Process Description

Goals for the Title V MCH Program Five-Year Needs Assessment included surveying the community partners serving MCH populations to help guide the priority needs for the Title V MCH Program, reviewing Federally Available Data (FAD) for Nevada and other state-specific MCH data, linking National Performance Measures (NPMs), Evidence-based or -informed Strategy Measures (ESMs) and State Performance Measures (SPMs) to the state priorities, and identifying the best use of Health Resources and Services Administration (HRSA) Title V MCH Block Grant resources to improve health outcomes in each of the Title V MCH domains.

The Maternal, Child and Adolescent Health (MCAH) Section houses the Title V MCH and the Maternal, Infant and Early Childhood Home Visiting (MIECHV) programs. Title V MCH and MIECHV collaborated on the HRSA needs assessments required by each grant, discussed goals for each program, and agreed upon a selection process for State Master Service Agreement agencies qualified to coordinate and complete a Five-Year Needs Assessment. After the selection process, Title V MCH and MIECHV staff chose Health Management Association (HMA) to complete the Five-Year Needs Assessment. HMA implemented a mixed method research design to inform the Needs Assessment, including multiple strategies to gather stakeholder and public input from across the state. MCAH staff presented to the Intertribal Council and Tribal Health Director’s meetings, the Nevada Governor’s Council on Developmental Disabilities, the Maternal and Child Health Advisory Board, and many other venues to heighten awareness of the Needs Assessment and engage collaboration on survey engagement.

HMA worked with Title V MCH and MIECHV program staff to identify and interview key stakeholders working in Title V MCH and MIECHV-funded programs or working with targeted population groups. Key stakeholders identified additional stakeholders for interviews or focus groups through the interview process, which allowed HMA to access a large and diverse number of stakeholders for information gathering. HMA then hosted an online community survey dispersed via Title V MCH and MIECHV staff, partner organizations, and social media channels and a series of focus groups were conducted across the state. Finally, HMA conducted secondary analyses of publicly available population health and surveillance data.

Key Informant Interviews

Twenty (20) semi-structured, in-depth interviews were conducted with a total of 33 key leaders working in maternal, child and adolescent health and wellness from Carson City, Churchill, Humboldt, Storey, Washoe, Mineral, Lyon, Clark, Elko, Eureka, and Nye counties (11 of 17 total counties). Interviews were designed to gather information about the most pressing health issues facing MCH population groups and what is most needed to effectively address these health issues. Leaders included those from organizations associated with special needs transportation, rural/frontier families, undocumented populations, foster care representation, child/abuse neglect, family resource centers, etc. Interviewees were also asked about gaps and barriers in services and programming in Nevada for MCH population groups. Finally, key informant interviews sought to gather information about disparities related to geography, race and ethnicity, and other identified socio-cultural differences.

The list of key informant interviews was finalized in collaboration with Title V MCH and MIECHV program staff and included providers of physical and mental health services, county and city officials, tribal representatives, academic institutions, and leaders at key social service organizations, including family resource centers, juvenile probation offices, Lesbian, Gay, Bisexual, Transgender, and Queer or Questioning (LGBTQ) centers, and county coalitions. Informant selection methodology ensured diversity across expertise area and geography.

Notes from each key informant interview were reviewed using NVivo for health topic themes such as access to care, mental health, or oral health. The guide acted as the starting place for coding notes, and when possible, each set of codes were grouped into themes by MCH population group and geography.

Community Survey

In October 2019, HMA developed an online community survey in collaboration with Title V MCH and MIECHV program staff to seek feedback from communities regarding the most important health needs for each MCH population group. Survey respondents were asked about health needs and issues in their community and what resources exist to address those health needs and issues. They were also asked about inequities within the MCH populations and where respondents think MCH population groups turn for information and resources. Finally, for each MCH population group, respondents were provided a list of health topics and asked to select the top three (3) health needs for each group.

The survey was posted online from November 21, 2019 to December 16, 2019 and a link to the survey was posted on the Division of Public and Behavioral Health (DPBH) homepage. Internal and external partners, stakeholders, and program subawardees were sent the survey link via email, along with information on survey purpose. Information about the survey, as well as the survey link, was posted on DPBH social media accounts. In total, 339 individuals responded to the online survey, of whom 46 percent (n=157) identified as a “community member,” 46 percent (n=157) as a “service provider/partner or public health professional in maternal and child health services,” and seven (7) percent (n=25) as a “service provider/partner or public health professional in a Maternal, Infant and Early Childhood Home Visiting Program.” Among service providers, 30 percent were health care professionals and approximately 26 percent identified as community service providers. Public health professionals identified as 16 percent of providers, with just six (6) percent identifying as an educator and one (1) percent as a school nurse. Throughout the report, all service providers/partners and public health professionals who responded to the survey are noted as “MCH professionals and service providers.”

Descriptive analysis was conducted for each of the survey questions, including a description of the number of people who included a given topic as a top three (3) issue, per MCH population group. Cross tabulations were conducted to understand whether variation existed in responses between respondent type (i.e., service provider or community member). Broad themes for any open-ended responses were determined through manual review.

