III.C.2.a. Process Description
Five-Year Needs Assessment Summary
The following is a summary of the California Department of Public Health (CDPH) Maternal, Child and Adolescent Health (MCAH) Division Title V Needs Assessment (NA) process, findings, and identified priority needs for the next five years. Each section includes specific information for the five Title V population domains: Women/Maternal, Perinatal/Infant, Child, Adolescent, and Children and Youth with Special Health Care Needs (CYSHCN).
PROCESS DESCRIPTION
CDPH/MCAH worked closely with a diverse group of stakeholders and multidisciplinary groups of state staff to assess the needs of the MCAH population in California. Each population domain has an assigned state MCAH lead and co-lead who coordinate ongoing workgroups (referred to as Domain Teams) that include representation from staff with program, evaluation and epidemiology expertise across the Division. These domain leads, along with relevant Division managers and subject matter experts, form CA’s State Title V Leadership Team.
The Leadership Team drew from several public health frameworks, including the life course perspective, social determinants of health, and the socio-ecological model, to implement a standard overarching NA structure. To capture health disparities and inequities, CDPH/MCAH aimed to use a health equity lens throughout and plans to expand this focus in the future. In addition, each Domain Team designed a unique process tailored to their specific environmental context, population needs, capacity and key partnerships. Most notably, the process differed in the Child and CYSHCN domains, since activities are under development and MCAH has been focusing on planning and building capacity, partnerships, expertise. As such, these Domain Teams’ NA processes involved extensive outreach to and engagement of stakeholders and experts. Each of the five Domain Teams utilized program data, population data, Local MCAH NA findings from the 61 Local Health Jurisdictions in CA, and survey data gathered from general and domain-specific NA activities to develop priority needs statements and corresponding measures. Below is a description of general and domain-specific NA efforts and activities.
CDPH/MCAH implemented a structured data-gathering process involving detailed input from each of the 61 Local MCAH programs in California, with support provided through a contract with the University of California San Francisco (UCSF) Family Health Outcomes Project (FHOP). Local MCAH programs conducted individual county and community-level NAs that captured the needs, priorities, and challenges of their local areas. CDPH/MCAH worked with UCSF FHOP to provide 73 data indicators available at the county or regional level. Based on the data provided and other information gathered at the local level and through stakeholder meetings, Local MCAH programs were asked to rank their top areas of concern for each of the CDPH/MCAH domains (Attachment 1). These concerns were captured via a package of forms designed by CDPH/MCAH. Local MCAH also provided in-person and survey NA feedback during statewide and regional MCAH meetings. To facilitate and inform local NA efforts, CDPH/MCAH and FHOP provided Local MCAH programs with ten webinars on best practices and strategies for local NA.
In parallel with the structured data gathering process for Local MCAH, CDPH/MCAH hosted various information-gathering and brainstorming sessions with other state agencies, university researchers, health care providers, local MCAH-funded program staff and program clients, families, community-based organizations, foundations, health plans, and others. Domain Teams used information gathered from these meetings along with population-based health data to complement and further inform local NA findings. Population-based data sources included vital records, hospitalizations, education data, newborn screening data, and survey data from the Maternal and Infant Health Assessment (MIHA) Survey, the Youth Risk Behavior Survey (YRBS), the California Health Interview Survey (CHIS), and the National Survey of Children’s Health (NSCH).
CDPH/MCAH Domain Teams utilized the data gathered from these various activities to draft priority need statements and focus areas. Then, CDPH/MCAH designed and facilitated an iterative stakeholder meeting process, ending with seven in-person regional meetings with Local MCAH programs across the state, to fine-tune and vet identified priority needs and focus areas. Lastly, CDPH/MCAH finalized priority needs statements for 2021-2025 (see the Priority Needs section). These priority needs and corresponding focus areas informed CDPH/MCAH’s 5-year Title V action plan, which will align with the scope of work for all Local MCAH programs throughout the state.
All Domain Teams participated in the following activities:
- Reviewed 2016-20 Title V priority needs and relevant priorities from other sources (e.g., Healthy People 2020, Center for Family Health Results Based Accountability Framework)
- Sorted and analyzed available data, including population-level indicators
- Reviewed evidence and literature related to the focus areas and populations
- Engaged stakeholders, LHJs, funded-agencies and partners
- Analyzed and incorporated information provided by Local MCAH programs
- Discussed opportunities to address health disparities and advance health equity
- Assessed program capacity
- Developed priority needs and corresponding focus areas to structure the action plan
Domain-specific NA efforts and activities included:
Women/Maternal:
The Women/Maternal Domain followed the general process outlined above, with a particular focus on life course theory and addressing health equity.
Perinatal/Infant:
The Perinatal/Infant Domain considered highlights from listening sessions and key informant interviews with State CDPH/MCAH and Department of Health Care Services (DHCS) Program staff, the California Perinatal Quality Care Collaborative’s Health Equity Task Force and others. The domain process was guided by The Spectrum of Prevention (Attachment 2a) and a Social Determinants of Health (SDOH) framework (Attachment 2b). The Spectrum of Prevention, developed by the Prevention Institute, moves away from the traditional prevention focus on individual health behaviors toward a multi-level systems approach to health-related interventions.
Child:
The Child Domain process used information gleaned from Local MCAH reports, stakeholder meetings, and key informant interviews, largely conducted in collaboration with the CYSHCN Domain. The Child Domain Team also gathered information from additional key informant interviews with child health and public health experts, in-person stakeholder meetings (e.g., Statewide Screening Collaborative meetings), and email communications with thought leaders in child health.
