydia, treatment, and data analysis) is a joint project of Family Planning, STD, and the State Laboratory. Although federal support for the regional project has ended, Tennessee is continuing screening and treatment for Chlamydia.

 

The Tennessee Breast and Cervical Cancer Early Detection Program (TBCCEDP): This program provides breast and cervical cancer screening, diagnosis and treatment to uninsured women over age 50. About 14,000 women are screened annually and enrolled in TennCare, if necessary, for treatment. The program accepts referrals of any age from family planning for diagnostics. The program accepts any referrals of eligible symptomatic women.

 

Office of Nursing: MCH central office nursing staff routinely provide program updates at the quarterly statewide Nursing Directors' meetings. They also serve as consultants to answer health questions related to their respective programs i.e., Family Planning, SIDS, Lead Poisoning Prevention, Home Visiting, etc.

 

Women Infants and Children: CSS makes direct referrals to WIC on all clients under 5 or mothers of CSHCN who are pregnant. CSS purchases special formula if they need amounts above the allowed allocations under the WIC program. CSS also assists in obtaining special foods for children with PKU.

 

Division of Population Health Assessment: Staff collaborate with Health Statistics on dissemination of data releases and special reports, data collection for the joint Annual Report of Hospitals, data collection for the Region IV Women and Infant Health Data Indicators Project, and other MCH data projects. Staff coordinate on data matching and reports for the newborn hearing screening program and on the SSDI grant. The SSDI competitive grant was approved for TN but the time period was shortened to three years. SSDI funds will be used to maintain the Health Information Tennessee site which provides the most current state information through a web based application that can be customized by the user. Grant funds will also be used to develop system wide understanding and application of the life course theory as required by the funding source.

 

Tennessee Adolescent Pregnancy Prevention Program: Tennessee's adolescent pregnancy prevention efforts encompass two different strategies--the Tennessee Adolescent Pregnancy Prevention Program (TAPPP) and the Abstinence Education Program. TAPPP councils operate in four of the six metropolitan areas and in 6 of the 7 rural regions. The 10 Coordinators serve as the community contacts/resource persons for adolescent pregnancy issues. All council memberships are broadly representative of the surrounding community, and include Girl Scouts, March of Dimes, Department of Human Services, Department of Children's Services, community based youth serving organizations, hospitals, local businesses, schools, universities, adoption service agencies, faith-based organizations, juvenile justice agencies, media representatives, and regional and local health councils. Each council participates in a wide range of activities, depending on local priorities and resources, including conferences, parenting and adolescent health fairs, workshops, legislative briefings, and training for professionals. TAPPP councils operate in three of the six metro areas. Each Metro and Regional Health Department utilizes health educators to implement a wide range of activities, depending on local priorities and resources, including educational classes, teen pregnancy and parenting events, conferences, adolescent health fairs, workshops, legislative briefings, and training for professionals. The TN State Department of Health Program Director for Adolescent Pregnancy Prevention and Abstinence Programs and TAPPP Coordinators participate in quarterly conference calls to discuss regional program updates, upcoming events and effective collaborations for future community activities. The Department of Health/MCH is the current recipient of the Pregnancy Assistance Fund (PAF) grant. The PAF grant was transferred to the Department of Health on July 1, 2011. Services consist of access to prenatal care, well child clinical services, a standardized tracking system for program participants, a Baby Store incentive program to purchase needed child care items, and educational information and resources.

 

Tennessee Primary Care Association (TPCA): Department staff work with the TPCA primarily through the Office of Health Access, Regional and Local Health Councils, and the Women's Health Advisory Committee. The state's Breast and Cervical Screening Program is partnering with TPCA and member organizations to explore the options for developing a training mechanism for community health workers and patient navigators across systems.