Focus Groups

Between August 2019 and January 2020, HMA held 14 focus groups at different locations across Nevada. All focus groups took place in one (1) of the following Nevada counties: Carson City, Washoe, Clark, Storey, and Nye.

Participants were asked about:

1. Health needs of different MCH populations in Nevada;
2. Health needs of friends/family members;
3. Where clients receive health information;
4. What problems/barriers clients experience when trying to access services;
5. Services needed but not accessible, available, and/or affordable;
6. What are homes, schools, and communities doing to improve health and safety; and
7. What is Nevada doing well or what areas need improvement to address the health of MCH population groups across the state.

Specific focus groups were convened to better understand the perspective of populations including at-risk youth; parents engaged in home visiting; Spanish speakers; mothers in recovery from substance use; community members who identify as LGBTQ; families with children and youth with special health care needs (CYSHCN); and participants from frontier or rural communities. To support free flow of information, a list of open-ended questions was used to explore participant’s insights. Analysis of focus group notes was conducted similarly to key informant notes using NVivo to note the health topic themes, such as access to care, mental health, or oral health, for example.

Data Sources Utilized

Along with the key informant interviews, surveys, and focus groups, HMA used a variety of national data sources including the National Vital Statistics System (NVSS), National Survey on Children’s Health (NSCH), Behavioral Risk Factor Surveillance System (BRFSS), American Community Survey (ACS), Youth Risk Behavioral Survey (YRBS), National Survey on Drug Use and Health (NSDUH), Pregnancy Risk Assessment Monitoring System (PRAMS), as well as state data sources including the Nevada Report Card published by Nevada Department of Education (NDE) and the Nevada Rural and Frontier Data Book published by the University of Nevada, Reno, School of Medicine.  FAD and MIECHV federal data were also integrated into the assessment.

The Title V MCH Program and MIECHV staff, led by the State Systems Development Initiative (SSDI) Manager met weekly to discuss the findings of the Five-Year Needs Assessment. In the meetings, staff reviewed current priorities and performance measures and compared them to the needs indicated by Needs Assessment survey respondents and to state and federal data indicators. Common needs appeared throughout the assessment drafts and Title V MCH Program staff and the SSDI Manager created the Title V MCH Program logic model (see attachment). The logic models helped focus the priorities and performance measures.

MCH Population Health Status

Data suggest Nevada improved on several indicators relevant to MCH population groups compared to the United States as a whole since 2015. This assessment goes beyond key performance measures to understand root causes or drivers of MCH health and wellness outcomes, including both strengths and opportunities for improvement in Nevada.

The Needs Assessment identified strengths among MCH population groups, specifically:

• The community survey revealed respondents felt their communities were good places to raise children, including satisfaction with local schools and recreational facilities.
• Stakeholders felt a sense of commitment and urgency for improving the health and well-being of MCH population groups.
• Many communities engaged partners and leaders who were willing to work on solutions to improve MCH outcomes statewide.
• Nevada was ranked 11th in decline of teen pregnancy rate compared to the United States over the past decade.

Despite these strengths, for many MCH indicators, racially and ethnically diverse and low-income families in Nevada are disproportionately negatively impacted. The assessment identified significant age, gender, geographic, and racial and ethnic disparities.

The Needs Assessment identified opportunities for improvement among MCH population groups, specifically:

Women/Maternal Health

• Nearly one (1) in five (5) women in Nevada (19.6%), ages 19-44 years, are uninsured (higher than the United States at 15.2%), according to the 2017 American Community Survey.
• Across all MCH populations, a higher percentage of Hispanic women and children are uninsured compared to other race/ethnicity groups, according to the 2017 American Community Survey.
• Single mothers experience the highest poverty rates, at more than twice the rate of two-parent households, according to the 2017 American Community Survey. Single mothers of children younger than five (5) years are most vulnerable to poverty.
• Mental health was a predominant issue noted across all MCH population groups, according to Nevada survey respondents.
• Violence, including both violence to women (23%) as well as child abuse and neglect (26%), ranked high as health problems/issues for women of reproductive age and children birth to five (5) years according to Nevada survey respondents.

Perinatal/Infant Health

• Nevada’s rate of sleep-related sudden unexpected infant death (SUID) reached a nine (9) year high in 2016 of 124.1 deaths per 100,000 live births but decreased in 2017 to 81.1 deaths per 100,000 live births. Rates disproportionately affect Black or African American infants with 233.8 deaths per 100,000 live births, while white infants and Hispanic infants had the lowest rates at 90.3 and 57.8 deaths per 100,000 live births respectively according to National Vital Statistics System 2017 data. 
• Nevada’s infant mortality rate has remained stable since 2009, with a rate of 5.8 deaths per 1,000 live births in 2017. Black or African American infants have disproportionately higher rates, with 9.9 deaths per 1,000 live births. White and Hispanic infants had the lowest rates, at 4.7 and 4.9 deaths per 1,000 live births respectively, according to National Vital Statistics System 2016 data. 
• The Health Care Cost and Utilization Project-State Inpatient Databases indicates the highest rate of infants born in Nevada with neonatal abstinence syndrome (NAS) per 1,000 birth hospitalizations was amongst White infants (13.7), with the lowest rates among Hispanic infants (2.7) in 2017.