Adolescent:
The Adolescent Domain process assessed Local and State needs by reviewing information collected from a host of stakeholders, including the Adolescent Sexual Health Workgroup (ASHWG), 20 Adolescent Family Life Program (AFLP) agencies, 22 California Personal Responsibility Education Program (CA PREP) agencies, and 14 Information and Education (I&E) agencies. State MCAH staff assigned to the Adolescent Domain Team facilitated additional NA-related discussions with the ASHWG Steering Committee, adolescent health program directors, other CDPH partners and Local MCAH Directors.
Children and Youth with Special Health Care Needs:
The CYSHCN Domain process was different than those described above due to historical and organizational factors. CDPH/MCAH conducted a comprehensive, multi-year NA to identify gaps, needs and opportunities to better support all CYSHCN in CA. CDPH/MCAH coordinated with the DHCS Integrated Systems of Care Division (ISCD), who also conducted an aligned NA focused on CYSHCN. A portion of California’s Title V funding supports county administration and quality improvement efforts for the DHCS/ISCD California Children’s Services (CCS) program, which provides diagnostic and treatment services, medical case management, and physical and occupational therapy services to children with chronic medical conditions [1]. As part of an overarching process to assess and expand the role CDPH/MCAH should have in improving systems for CYSHCN, the CYSHCN Domain Team initiated an intensive process of information gathering to better understand the current and potential public health role for CYSHCN, in close consultation with the Child Domain. This “Year of Learning” was part of the 2021-25 needs assessment and is graphically depicted in Attachment 3. Due to the extent of activities involved in this expanded needs assessment, please refer to Attachment 4 for a complete description.
II.C.2.b Findings
III.C.2.b.i MCH Population Health Status
FINDINGS
MCH Population Health Status
The information in this section describes key population health status findings by domain from the CA Needs Assessment (NA). The CA Maternal, Child and Adolescent Health (MCAH) program used these findings to inform the Title V priorities and the 5-year Action Plan.
Women/Maternal:
The findings below highlight the key issues and focus areas that emerged related to the health of women of reproductive age, before, during and beyond pregnancy. All figures are located in the Appendix.
Maternal Mortality: CA’s maternal mortality rate is one of the lowest in the country. [1] Though rates of maternal deaths have decreased across all racial/ethnic groups in CA, the rate for Black women continues to be roughly two to four times higher than the rates for other racial/ethnic groups (FIGURE 1). Cardiovascular disease, preeclampsia, and obstetric hemorrhage were the leading causes of pregnancy-related deaths (2002-2007). [2] Maternal mortality, with a focus on reducing racial disparities, remains a critical issue for CA.
Maternal Morbidity: CA’s delivery hospitalization data reveal increasing trends in maternal morbidity and racial/ethnic disparities. Chronic conditions exacerbate maternal morbidities and increase the likelihood that women will experience negative outcomes during childbirth with short and/or long-term impacts for the parent and baby. Between 2006 and 2015, among CA women giving birth in hospitals, diagnosis of hypertension, asthma and diabetes increased (FIGURE 2). Hypertension and asthma were most prevalent among Black women, followed by American Indian/Alaska Native (AIAN), White, Hispanic, and Asian/Pacific Islander (PI) women. Diabetes was more common among Asian/PI, AIAN and Hispanic women (FIGURE 3). Among women who gave birth in 2017, over half were overweight or obese before pregnancy (FIGURE 4, 5).
CA’s data on severe maternal morbidity, i.e. life-threatening complications at delivery, is on the rise. [3] Between 2006 and 2014, the rate of severe maternal morbidity increased by 60.5% (FIGURE 6). Moreover, racial/ethnic disparities persist. In 2015, Black women reported the highest rate (FIGURE 7).
Maternal Mental Health: The top priority from the Local MCAH NA was maternal mental health. In CA, about one in five women report depressive symptoms during the perinatal period (FIGURE 8). There are notable and urgent health disparities among women who experience mental health concerns before and after pregnancy. These include disparities on the basis of race/ethnicity, sexual orientation and gender identity, socioeconomic status, age, social and geographic isolation, and other factors. In 2013-2015, Black and Hispanic women had the highest prevalence of depressive symptoms before pregnancy and after delivery compared to other racial/ethnic groups (FIGURE 9). In addition, mental health conditions and psychosocial stressors were highly prevalent among women who died by suicide within a year of pregnancy (87% and 85%, respectively). [4] The need to support maternal mental health is significant and MCAH can play an important role to partner and support efforts and ensure that new parents have supports and are linked to needed services.
Well-Woman/Post-Partum Visits: Investing in women’s health throughout the life course, particularly during reproductive age, is key to improving maternal health outcomes. Wellness visit attendance differs greatly by health insurance status. During 2015-2016, only 43.9% of uninsured reproductive-aged women reported attending a yearly wellness visit, compared to 67.1% of those covered by private insurance. Similarly, while most women in CA (90.1% in 2017) report attending a postpartum visit, disparities exist on the basis of race/ethnicity, income level, and medical coverage. [5] Lack of providers and transportation barriers in rural areas can further exacerbate disparities. These interrelated issues demonstrate the need to ensure that women of reproductive-age have equitable access to quality care before, during, and after pregnancy.
Perinatal Substance Abuse: Perinatal substance use was a top priority identified by Local MCAH programs and other stakeholders. The most commonly used substances during pregnancy are alcohol, tobacco and cannabis, and opioid use during pregnancy is increasing. [6] Between 2008 and 2015, the rate of maternal substance use (diagnosis at delivery) increased by nearly 60% (FIGURE 10). In 2015, the maternal substance use rate for Black women was more than twice the rate for White women and nearly four times the rate for Hispanic women (FIGURE 11). As rates of perinatal substance use increase, there is also an increase in rates of neonatal abstinence syndrome (NAS). [7-9] Between 2006 and 2015, the rate of NAS in CA doubled (FIGURE 12). Rates of NAS vary by race/ethnicity with the highest rates among White newborns and by insurance with higher rates among Medi-Cal patients (FIGURE 13, 14).