 

March of Dimes: MCH staff began partnering with March of Dimes many years ago and support the organization's work on decreasing and preventing prematurity, decreasing infant mortality and enhancing the newborn screening program. Staff also support the March of Dimes programs by serving on various local and state committees. The Department is partnering with the March of Dimes, TN Hospital Association, and TIPQC on an initiative to reduce early elective deliveries. Products of the collaborative have included a new website, a letter issuing a challenge to hospitals (attached to this section), social media, presentations, and articles.

 

Tennessee Chapter, American Academy of Pediatrics (TNAAP): TDH staff participate in quarterly meetings with representatives from TennCare and the Tennessee Chapter of the American Academy of Pediatrics (TNAAP). MCH Block Grant funds have been used to sponsor TNAAP educational events and the Division Director routinely attends TNAAP board meetings and functions to provide updates on state-level MCH activities. Universities: FHW collaborates regularly with university partners across the state on project implementation, evaluation, and consultation. Examples of such collaboration include: program evaluation training for FHW staff by faculty from four Tennessee universities (UT Knoxville, University of Memphis, Tennessee State University, and East TN State University).

Through the needs assessment and prioritization process, described previously, the following priorities were chosen for the FY21-25 grant cycle.  The prioritization process included utilizing a prioritization matrix, where potential priorities were scored against multiple criterion.  A breakdown of the scores for each potential priority can be found in the Supporting Documents section.

 

There were two topics that bubbled up across all the domains:  mental health and health equity.  It was decided that these would not be placed in the Cross-Cutting Domain but would instead be incorporated into all priorities.

 

Maternal and Women’s Health

 

Family Planning

 

This priority was chosen because the team felt that it impacted most of the potential priorities on the prioritization matrix.  Pregnancy and parenthood affect so many areas of health.  It was felt that focusing on this priority would broadly impact many areas of women’s health.

 

Pregnancy-Associated Mortality

 

Maternal mortality was ranked 3rd on the prioritization matrix for this domain.  Although it was not at the very top, once again it was felt that work around this priority would impact most of the other potential priorities.  The priority was renamed to pregnancy-associated mortality to be more specific.

 

Perinatal and Infant Health

 

Breastfeeding

 

Breastfeeding was the top ranked potential priority for this domain.  This is a health behavior that impacts many areas of health.  The state has seen a lot of success in this area, particularly around initiation.  The team would like to build on that success and work to improve duration for even more improved outcomes.

 

Infant Mortality

 

Infant mortality came in 2nd on the prioritization matrix, just behind breastfeeding.  While the state has seen an improvement in this area, the state rate remains well above the national average.  Infant mortality is a measure of population health and the quality of health care.  Therefore, the team felt that it should continue to be a priority for this domain.

 

Child Health

 

Overweight/Obesity

 

This was ranked 2nd through the prioritization matrix.  Overweight/obesity continue to be an issue within the state that once again affects many other areas of health.  Therefore, the team decided to continue with this priority.

 

Adverse Childhood Experiences (ACEs)

 

ACEs were the top ranked potential priority on the prioritization matrix for this domain.  This is also a priority area for the state in general, due to the impact these events have on health later in life.  Therefore, the team chose to continue with this priority.

 

Adolescent Health

 

Tobacco and E-cigarette Use

 

Exposure to nicotine (to encompass combustible and e-cigarettes) ranked 2nd only to mental health in the prioritization matrix.  Since this health behavior is common in the state and has health implications that impacts smokers and non-smokers (through second-hand smoke exposure) the team decided on continue with this priority.  Mental health bubbled up in each domain and is therefore being incorporated into each priority.

 

Children with Special Health Care Needs

 

Medical Home

 

This priority was chosen because the team felt that it could address many of the top ranked potential priorities through this one priority.  There has been work done around in this area in the past but there is still room for improvement.

 

Transition from Pediatric to Adult Care

 

Transition from pediatric to adult care is especially important for children with special health care needs.  They have more health care needs than the general population, and therefore need access to providers.  This was chosen as a priority since it is critical to their care that the transition be a smooth one.