Child Health

• According to the 2018 National Children’s Health Survey, while insurance rates are generally high among children, access to consistent and adequate health insurance coverage is lower in Nevada (63.4%) compared to the United States (67.5%).
• The State of Nevada, Division of Child and Family Services 2016 Statewide Child Death Report indicates there is a racial and ethnic disparity among statewide child deaths, as Black or African American child deaths (ages 0 to 17 years) are disproportionately higher at 23.6 percent versus their population distribution in Nevada (10%) .
• More children in Nevada (22%), compared to children nationwide (18.6%), have ever experienced two (2) or more Adverse Childhood Experiences (ACEs), particularly parental separation or divorce, living with someone with substance use problems, and having a parent who served time in jail, according to the 2018 National Children’s Health Survey.

Adolescent Health

• Lesbian, Gay, and Bisexual (LGB) youth experience high levels of bullying and violence, homelessness, fear, and mental health issues compared to their heterosexual peers, according to the 2017 Nevada Youth Risk Behavior Survey (YRBS): Sexual Identity Special Report.
• Nevada ranks 41st among states in the 2017 teen pregnancy rate; however, Nevada is ranked 11th nationwide in decrease of the teen pregnancy rate across all racial and ethnic groups. Black or African American teens continue to experience the highest teen birth rates in Nevada, at 38.4 per 1,000 girls ages 15 to 19 years.
• Data from the Centers for Disease Control and Prevention (CDC) shows the number of deaths among all female adolescents in Nevada due to intentional self-harm is one of the highest in the nation, at 11 deaths per 100,000 population, compared to the US average of 6.2 deaths per 100,000 population.

Children and Youth with Special Health Care Needs

• Access to a medical home (i.e., patient-centered comprehensive coordinated care) occurs for less than half of Nevada’s children, according to data from the National Survey of Children’s Health. Among CYSHCN, this is less than one-third, lower than the United States average. Access to a medical home is lowest among CYSHCN, ages 0-5 years (16.3%), compared to the same age group of children without special needs (40.8%).

Cross-Cutting

• The difference between families experiencing poverty in rural and frontier communities who are also connected to benefits, such as food stamps/SNAP benefits, is greatest in Nye (10.4%), White Pine (10%), and Mineral (9.9%) counties, according to the 2017 American Community Survey. For Nevada as a whole, 16.1% of families live below the poverty level, while only 12.3% are connected to food stamp/SNAP benefits.
• Language and insurance status (i.e., uninsured or Medicaid) are shared risk factors across MCH population groups regarding access to services and are reported to be a common reason why people report experiencing unequal treatment in receiving services.
• Data from the 2018 Nevada Substance Abuse Prevention and Treatment Agency (SAPTA) Epidemiologic profile shows overall self-reported tobacco use among mothers during pregnancy decreased since 2010 from 66.8 to 48.2 per 1,000 live births in 2017; however, the rate among mothers living in rural communities increased to an eight (8) year high at 132.5 per 1,000 live births in 2017.
• Substance use was a concern among adolescents, pregnant, and one-year postpartum women.
• Alcohol and marijuana were the most reported substances used during pregnancy among Nevada mothers, with marijuana surpassing alcohol use in 2015 (5.3 and 5.0, respectively, per 1,000 live births) and increasing in 2017 (8.5 and 5.6 per 1,000 live births) according to the Nevada SAPTA Epidemiologic profile.

Access to Services

Access to services is a significant barrier to health and wellbeing, with community members reporting lack of providers, needed services offered by a local provider, and physical access to providers as key barriers. Both community members, MCH professionals, and service providers identified the same set of resources needing improvement (or those services not available, accessible, affordable, and/or high quality) in their community to benefit MCH population groups: mental health services, childcare options, housing, health care options, and good paying jobs with livable wages.

The barriers are particularly prevalent in rural or frontier communities in Nevada. Only 5.3% of health care and social assistance employees in Nevada live in rural and frontier counties (despite 9.5% of Nevada’s population living in these areas). Overall, more than two-thirds of Nevada’s population live in a federally designated primary medical care health professional shortage area (HPSA). The proportion of populations who reside in dental and mental health care HPSAs is even larger with almost 100% of the population in all rural and frontier counties living in a mental health HPSA.