Perinatal/Infant:
Preterm Birth and Infant Mortality: The most pressing need for CA with regards to preterm birth and infant mortality is to address the significant racial disparities that exist. A stratified analysis in 2017 revealed that infants born to Black mothers are most likely to be born preterm (12.6%), followed by those born to AIAN (11.4%), Hispanic (9.0%), PI (9.0%), Asian (7.9%), and White (7.5%) mothers (FIGURE 15). Likewise, CA’s infant mortality rate shows striking disparities among Black births as compared to other racial/ethnic groups (FIGURE 16). When looking at Sudden Unexplained Infant Death (SUID) as a cause, among Black infants the 2017 SUID rate (193.5 deaths per 100,000 live births) was more than nine times the rate among Asian/PIs (20.4) and more than four times the rate among Hispanic (46.8) and White infants (47.2) (FIGURE 17). Decades worth of data indicate that these racial/ethnic disparities are persistent and require interventions that address longstanding structural inequities and racism.
Low Birthweight: Birthweight is closely tied to infant mortality and is tracked primarily via low birthweight (LBW, weight under 2500 grams) births. This indicator, while quite stable in CA (6.8% in 2008 and 6.9% in 2017) (FIGURE 18), also varies by race/ethnicity, ranging from a high of 12.2% among Black births to a low of 5.7% among White births (FIGURE 19).
Breastfeeding: A number of factors influence women’s ability to breastfeed their infants, including income and poverty level, workplace policies, lactation accommodations, hospital policies, age, social norms, and the level of support they receive from their families, communities and providers. Data from 2017 shows that more CA women are exclusively breastfeeding their infants through 3 months postpartum compared with 2011 (FIGURE 20). However, disparities by race/ethnicity, age and income level were striking, with Hispanic, Black, and Asian/PI women less likely to exclusively breastfeed compared with White women during 2015-2016 (FIGURE 21). [10, 11]
Child:
A child’s experiences and life circumstances during their early years impact development, health outcomes, and general well-being across the life course and potentially for generations to come. This understanding of the importance of early childhood experiences informed the needs and focus areas for this domain.
Nearly one in five (19%) CA children from birth through five lives in a family with an income below the poverty level and significant differences exist across racial/ethnic groups. Black children experience the highest rates of family poverty at 32%, followed by Hispanic children (25%) Asian children (10%) and White (9%). [12] Other factors beyond income, such as homelessness, also contribute to children’s exposures to unsafe and stressful environments. Based on the CA Poverty Measure, access to safety net resources provide some relief for families, without which childhood poverty would be much higher. [13] However, much more work is needed to address the systemic roots of inequity in order to improve child health outcomes.
Developmental and Social-Emotional Screening: The AAP recommends that all children under the age of three are screened routinely for early identification of potential developmental and behavioral concerns. [14] In 2017-18, among CA children aged 9 through 35 months, only 26% received developmental screening by a health care provider in the past year. [15] Expanding and supporting developmental and social-emotional screening was a key area of need identified by the Local MCAH programs and key partners throughout the needs assessment process and is important to help ensure children in need receive early intervention services and supports.
Resilience and Adverse Childhood Experiences (ACEs): Flourishing is a term that captures the concept of a child receiving all of the support and care needed to reach their full potential. For children aged 6 months to 5 years, flourishing is defined using four items: bounces back quickly when things do not go their way, affectionate and tender with their parent, shows interest and curiosity in learning new things, and smiles and laughs a lot; for those aged 6-17 years, it is defined as: shows interest and curiosity in learning new things, stays calm and in control when faced with a challenge, and works to finish the tasks she/he starts. [16] Data indicate that the proportion of children who are flourishing has substantial room for improvement. [17] Another critical concept is resilience: access to support and resources that allow children to bounce back from stressful experiences. Key factors in developing resilience include stable, nurturing relationships and interactions with trusted and supportive adults.
ACEs are physical, emotional, or social events that cause stress and trauma, and can have negative, long-term effects on a child and their family. [18, 19] Trauma affects a young child’s rapidly developing brain and body and can shape health trajectories throughout the life course and into future generations. [19, 20] In CA, nearly one in three (29%) children aged 0-5 years experienced at least one ACE; for those aged 6-11 years, the prevalence estimates are higher at 38% experiencing one ACE. [15] Through the NA, prevention of childhood adversity and promotion of resilience were high priorities at the Local and State levels.
In terms of behaviors that support resilience, overall, 65% of CA children aged 0-5 years were read to by their parents or guardians every day. Prevalence varied by race/ethnicity, with a higher percentage of White children (86%) being read to by their parents/guardians, as compared to Asian (62%), Latino (55%), and Black (54%) children. [21] There is a need for improved support to help parents and caregivers access the time, resources, and skills they need to nurture resilience in their children.
Physical Health: Physical well-being and access to health care for children are areas of need where MCAH plays a critical supporting and partnership role. Two of the top priorities identified in this area throughout the needs assessment were oral health and healthy weight. In CA, among children aged 1-5 and 6-11 years, 57% and 89%, respectively, had a preventive dental visit in the past year. There is a clear need for MCAH to support interventions that enable children – especially in early childhood – to have access to routine dental services. With regard to healthy weight, nearly one in three youth (age 10-17) had a BMI indicating that they were overweight or obese. While BMI is an imperfect measure, this indicates a need for support of interventions that promote access to healthy food, safe and walkable communities and spaces to be physically active, and promotion of adequate sleep and other behaviors that support healthy weight. Because interventions focusing on individual behavior change are minimally effective and difficult to sustain, public health should focus on population-based strategies related to changes in policies, systems, and environment. [22, 23]
Adolescent:
Adolescence is a critical life stage characterized by physical, emotional, intellectual, and psychological changes, as well as the development of health behaviors that can last a lifetime. [24-26] Research shows that connection with a caring adult, high expectations for the future, and opportunities for contributing to their families and communities are important determinants of resilience and of positive outcomes among youth. [27] In CA, nearly one in four adolescents aged 12-17 years reports not having a caring adult with whom they can talk about serious problems. [28] MCAH continues to identify the need to increase support for youth and promote positive youth development.