Protective factors for adverse health outcomes for MCH population groups are less prevalent in Nevada. For example:

• Nevada ranks 47th nationwide in the percent of children who experience protective family routines and habits using data from the 2018 National Children’s Health Survey
• Using data from the American Community Health Survey, one (1) in ten (10) youth (ages 16 to 19 years) are disconnected in Nevada (defined by neither working nor in school), putting them at greater risk of increased violent behavior, smoking, alcohol consumption and marijuana use, and emotional and cognitive deficits than their peers who are working and/or in school.
• The percentage of parents who report feeling their child lived in a safe neighborhood and was safe at school was lower in Nevada (59.6%) compared to parents across the United States (65.3%), according to the 2018 National Children’s Health Survey.
• 2018 KidsCount data shows more children in Nevada ages three (3) to four (4) years are not enrolled in school (62%), including preschool or pre-kindergarten, than in the United States (52% not enrolled); this is most prevalent among children who are low-income (82%) and children who are Hispanic (72%).

Funding for public health is, in part, an indicator of the resources available to improve population health. Nevada is identified as the least healthy state when considering the amount of public health funding available relative to other states, including both a combination of state dollars dedicated to public health and federal dollars directed to states by the CDC and HRSA. Per-capita public health funding amounts to $46 in Nevada, lower than the United States per-capita average of $87, according to Trust for America’s Health. 

The Nevada Title V MCH Program will continue collaborations with public and private partners to improve the health of the Nevada MCH populations in areas of need identified by state data, FAD, and Needs Assessment feedback. The Five-Year Needs Assessment and state and federal data informed the state priorities, objectives, and strategies for the current State Action Plan.

Organizational Structure

The Governor of Nevada and the Cabinet and elected constitutional officers make up the Executive Branch. The Governor is the chief magistrate, the head of the executive department of the state’s government and the commander-in-chief of the Nevada military forces. Steve Sisolak was elected Governor of Nevada on November 2, 2018.

The Department of Health and Human Services (DHHS) is the largest department in the Nevada Executive Branch. DHHS is comprised of five (5) Divisions along with additional programs and offices overseen by the DHHS Director’s Office. Richard Whitley, MS, is the DHHS Director and was appointed by Governor Brian Sandoval in June 2015. The Divisions under DHHS include: the Division of Public and Behavioral Health (DPBH), Aging and Disability Services Division (ADSD), Division of Child and Family Services (DCFS), Division of Health Care Financing and Policy (DHCFP, aka Nevada Medicaid), and Division of Welfare and Supportive Services (DWSS).

DPBH is led by Administrator Lisa Sherych and organized into four (4) branches: Administrative Services; Clinical Services; Community Services; and Regulatory and Planning Services. Within Community Services, led by Deputy Administrator Julia Peek, MHA, CPM, is the Bureau of Child, Family, and Community Wellness (CFCW), led by MCH Director and Bureau Chief Candice McDaniel, MS. The MCAH Section is led by the CYSHCN Director, Vickie Ives, MA, and is within CFCW. The MCAH mission is to improve the health and wellbeing of Nevada’s pregnant women, women of childbearing age, infants, children and youth, including CYSHCN, and their families to protect and advance health, safety, and quality of life through development of partnerships, education, health promotion, and disease and injury prevention. MCAH understands active engagement of families, caregivers, and communities is integral to positively impacting the health of MCH populations. 

The Title V MCH Program is in the MCAH Section and is organized into the Maternal and Infant Health Program (MIP), Adolescent Health and Wellness Program (AHWP), CYSHCN Program, and MCH Epidemiology/Evaluation. The Health Program Manager I, Brian (Mitch) DeValliere, DC, leads the Title V MCH Program and collaborates closely with the Health Program Specialist II, SSDI Manager position, Tami Conn, and the DHHS Office of Analytics to ensure MCH data needs are supported. 

Nevada's Title V MCH Program supports and is advised by a Maternal and Child Health Advisory Board (MCHAB). The Nevada MCHAB was established via executive order in 1989 and established by law in 1991 in Nevada Revised Statute 442.133 and meets quarterly. MCHAB is comprised of nine (9) individuals appointed to two (2) year terms by the State Board of Health from a list provided by the DPBH Administrator and two (2) legislators appointed by the Legislative Counsel. Members of MCHAB make MCH-related recommendations to the DPBH Administrator.

Title V MCH staff collaborate with other sections and programs within DPBH, as well as with other state agencies within DHHS. Title V MCH staff also collaborate with NDE and the Department of Taxation.

Agency Capacity

The Title V MCH Program functions as a unit within the MCAH Section of CFCW, DPBH and takes a coordinated, systems-based approach to improving MCH health and wellbeing. Title V MCH Program Coordinators work to improve the function of each program unit within Title V MCH. For example, the AHWP Coordinator and CYSHCN Coordinator collaborate to improve transition from adolescent to adult health. The MCAH Rape Prevention and Education Coordinator collaborates with the AHWP and CYSHCN Coordinators to prevent intimate partner violence and promote shared protective factors. The MCH Epidemiologist coordinates data requirements with each Title V MCH program unit to enhance reports for internal/external partners and the MCHAB and links MCH to SSDI and PRAMS efforts as part of MCH data efforts led by the SSDI Manager.

The Title V MCH Program also coordinates efforts with other sections/programs within DPBH through Memoranda of Understanding (MOU). MOUs support the DPBH Office of Public Health Investigations and Epidemiology (OPHIE) and the DHHS Office of Analytics provides data for Title V MCH Block Grant narratives and reports, as well as for special reports requested by leadership, stakeholders, and the public. DPBH Community Health Services (CHS) promotes well visits for women of childbearing age, adolescent preventive medical visits, and health care transition from pediatric to adult care for adolescents and CYSHCN. The DPBH Primary Care Office improves health care outcomes through its efforts to coordinate the federal shortage designation process, the J-1 Physician Visa Waiver Program, and other healthcare worker recruitment and retention programs. The CFCW Chronic Disease Prevention and Health Promotion Section provides resources for the SSDI Manager. The CFCW Immunization (IZ) Program co-funds a fiscal position and promotes Title V MCH population-related immunizations, including maternal and adolescent vaccines and provides reports on activities for MCHAB quarterly meetings.

The MCH Director is the CFCW Bureau Chief and is supported by the Deputy Bureau Chief, Karissa Loper, MPH, who leads IZ and MCAH efforts. The CYSHCN Director is the MCAH Section Manager. The CYSHCN Coordinator works with the CYSHCN Director and Title V MCH Program Manager to ensure CYSHCN and their families and/or caregivers receive the resources needed to support access to appropriate referrals and health care. In addition, the CYSHCN Program coordinates efforts to increase the number of children who have a Medical Home, leads the critical congenital heart disease (CCHD) registry, and supports transition from pediatric/adolescent to adult health care. 

Nevada DHHS Tribal Liaisons and Title V MCH staff collaborate to share resources to address the needs of MCH populations in Nevada Tribal Nations and support targeted an injury prevention efforts. DHHS has MOUs with all 27 federally recognized Tribes of Nevada. These MOUs extend to the five (5) Divisions, including DPBH which houses the Title V MCH Program. DCFS has an additional MOU with Nevada Tribes for the Indian Child Welfare Act (ICWA) Program. A Tribal Consultation process is established at DHHS to guide the work and interactions with federally recognized Tribes in Nevada and must meet federal regulations. All topics and issues related to the health and wellbeing of Nevada Tribal members is important to discuss at Tribal Consultations which are held quarterly by DHHS.

The most important pieces of Tribal Consultation consist of the following: open and ongoing information exchange prior to implementing any proposed policies affecting Tribal Nations, including informal discussions and information sharing which leads to informed decision-making; creating the opportunity for DHHS to be responsive to the issues and concerns expressed by the Tribal Nations; continuation of trust, transparency and collaboration with the Tribal Nations; the commitment to work together to improve the quality, availability and accessibility to public health, human services and behavioral health care for Tribal communities in Nevada. DHHS agencies collaborate to present on the Divisions’ current topics of importance and topics requested by the Tribal Nations at Consultation.

To support the ongoing communication and trust between Tribal Nations and DHHS, the Tribal Liaisons have traveled to all the Tribal Health Clinics to meet face-to-face with the Health Directors, Tribal Council Members, and other tribal organization staff (i.e., Social Service Program Directors). Additionally, to support Tribal partners, the DHHS Tribal Liaisons attend all meetings hosted at the Inter-Tribal Council of Nevada (ITCN) and meetings related to Tribal matters, as applicable. Also, with the partnership of other DHHS agencies, many community events are attended. MCAH staff presented on the MCAH Programs and Five-Year Needs Assessment at ITCN and Tribal Health Directors meetings and provided MCAH resource packets to the Tribal Liaisons for their visits as guests of the Tribal Health Clinics.

MCH Workforce Capacity

The Title V MCH Program supports 11 full-time equivalent (FTE) positions located in Nevada’s capital city, Carson City. FTE positions include a MIP Coordinator, an AHWP Coordinator, a Health Program Manager 1 (HPM 1), a MCH Epidemiologist, a Rape Prevention and Education (RPE) Coordinator, as well as 6 employees in various roles and capacities including the MCH Director and Bureau Chief (supported by a Deputy Bureau Chief with MCAH and IZ oversight), CYSHCN Director and Section Manager, two (2) Management Analysts, and two (2) Administrative Assistants in the Bureau of CFCW. The SSDI Manager and a part time Accounting Assistant III are funded through internal MOUs.

The MCH Director and CFCW Bureau Chief provides oversight of MCAH and across diverse programs and sections and is supported by the Deputy Bureau Chief, who leads IZ and MCAH efforts and programming, and Bureau Office Manager McKenna Bacon. The CYSHCN Director and MCAH Section Manager manages the Title V MCH Program and other MCAH programs and projects. The Title V MCH Program Manager oversees the Nevada Title V MCH Program and is responsible for Title V MCH Block Grant, MCH staff support, budget development and oversight, and grant fiscal administration.

The MIP Coordinator position is currently vacant. Eileen Hough, MPH, is the AHWP Coordinator; Kagan Griffin, MPH, RD, is the MCH Epidemiologist and PRAMS Lead Coordinator; Larissa White, MPH, CPH is the CYSHCN Program Coordinator; Yesenia Pacheco is the RPE Coordinator; Lisa Light is the Accounting Assistant III (0.5 FTE); and Desiree Wenzel is the MCAH Office Manager.