Sexual and Reproductive Health: Through the local needs assessment, approximately 44% of the LHJs identified sexual and reproductive health as a key area of need. LHJs and key partners highlighted the need for the provision of youth-friendly information, comprehensive sexual health education, and linkage to sexual and reproductive health services including support for building healthy relationships and services for youth experiencing intimate partner violence. Disparities in the adolescent birth rate (ABR) persist and rates of sexually transmitted infections among young people in CA are on the rise. In 2018, more than 16,000 babies were born to CA mothers 19 years old and under, with 15 percent of those births being a second or subsequent child born during adolescence. Sixty-six percent of adolescents 19 and under with a subsequent birth experienced a suboptimal interpregnancy interval, which increases the risk of adverse pregnancy outcomes. Black and Hispanic females aged 15-19 years were, respectively, 3 and 4 times more likely to give birth as were their White peers and in 2018 there was a five-fold difference between the county with the highest and lowest birth rates in the state. [29] In 2017, there was the largest number of reported Chlamydia and Gonorrhea cases among CA’s youth (aged 15-24 years) since 1990 when reporting began. [30]
On a national level, evidence suggests that ABRs are declining largely because more youth are using contraception; however there is still more work to do. [31] CA data from 2017 reveal that among sexually active high school students, 47% used only condoms, 23% used only hormonal or long-acting reversible contraception (LARC), and 7% used both condoms and hormonal contraception or LARC, and 23% reported no contraceptive method [32]. A number of youth populations experience higher rates of birth and sexually transmitted infections (STIs), including HIV, compared to adolescents in general. These populations include youth in foster care, youth experiencing homelessness, male youth who identify as gay or bisexual and/or have same-sex sexual partners, and female youth who identify as lesbian or bisexual and/or have same and other-sex sexual partners. [33-36] These findings highlight some of the complexities of adolescent sexual behavior, development, and identity, which further supports the need for continued investment in inclusive and affirming adolescent sexual health efforts.
Additionally, in CA, about 10% of high school students reported experiencing sexual violence, 8% reported experiencing physical dating violence, and 18% reported being bullied on school property. [32] Furthermore, in CA, one in five young mothers aged 15-17 years old experienced intimate partner violence during pregnancy (compared to 9% or less among other age groups). [37] Given that such violence can impact all aspects of health and well-being there is an urgent need to address and respond to these issues.
Access to Care: Having access to youth-friendly, quality health care services, including sexual and reproductive health services and mental health services, is critical to the health and well-being of the adolescent population. [38] Access to such services is facilitated by insurance coverage and survey data indicate that just 68.3% of 12-17 year-olds in CA are continuously and adequately insured. [15] Barriers to accessing care for young people include transportation, availability of nearby services, worry about confidentiality, judgement, or disrespect, and cost. [39]
Mental Health: Local MCAH programs identified adolescent mental health as one of the highest priority need areas across all domains (Attachment 1). Fifty-four percent of LHJs reported mental health as their priority need for adolescent health in their needs assessment. LHJs highlighted needs around depression and anxiety disorders, mental health hospitalizations, and rates of suicide, particularly among sexual minority youth. Data indicate that 32% of CA’s high school students stated that they felt sad or hopeless almost daily for at least two weeks in a row. Moreover, 9% attempted suicide one or more times during the 12 months prior to taking the survey. [32] In 2017, suicide was the second leading cause of death among adolescents aged 15-19 (FIGURE 22). According to CA data, the rate of hospitalizations due to mental health issues among youth has been increasing since 2008 and, in 2017, accounted for the largest percentage of hospitalizations among youth aged 0-17. [40] To address adolescent mental health and well-being, state and local MCAH recognize the need to provide youth with the skills that promote resilience, positive identity/self-esteem, and coping/emotion regulation skills, while simultaneously investing in systemic changes needed to increase access to mental health care, normalize open discussions and build strong supportive relationships.
Physical Activity and Nutrition: Engaging in physical activity and receiving good nutrition are essential for individuals of all ages, but especially for adolescents during a time in life where health behaviors develop and often carry into adulthood. CA data indicate that in 2018 more than one in three 9th graders were overweight or obese. [41] While weight is only part of the picture of access to healthy food and physical activity, this data supports the need for MCAH to partner on education, prevention, policy, systems, and environmental changes that promote physical activity and healthy eating among young people in CA.
Children and Youth with Special Health Care Needs:
The CYSHCN Domain differs historically and organizationally from the other four domains. The Title V CYSHCN initiative is in a transitional stage, with leadership and focus shifting from its historical location in the Department of Health Care Services (DHCS), CA’s health care delivery agency, back to CDPH/MCAH due to the clear need to increase public health strategies to improve systems for all CYSHCN. About one in seven (13.9%) – or about 1.3 million – of CA’s children aged 0-17 years have special health care needs. Of these, less than one in ten families report that their child receives care in a well-functioning system. [15] The CYSHCN NA highlighted systematic and social factors that impact the population health status of CYSHCN. Race/ethnicity, poverty, experiences of trauma, and other social determinants of health can both cause and exacerbate special health needs, particularly the need for increased services, such as mental and behavioral health supports. For CYSHCN, these influential relationships can be particularly pronounced. To improve the population health status of CYSHCN, initiatives need to go beyond the provision of direct services to include creating positive systematic and social changes.