The Nevada SSDI Manager, Tami Conn, leads MCH data efforts, supervises the MCH Epidemiologist and PRAMS Program and supports evaluation activities regarding NPMs, contributing to building the evidence base for the Title V MCH Block Grant; the SSDI Manager also supports the Nevada Maternal Mortality Review Committee (MMRC) and Alliance for Innovation on Maternal Health (AIM) efforts.

Misty Allen, MA, the Office of Suicide Prevention (OSP) Manager, coordinates suicide prevention efforts and provides Suicide Hotline data for Title V MCH reporting. Jie Zhang, MS, supports all MCAH data needs as the MCH Biostatistician II in the DHHS Office of Analytics and works closely with the MCAH and MCH teams. Further, eleven (11) Community Health Nurses (CHNs) provide services for MCH populations in rural communities and are partially funded by MCH, as well as a Primary Care Office (PCO) position, and a School Wellness Coordinator & Liaison at NDE.

Workforce challenges include recruiting and maintaining qualified and experienced public health professionals, the time needed to fill vacant positions due to state human resource processes, as well as needing to use contracted employees for key positions.  The financial consequences to Nevada as a result of COVID-19 have culminated in a hiring freeze and furloughs of one (1) day per month for six (6) months from January 2021 – July 2021, impacting the state’s ability to recruit staff for vacant positions and to renew contracted staff.

Serving the diverse MCH population in Nevada, addressing health disparities, increasing engagement with MCH leaders with lived experience, and family and adolescent engagement are important goals of the Title V MCH Program. Attending Culturally and Linguistically Appropriate Services (CLAS) Standards trainings, racism and health outcomes trainings, family and adolescent engagement trainings, and implicit bias trainings are key to staff development and improving MCH staff understanding of root causes of disparity and pathways to authentic engagement and partnership so activities can be designed and implemented to move data to action in collaboration with funded partners, MCH stakeholders, family members, and those with lived experience who are served by Title V MCH programs.

Title V Program Partnerships, Collaboration and Coordination

The Nevada Title V MCH Program collaborates with a network of partners, stakeholders, and agencies to support a systems-based model of delivering public health and enabling services to Nevada’s MCH populations. Partnerships include the local Family Voices affiliate, Family TIES of Nevada led by Mary Meeker, state agencies, Local Health Authorities (LHAs), the Nevada System of Higher Education (NSHE), non-profit organizations, MCH Coalitions, community partners, and advocacy groups.

DHHS formed an Office of Analytics under the DHHS Director’s Office to consolidate data capacity and facilitate cross training and data analytics support. Title V MCH funds the MCH Biostatistician and a Health Resource Analyst (HRA) position within this group. The MCAH Section also staffs two (2) HRA positions in the DHHS Office of Analytics to work with Nevada Early Hearing Detection and Intervention (EHDI) Program and Nevada Home Visiting (NHV/MIECHV) data. These positions are crucial members of the MCAH team and increase MCH data support and analytics capacity, accessing primary data and generating analyses and reports on behalf of MCAH and Title V MCH, in addition to the work of the MCH Epidemiologist and SSDI Manager.

Title V MCH continues to integrate with SSDI; MCAH created an organizational unit which includes PRAMS, SSDI, and MCH Epidemiology to foster cross-training and to meet program data needs. The MCAH Section Manager and Office of Analytics Manager meet regularly with staff regarding MCAH data needs. SSDI enhances Nevada Title V MCH data capacity to allow for informed decision making and resource allocation supporting effective, efficient, and quality programming. The Title V MCH Program plans to improve NPM evaluation activities using PRAMS, MMRC, and AIM efforts, as well as a pending MCAH data dashboard project to support enhanced surveillance capabilities to drive data-informed decision-making.

Other programs partnering to promote Title V MCH priorities in Nevada include: the DHHS Office of Analytics, NHV/MIECHV, EHDI, Teen Pregnancy Prevention (TPP), the Nevada Governor's Council on Developmental Disabilities, the Individuals with Disabilities Education Act (IDEA) Part C Office, Nevada Early Intervention Services (NEIS), the Nevada Office of Minority Health and Equity (NOMHE), the PCO (addresses access to health care and identifies workforce shortage areas), the Oral Health Program, CHNs, the Office of Public Health Investigations and Epidemiology (OPHIE), the Substance Abuse Prevention and Treatment Agency (SAPTA), the Division of Child and Family Services (DCFS), the Chronic Disease Prevention and Health Promotion (CDPHP) Section, the Nevada Women, Infants, and Children (WIC) Program and the Nevada State Immunization Program (IZ).

Nevada’s Children’s Health Insurance Program (CHIP), Nevada Check-Up, provides coverage to low- and moderate-income children. Nevada Medicaid and NV Check-Up are administered through the Division of Health Care Financing and Policy (DHCFP), with enrollment administered by the Division of Welfare and Supportive Services (DWSS) for NV Check-Up and Medicaid. Both Fee for Service (FFS) providers and Managed Care Organizations (MCOs) operate in Nevada. Rural areas are served by FFS providers and the urban areas of Clark and Washoe counties are served by contracted MCO providers. 

NDE and DPBH collaborate through an interlocal contract to support a statewide School Wellness Coordinator. The School Wellness Coordinator, funded by Title V MCH, will support strengthening collaborations between MCAH and NDE, as well as with the Nutrition Unit, Immunization, and CDPHP Sections; contracts/MOUs with the Oral Health Program and ADSD also support MCH goals.

DHHS and DPBH partner with 27 Tribes across Nevada through a Tribal Consultation Process Agreement to strengthen ties and relationships with Tribal Governments. The Regional Emergency Medical Services Authority (REMSA), a Title V MCH partner, distributes car seats and provides safe sleep education and injury prevention information as part of the MCH injury prevention pilot developed with key staff at participating Tribal Nations.

The Title V MCH Program partners with Nevada WIC, MCH statewide coalitions, breastfeeding coalitions, community-based programs, LHAs, and public and private stakeholders to increase breastfeeding rates by improving access to breastfeeding supports for new mothers. Breastfeeding campaigns and a MCH-administered website are designed to increase awareness, promote breastfeeding services, and normalize breastfeeding in public locations in partnership with WIC staff.

Title V MCH funds the Nevada Institute for Children’s Research and Policy (NICRP) to conduct an annual health survey of children entering kindergarten, in partnership with all school districts. Other state and local public and private organizations serving MCH populations funded by MCH include: Family TIES, which also hosts the CYSHCN toll-free help line; Children’s Cabinet; Washoe County Health District Fetal Infant Mortality Review (FIMR) Committee; University Center for Autism and Neurodevelopment (UCAN); University of Utah Medical Home Portal; Nevada 211; REMSA; Immunize Nevada; Nevada Broadcasters Association; Urban Lotus; and the Statewide MCH Coalitions. Family TIES of Nevada, a Title V MCH-funded Family Voices partner, provides interpretation and translation services at the University of Nevada, Reno, Craniofacial Clinic. Nevada Title V MCH also funds a bilingual Community Health Worker (CHW) in Elko County. Partners disseminate information and materials which are culturally appropriate. Internal translation support for written educational materials is provided by MCAH and CFCW staff when needed. Nevada’s Children’s Cabinet Technical Assistance Center on Social Emotional Intervention (TACSEI) provides technical assistance and facilitates parent involvement in social emotional Pyramid Model activities. 

Money Management/Nevada 211 provides information and referrals via www.nv211.org, a toll-free phone number, text support, as well as hosting the Title V MCH toll-free phone line, supporting the MIP resource sections, and educating women on the priority status of pregnant women at SAPTA-funded treatment centers. Urban Lotus provides trauma-informed yoga to at-risk youth. REMSA, in addition to distributing car seats, provides safe sleep media outreach and distributes Infant Safe Sleep Survival Kits to at-risk families via statewide partners.

Immunize Nevada supports staff training and workforce development, including planning and hosting the statewide Nevada Health Conference with trainings to build topical MCAH knowledge in cross-cutting health topic areas, including CDPHP, IZ, etc. Nevada Broadcasters Association is funded to promote Safe Sleep, PRAMS, and Sober Moms Healthy Babies (SMHB) PSAs. DP Video is funded to promote adolescent physical activity, tobacco quit-line, transition to adult, and SMHB social media campaigns. The Statewide MCH Coalition is funded to support website maintenance, communication, maternal mental health and other MCH trainings, promote the Go Before You Show campaign, and plan conferences with partners for meeting the community needs of diverse MCH populations.

Identifying Priority Needs and Linking to Performance Measures

The Title V MCH Program staff and SSDI Manager met weekly to discuss the results of the Five-Year Needs Assessment. Staff reviewed Nevada’s current Performance Measures and compared them to the needs indicated by the state data, FAD, and the needs assessment focus groups, interviews, and surveys. Common themes appeared throughout the Needs Assessment and the Title V MCH Program staff created a logic model for each program unit, as well as an overarching Title V MCH Program Logic Model containing eight (8) National Performance Measures (NPMs):

• NPM 1: Percent of women, ages 18 through 44, with a preventive medical visit in the past year
• NPM 4 A: Percent of infants who are ever breastfed and B: Percent of infants breastfed exclusively through 6 months
• NPM 5 A: Percent of infants placed to sleep on their backs, B: Percent of infants placed to sleep on a separate approved sleep surface, and C: Percent of infants placed to sleep without soft objects or loose bedding
• NPM 6: Percent of children, ages 9 through 35 months, who received a development screening using a parent-completed screening tool in the past year
• NPM 10:  Percent of adolescents, ages 12 through 17, with a preventive medical visit in the past year.
• NPM 11: Percent of children with and without special health care needs, ages 0 through 17, who have a medical home
• 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
• NPM 14: Percent of women who smoke during pregnancy