Many of the primary findings for the CYSHCN domain are covered in the following sections including agency capacity. Most population health status data come from the NA that was funded through the Title V interagency agreement with DHCS/ISCD and primarily focused on the CA Children’s Services program, which serves the most medically fragile children in the CA. Highlighted data are included below, using the six HRSA/MCHB components of an effective system of care for CYSHCN as a framework (i.e., Families are Partners in Care, Continuous Screening, Community-Based Services, Adequate Insurance, Transition to Adult Care, and Medical Home). [42] A full report of the findings is included in Attachment 2.
Families are Partners in Care: The CYSHCN Family Survey indicates that medical providers (primarily in the CCS Program) in CA are generally doing well in this area. Approximately 86% of families felt that their providers always or usually worked with them in partnership to make health care decisions for their child, and 87.1% felt that their doctors/providers always or usually talked about the range of treatment and care choices for their child. In recent years, the CCS program has increased its family engagement efforts, and some county CCS programs have implemented family advisory committees. However, there is a need to improve family engagement in their child’s health and care, particularly for those CYSHCN who are not eligible for the CCS program.
Continuous Screening: While CA does a good job with newborn screening (all infants born in CA are screened for 80 different genetic and congenital disorders [43]), the same cannot be stated for childhood screening rates. Due to a host of factors – including geographical challenges, inadequate reimbursement rates, cultural barriers, information asymmetries with respect to developmental milestones, and others – CA’s childhood screening rates lag behind those of other states. [44] There is a need for significant improvement – as mentioned above in the Child section. A lack of timely screening can mean that those with conditions of concern will fail to get needed services.
Community-Based Services: When Family Survey respondents were asked how often their child’s services are coordinated in a way that makes them easy to use, 53% said always, and 29% said usually, with 18% indicating sometimes or never. With regard to coordinating physical or occupational therapy in the school setting, 49% of respondents said that coordination is always easy, 21% indicated it usually is, 17% said it is only sometimes or it never is, and 12% did not know. Responses to both of these questions indicate that there are opportunities for improvement in the coordination of community-based services. Many of the qualitative findings of the CYSHCN NA touched on the need for better communication within and between systems (i.e., health care, social services, education, public health, and others) that serve families of CYSHCN.
Adequate Insurance: Overall, CA has made great progress in increasing the number of children with health insurance. However, there are ongoing challenges including maintenance of insurance coverage and provision of all necessary services for insured CYSHCN. The Needs Assessment revealed inconsistent practices for helping children maintain Medi-Cal and CCS coverage. This variation occurs as different entities re-determine eligibility at different points in time and as families are often challenged to provide needed documentation. County CCS Administrators refer to this sub-par situation as “Medi-Cal Churn” and report that, not surprisingly, it leads to poor case management and fragmented services. Please note, many of these challenges may have been inadvertently helped by new policies developed to increase the ease of health care access authorizations and promote continuity of care in response to the COVID-19 public health emergency.
Transition to Adult Care: As a young person with special health care needs transitions into adulthood, they often require tailored support to ensure continuity in receiving needed medical care and a wide range of other services. Less than optimal transition support can compromise an individual’s overall health status. [45] While this data should be interpreted with caution due to a wide confidence interval, the National Survey of Children’s Health estimates that just one in eight (12.6%) of CYSHCN aged 12-17 in CA receives services necessary for transitioning to adult health care. [15]] NA findings on the CYSHCN transition to adult care reveal the difficulty these individuals have in finding adult health care providers who have the knowledge and expertise to work with individuals with complex health care needs, especially needs which originated in childhood. Of the parents who completed the Family Survey and had a child who was at least 14 years of age, about one in three reported that their child had been spoken to about how her/his health care needs would be met upon turning 21, and about one in five had been assisted by CCS to find an appropriate medical provider.
Medical Home: Access to a medical home for CYSHCN is associated with positive impacts on health care utilization and on family-centered care. [46] Of the Provider Survey respondents, about half (48.8%) agreed that their practices could be medical homes for CYSHCN, based upon the American Academy of Pediatrics’ Medical Home definition. [47] While some providers within pediatric practices and CCS Special Care Centers do consider their practices to be medical homes (already), this is an area where barriers exist and progress is needed. Needs include more support for case management and care coordination, increased availability of specialty providers, and improved reimbursement rates. Detailed findings on the top resources that providers identified they would need in order to become a medical home are described in Attachment 2. A number of resources, changes, and supports are necessary to enable provider practices to become medical homes.
III.C.2.b.ii. Title V Program Capacity
III.C.2.b.ii.a. Organizational Structure
Program Capacity – Organizational Structure
California’s Title V reporting requires significant and ongoing effort from all areas of the MCAH Division. CDPH/MCAH’s organizational structure has changed substantially over the course of the NA process due to staff being redirected to the COVID-19 response, staff taking extended leave due to COVID-19 school and childcare closures, and Division leadership leaving to pursue other opportunities. The description below captures the current staffing and structure as of July 2020. Please see Section VI for a complete organizational chart.
The California Department of Public Health (CDPH) resides under the umbrella of the California Health and Human Services Agency (HHSA), as one of twelve departments and six offices that comprise the Agency. The HHSA Secretary, Dr. Mark Ghaly, is a member of Governor Gavin Newsom’s cabinet. These eighteen entities provide a range of services including public health, health care delivery, social services, rehabilitation, developmental services, patient advocacy, emergency medical services, and others. CDPH is composed of 6 centers and 7 offices, encompassing approximately 3,800 employees. MCAH is one of three Divisions within the CDPH Center for Family Health (CFH). The other two CFH Divisions are WIC and the Genetic Disease Screening Program. Connie Mitchell, MD, MPH is the Deputy Director of the Center for Family Health. She also serves as the Region IX Board Member of the Association of Maternal and Child Health Programs.
Within MCAH, a team of managers and staff direct, coordinate, and contribute to the comprehensive reporting required by Title V. This effort is overseen by MCAH’s Division Chief, who serves as the Title V MCH Director for California. This role is currently divided between Acting Division Chief Romeo Amian (formerly the Assistant Division Chief, who oversees fiscal, contractual, and administrative efforts) and Sarah Leff (Title V CYSHCN Director) currently acting as Title V MCH Director. All five Branches within the MCAH Division are directly involved with Title V reporting efforts. These include: 1) the Administrative Support Branch, led by Mónica Nelson, 2) the Epidemiology, Surveillance, and Federal Reporting Branch led by Shabbir Ahmad, 3) the Child and Adolescent Health Branch led by Lissa Pressfield, 4) the Maternal and Infant Health Branch, also led by Lissa Pressfield due to a current vacancy, and 5) the Program Evaluation and Data Systems Branch led by Michael Curtis. Clinical expertise is provided by MCAH’s Medical Officers, Diana Ramos (OB/GYN) and Eileen Yamada (Pediatrician). Additionally, the Outreach and Communications Unit headed by Erica Root provides support to all branches. To compile and complete all required components of the report, the Title V MCH Director works closely with the Local MCAH Unit Chief, Mary DeSouza. Lastly, CDPH/MCAH worked closely with all 61 Local MCAH programs throughout the NA, development of priority needs, and planning of activities to ensure that reporting reflects an accurate and complete picture of programmatic efforts and community needs.
III.C.2.b.ii.b. Agency Capacity
PROGRAM CAPACITY – AGENCY CAPACITY
CDPH/MCAH uses Title V funds to support state and local activities that promote, protect and improve the health of MCAH populations. The following section captures key programs and initiatives within each domain. All program activities receive support from the Epidemiology, Program Evaluation, Contracts, and Fiscal teams within the State MCAH program.
The Women/Maternal Domain and Perinatal/Infant Domain both sit within the Maternal and Infant Health (MIH) Branch. This Branch administers programs and initiatives focused on preconception and perinatal health including: the Perinatal Equity Initiative (PEI), the Black Infant Health Program (BIH), the California Home Visiting Program (CHVP), the California Diabetes and Pregnancy Program (CDAPP) Sweet Success, and Local MCAH programs, which include the Comprehensive Perinatal Services Program (CPSP) as well as a broad range of public health services for MCAH populations. Many of these programs are funded primarily through Title V; however, support for PEI comes from State General Funds (SGF), BIH recently received SGF for expansion in addition to Title V, and CHVP is funded through Maternal, Infant, and Early Childhood Home Visiting (MIECHV) and SGF. In addition, the MIH Branch oversees the Regional Perinatal Program of California (RPPC), Fetal Infant Mortality Review (FIMR), and the Sudden Infant Death Syndrome (SIDS) Program. The Branch supports the Pregnancy-Associated Mortality Review (PAMR). The MIH Branch is led by Lissa Pressfield, Health Program Manager, in a temporary Acting role. The Title V Women/Maternal Domain is led by Health Program Specialist, Cielo Avalos and Public Health Medical Officer, Diana Ramos. The Perinatal/Infant domain is led by Health Program Specialists, JaRita Booker-Pichon and Sheila Thompson, who has been redirected to support the COVID-19 response.
The Child, Adolescent, and CYSHCN Domains sit within the Child and Adolescent Health (CAH) Section. The Child Domain works closely with the CYSHCN Domain to identify overlapping needs and potential collaborations. In addition, the Child Domain collaborates with BIH, AFLP, CHVP, and supports division-wide efforts geared towards the benefit of children in California. MCAH funds and supports the Statewide Screening Collaborative and participates in other key initiatives, such as the Essentials for Childhood initiative. The Child Domain is led by Public Health Medical Officer, Eileen Yamada, who is on extended leave, and Health Program Specialist, Shawn Savolainen, who was redirected due to COVID-19. During this time, the Child domain is led by acting Title V MCH Director, Sarah Leff.
Within CAH, the Adolescent Health team oversees three programs and supports statewide adolescent health initiatives. CDPH/MCAH leads and funds LHJs and community-based organizations (CBOs) to implement the Adolescent Family Life Program (funded by Title V and the Pregnancy Assistance Fund (through June 2020)), the Personal Responsibility Education Program (funded through the Family and Youth Services Bureau), and the Information & Education Program (funded through SGF). In addition, CDPH/MCAH funds and sits on the steering committee for the Adolescent Sexual Health Work Group, and is a member of the CDPH Adolescent Preventive Health Initiative. The Adolescent Domain is led by Health Program Specialist, Merrill Lavezzo, and CAH Section Chief, Lissa Pressfield.
The CYSHCN Domain team led the recent efforts to assess and expand public health capacity to improve systems that serve CYSHCN and their families, as well as support county administration and quality improvement for the CCS program (based in the Department of Health Care Services). More information is included in Attachment 3. The CYSHCN Domain is led by Title V CYSHCN Director and Acting Title V Director, Sarah Leff and co-led by Program Analyst, Tomás Guarnizo. For CCS, in-kind support is provided by two physicians, two health program managers, four analysts, and an accountant.
III.C.2.b.ii.c. MCH Workforce Capacity
program capacity – workforce development
The CDPH/MCAH Division is composed of 129 State staff and 1,370 Local MCAH staff who contribute approximately 782.31 Full-Time Equivalents (FTEs). This estimate has not been updated to reflect temporary staff redirections to support the COVID-19 response. CYSCHN staff (related to the Department of Health Care Services’ California Children’s Services program), funded through multiple sources (i.e., Title V, Title XIX, State General Funds, and local agency funds), include 1,250 Local FTEs and 30 part-time staff working under 4 Title-V funded subcontracts. Additionally, the CDPH/MCAH CYSHCN team works closely with the State’s Family Voices affiliate, Family Voices of California (FVCA). The State’s Family Representative, Ali Barclay, is FVCA’s Family Engagement Manager.