The Logic model also describes an outline for Evidence-Based or -Informed Strategy Measures (ESMs). After selecting the NPMs, weekly Title V Block Grant meetings focused on the selection of ESMs and State Performance Measures (SPMs). HRSA guidance and researching measures from other state programs led to the team to choose measures consistent with the selected NPMs and the priorities identified in the Needs Assessment. The final measures were incorporated into the State Action Plan and include:

• ESM 1.1: Percent of pregnant women who received prenatal care beginning in the first trimester
• ESM 4.1: Percent of PRAMS respondents who stopped breastfeeding due to a lack of support from family or friends
• ESM 5.1: Percent of PRAMS respondents who report their infants (under 1 year of age) were laid to sleep in a high-risk sleep position and/or environment
• ESM 6.1: Percent of Medicaid enrolled children, ages 9 to 35 months, who received a developmental screening using a standardized tool
• ESM 10.1: Percent of adolescents, ages 12 through 17, who received Medicaid and/or Nevada Check-Up covered preventive well visits
• ESM 11.1: Number of Nevada Medical Home Portal website views
• ESM 12.1: Percent of health transition training participants who reported a change in knowledge, practice, or policy
• ESM 14.1.1: Percent of PRAMS respondents who report that a doctor, nurse, or other health care worker asked if they were smoking cigarettes during any prenatal care visits
• SPM 1: Percent of mothers who reported late or no prenatal care
• SPM 2: Percent of women who used substances during pregnancy
• SPM 3: Repeat teen birth rate
• SPM 4: Teenage pregnancy rate

Emerging issues and some frequently cited needs were not selected as specific priorities for Nevada’s Title V MCH Program because of existing collaborative efforts with other agencies dedicated to these needs. Further, the Nevada Title V MCH Program continues to engage in and report on many issues related to MCH health even though they are not selected NPMs for the Block Grant.

Mental health was considered a top three (3) health problem in qualitative responses in three (3) domains: women and maternal health, adolescent health, and CYSHCN.  MCAH and the Title V MCH Program collaborate with other statewide agencies and stakeholders to advance mental health treatment and awareness. Title V MCH efforts include those to address perinatal mood and anxiety disorders (PMAD), a Suicide Prevention Hotline, NHV efforts to address infant mental health, MCH Coalition efforts, Mental Health First Aid, Urban Lotus Project’s efforts to provide Yoga classes to young people undergoing substance use and mental health treatment, participation in the HRSA Pediatric Mental Health Evaluation group and Systems of Care efforts, and the FIMR Case Review Team recommendation to develop a Spanish-speaking support group to address the need in Washoe County’s Latina population. 

Domestic or intimate partner violence was considered a top health problem for women of reproductive age and was also listed as a concern for pregnant and post-partum women. Title V MCH includes the RPE Program and integrates associated efforts to provide education and prevention support to partners who work with these populations.   TPP efforts related to providing information and education about human and sexual trafficking includes MCH participation.

Promoting healthy weight was listed as a top concern for children ages 6-11 years. Efforts related to increasing physical activity for children and adolescents are led by NDE and the Nutrition Unit within CFCW; the AHWP Coordinator participates in these efforts. Increasing adequate insurance coverage is addressed via existing statewide partnerships and program participation in efforts in place under other state agencies. The addition of safe sleep and increasing transition of care for adolescents and CYSHCN NPMs build on existing efforts and partner networks.

Some priority needs from the previous reporting cycle remain because the Title V MCH Program efforts are showing improvement or there is a need to make additional improvements. For example, improving preconception and interconception health among women of childbearing age, promoting breastfeeding, and reducing substance use during pregnancy are ongoing priority concerns and show some improvement as the Nevada and national statistics become closer to the same level. However, there is much room for improvement, particularly in relation to key perinatal outcomes.  Increasing developmental screenings and improving care coordination efforts remain priorities; it is important to Nevada to improve these measures to meet or exceed the national-level outcomes and improve the lives of Nevadans. Promoting safe sleep, promoting a medical home for every Nevada child, and increasing transition of care for adolescents and CYSHCN were chosen as needs based on data indicating a gap in state data compared to national data on these measures.

From MIECHV collaboration, to evaluating available data and Needs Assessment results, to selecting the priority needs and associated performance measures using logic models, the Nevada Title V MCH Program staff collaborated on a set of measures and priorities to guide implementation of efforts to improve the health of Nevada MCH populations over the next five-year period. This work synthesized community, family, stakeholder, and provider voices and feedback with key data on MCH needs and gaps.  By addressing existing state priorities and recognizing and adding new priorities and performance measures, Nevada’s Title V MCH Program is in a strong position to facilitate the enabling and public health services necessary to address the State Action Plan and improve outcomes using data to action interventions.

The Five-Year Needs Assessment can be found as an attachment as well as on the Division of Public and Behavioral Health website.  http://dpbh.nv.gov/uploadedFiles/dpbhnvgov/content/Programs/TitleV/dta/Publications/Needs%20Assessment%20Final(2).pdf