As of July 2020, many State and local staff have been redirected to respond to the COVID-19 public health emergency. While numbers fluctuate from week to week, at the time of writing nearly 20% of the MCAH workforce was redirected at the state level. This has resulted in reductions in capacity to implement MCAH programs as the pandemic response is a critical priority for the state. While this triaging of the workforce is unavoidable and understandable, it is likely to result in long-term impacts on MCAH staff and populations. This rapidly evolving situation will affect the MCAH and broader public health workforce for years to come.
More detail regarding workforce capacity is covered in the Organizational Structure and Agency Capacity sections.
III.C.2.b.iii. Title V Program Partnerships, Collaboration, and Coordination
Program Capacity – Program Partnerships, Collaboration, and Coordination
In many ways, partnerships form the foundation for California’s Title V program. Investing time and engagement in building strong relationships and supporting our partners is essential to creating a positive impact with limited resources. CDPH/MCAH leverages many diverse partnerships and collaborations to serve California’s MCAH population. CDPH/MCAH’s most extensive partnership is with California’s 61 LHJs, which implement Local MCAH programs across the state. Please see Attachment 4 for a full listing and description of the many other partnerships that contribute to the work of MCAH. A selection of key collaborations for each domain are highlighted below.
CDPH/MCAH partners with CDPH’s WIC Division, the Center for Health Statistics and Informatics, and the STD Control Branch, among others, on maternal health-related concerns. CDPH/MCAH maintains a number of collaborations with other departments within CHHS, such as DHCS. For maternal health, these partnerships support efforts addressing mental health concerns and substance use disorders as well as support for home visiting for American Indian families.
Related to infant health, CDPH/MCAH partners with local, non-profit, and state agencies through the BIH program to successfully share guidelines and best practices for Black mothers and infants. Moreover, CDPH/MCAH partners with medical health providers, physicians’ offices, hospitals, community clinics, hospital outpatient clinics, and alternative birth centers to successfully implement the CPSP program. Additionally, CDPH/MCAH’s coordinates efforts with partners to provide the latest AAP risk reduction messages and safe sleep guidelines to all parents and caregivers of newborns.
The Child Domain collaborates with other child-health-focused agencies and efforts across the State. To ensure that children receive updated and current developmental services consistent with current standards, the Child Domain shares information regarding developmental screening resources and best practices from the American Academy of Pediatrics. In partnership with LHJs, CDPH/MCAH supports the First 5 programming, which promotes children’s optimal health development via the “Help Me Grow” model.
The Adolescent Health Domain at CDPH/MCAH collaborates with a diverse group of State and Local partners across the public, nonprofit, and private sectors. Through the Adolescent Preventive Health Initiative, CDPH/MCAH works with the STD Control Branch, the Office of Health Equity, the Environmental Health Investigations Branch, the Immunization Branch, the Nutrition, Education, and Obesity Prevention Branch, DHCS and key stakeholders to carry out, and/or support, initiatives that promote preventive healthcare practices, to improve the health status of California’s youth. In addition, CDPH/MCAH has greatly expanded its capacity to improve sexual and reproductive health outcomes through the Adolescent Sexual Health Work Group.
The CYSHCN Domain Team engages in diverse partnerships to understand the strengths, challenges, and opportunities faced by the CYSHCN population. Partners include families and self-advocates, local MCAH program staff, health care providers, state agencies, non-profits and foundations, and universities.
In addition, CDPH/MCAH contracts with several universities (California State University at Sacramento, the University of California at San Francisco, and Stanford University) and other entities for training, technical assistance, survey administration, analytic support, and other MCAH expertise.
III.C.2.c. Identifying Priority Needs and Linking to Performance Measures
PRIORITY NEEDS AND PERFORMANCE MEASURES
This final section of the NA describes California’s Priority Needs for 2021-2025. Priority needs and their associated performance measures are presented by domain. As part of the NA process, MCAH created the concept of “focus areas” within each Priority Need. While these are not a formal or required part of Title V reporting, it was a useful construct to break overarching Priority Needs into focused, actionable areas. Priority Needs and focus areas were developed in response to the findings described in previous sections of the NA, and with substantial input from Local MCAH programs and other stakeholders.
WOMEN/MATERNAL Priority Need 1: Ensure women in California are healthy before, during and after pregnancy.
Focus areas:
- Reduce the impact of chronic conditions related to maternal mortality.
- Reduce the impact of chronic conditions related to maternal morbidity.
- Improve mental health for all mothers in California.
- Ensure optimal health before pregnancy and improve pregnancy planning and birth spacing.
- Reduce maternal substance use.
Relative to the priority statement for this Domain from the prior NA (“Improve preconception health by decreasing risk factors for adverse life course events among women of reproductive age”), the new statement expands focus beyond the preconception phase and includes women across various stages of the reproductive life course.
National Performance Measure (NPM) 1 – percent of women, ages 18 through 44, with a preventive medical visit in the past year – was chosen for this Domain. This measure is recommended by the American College of Obstetricians and Gynecologists and is linked closely with this Domain. Preventive care provides opportunities for women to receive recommended clinical services, including screening, referral, counseling, immunizations and interventions. These services enable identification, treatment, and prevention, helping women to optimize their health across the reproductive life course. [1]
PERINATAL/INFANT Priority Need 1: Ensure all infants are born healthy and thrive in their first year of life.
Focus Area:
- Improve healthy infant development through breastfeeding and caregiver/infant bonding.
PERINATAL/INFANT Priority Need 2: Reduce infant mortality with a focus on eliminating disparities.
Focus Areas:
- Reduce infant mortality with a focus on reducing disparities.
- Reduce preterm births.
Compared to the previous priority statement for this Domain (“Reduce infant morbidity and mortality” – which was addressed via activities related to prematurity, breastfeeding, and SUID), the current statements more broadly call out being born healthy and thriving as opposed to focusing only on morbidity and mortality. They also emphasize eliminating disparities, which was not called out before. These changes highlight California’s commitment to advancing health equity in infant health outcomes. The new broader priorities support innovation and are responsive to critical needs.
Finally, for this Domain, one NPM was selected and two SPMs were added to align with the two priority statements and their associated focus areas. The National Performance Measure chosen for this domain is NPM 3 – Percent of very low birthweight (VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU). Regarding NPM 3, the likelihood of survival of very fragile VLBW infants is greater when they are born and cared for within an appropriately staffed and equipped facility providing specialty care for high-risk patients. In 2016, 2% of California’s births were classified as VLBW. These infants accounted for half of all infant deaths. [2]
The SPMs chosen for this domain are percent of women who report exclusive breastfeeding at 3 months and preterm birth rate among infants born to non-Hispanic Black women.
CHILD Priority Need 1: Optimize the healthy development of all children so they can flourish and reach their full potential.
Focus areas:
- Expand and support developmental screening.
- Raise awareness of adverse childhood experiences (ACEs) and prevent toxic stress through building resilience.
- Support and build partnerships to improve the physical health of all children.
In comparing the above to what was included in the prior NA (“Improve the cognitive, physical and emotional development of all children”), the current statement is more future-focused, as it looks to support children flourishing and reaching their full potential. At the same time, there is continuity related to developmental screening.
For the Child Health Domain, NPM 6 was selected to align with the priority needs statement – Percent of children, ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year.
ADOLESCENT Priority Need 1: Enhance strengths, skills and supports to promote positive development and ensure youth are healthy and thrive.
Focus Areas:
- Improve sexual and reproductive health and well-being for all adolescents in California.
- Improve awareness of and access to youth-friendly services for all adolescents in California
- Improve social, emotional, and mental health and build resilience among all adolescents in California.
Relative to the previous priority statement (“Promote and enhance adolescent strengths, skills and supports to improve adolescent health”) the current statement extends beyond improving health to ensuring that youth thrive and reflects CDPH/MCAH’s commitment to positive youth development. This includes skill-building so youth are equipped to make healthy choices, develop a positive sense of self, foster healthy relationships, and fulfill their goals.
The Adolescent Health Domain chose NPM 10 – Percent of adolescents, ages 12 through 17, with a preventive medical visit in the past year. This NPM is suitably linked with the work in this Domain as MCAH at the state and local levels will aim to ensure that youth and their families are informed about and connected with preventive care, including sexual, reproductive, mental, and behavioral health care services.
CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS Priority Need 1: Make systems of care easier to navigate for CYSHCN and their families.
Focus Areas:
- Build capacity at the state and local levels to improve systems that serve CYSHCN and their families.
- Increase access to coordinated primary and specialty care for CYSHCN.
CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS Priority Need 2: Increase engagement and build resilience among CYSHCN and their families.
Focus Area:
- Empower and support CYSHCN, families, and family-serving organizations to participate in health program planning and implementation.
New information (gathered through the NA process) suggested that challenges in navigating systems and the lack of formal processes for communication between systems are among the top issues for this CYSHCN population. This was reinforced by Local MCAH Directors, who echoed the challenges that both families and health professionals face in navigating systems. These challenges are particularly salient for CYSHCN who often need additional support from an array of systems, particularly with the transition from pediatric to adult health care – including specialty care (e.g., mental and behavioral health care). Relative to the priorities included in the prior action plan (“Provide high quality care to all CYSHCN within an organized care delivery system” – with emphases on health care systems, medical homes, and transitions; and “Increase access to CCS-paneled providers such that each child has timely access to a qualified provider of medically necessary care” – with emphases on specialists and medical billing), the current needs statement includes expanded emphases on access to a broad range of needed services and on the development of public health capacity and strategies, which were not the focus previously.
Second, the Domain Team clearly identified the importance of meaningfully engaging and partnering with families in decision-making around practices and programs. This concept, which includes family-centered care, is an important aspect of the California’s Title V efforts. Evidence shows that family engagement has numerous benefits, including better quality of care, lower parental anxieties and fears, reduction of health care costs, more efficient use of services, and improved communication between families and health care providers. [3] Additional support for promoting this concept was garnered during discussions with stakeholders and during reviews of other states’ CYSHCN-related efforts. [4]
For the CYSHCN Domain, the following NPM was selected: NPM 12 – percent of adolescents with and without special health care needs, ages 12 through 17, who received services necessary to make transitions to adult health care. Navigation of systems and family engagement are both critical components to ensure a successful transition from pediatric to adult health care for CYSHCN.
NEEDS ASSESSMENT CONCLUSION
In this third and final section of this NA summary, a total of seven priority needs statements and 17 associated focus areas were presented across the five Domains. CDPH/MCAH chose performance measures from the list provided by HRSA/MCHB that best fit with the priority needs and strategies for each domain. Some common themes – including health equity, access to care, physical and mental health (to include substance use), and family and community engagement – emerged throughout the NA. CDPH/MCAH implemented a thoughtful process to identify priorities that are ambitious; data-driven; incorporate the voices of families, communities, and others stakeholders; and where the State MCAH program can have an impact. CDPH/MCAH is committed to continuing work during the next Title V cycle to improve the health and well-being of women, infants, children and adolescents throughout California.
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