Arkansas’s Title V Maternal and Child Health Services Block Grant

2019 Report/2021 Application

The 2021-2025 Five-Year NA process used quantitative and qualitative data and engaged internal and external stakeholders to assess their capacity to conduct work with the MCH population, and solicit their feedback on priorities, activities and future direction for work with the MCH populations

The MCH Planning Team (MCHPT) met throughout the NA process to discuss roles, responsibilities, and action items to assist with project management and implementation of activities including the development and administration of the MCH on-line community survey and data analysis. 

Data Sources and Input

Data was gathered through community-based listening sessions, focus groups, in-person and Zoom-based stakeholder meetings as well as both domain-specific and statewide surveys.  Additional data sources included the federally available data (e.g. U.S. Census Bureau, Healthy People 2020, AHRQ, American Fact Finder, America’s Health Rankings, CDC, HRSA Health Workforce, etc.,) and state data (e.g. Vital Statistics, Youth Behavioral Risk Factor Surveillance System Survey, data books, etc.,). 

Part 1 :  Online Title V MCH Community Survey

Between November 2019 and February 2020, the ADH’s FHB administered an online community survey among maternal, child, and adolescent health stakeholders and partners across the state.  The purpose of the online survey was to identify priority public health issues; current and new strategies; strengths, weaknesses, and gaps in the current public health system; and emerging public health needs. A total of 133 participants completed the survey.

Domain-Specific Gaps in Health Services

1. Women/Maternal Health

Mental health was a constant theme throughout the survey for this population.  Among the 53 participants responding to this question, approximately half (49%) cited mental health services as one of the three most important gaps in women’s health.  Mental health disorders were listed as the fourth most important public health problem affecting women in Arkansas.  Other important gaps in public health services for women and maternal health are the availability of healthcare providers (32%), transportation (30%), and illicit or other drug abuse prevention programs (30%).

2. Perinatal/Infant Health Domain

Half (47%) of the 49 survey participants for this question said availability of transportation was an important gap in the state for perinatal or infant health. Almost two-thirds (60%) of respondents said they would like to see new strategies or interventions for making transportation become more available in their area. Lack of healthcare providers and specialty care compounds the problem, particularly in the rural areas of the state. Survey participants had several suggestions for improving access to breastfeeding support and care: provide more access to lactation experts in communities, provide additional access to lactation experts beyond telephone services (i.e., face-to-face interaction), provide special group clinics with a nutritionist to encourage and assist new mothers in breastfeeding, provide more support and incentives to breastfeeding mothers, expand the health department’s breastfeeding program, provide better outreach for breastfeeding programs with local providers and hospitals, educate hospital nurses on how to encourage new mothers to breastfeed.

3. Child Health Domain

Developmental and behavior disorders (57%) was ranked as the most important public health problem by survey respondents. Almost half (48%) of respondents reported an existing strategy or interventions was in place for the children they serve and yet one-fifth (21%) or respondents felt developmental monitoring and screening was one of the top three areas where gaps still existed.  Childhood obesity and overweight (52%) and related risk factors such as physical inactivity (34%) and poor nutrition (32%) ranked as the second, third, and fourth most important public health problems among children in Arkansas.

4. Adolescent Health Domain

Overweight and obesity was recognized as the most important public health problem facing adolescents (55%). Compared to children, fewer respondents felt that key strategies or interventions for physical health education (32.6%) and nutrition education (27.9%) existed for adolescents. Tobacco use including vaping (48%) ranked as second most important public health problem for this group. Use of an electronic vapor product (i.e., e-cigarettes, e-cigars, e-pipes, vape pipes, vaping pens, e-hookahs, and hookah pens) has been on the rise in Arkansas as well as across the nation. 

5. Children with Special Health Care Needs (CSHCN) Domain

For CSHCN, transportation availability (50%) was cited as the most important public health need and only one-fourth (24.4%) of respondents said key strategies or interventions were in place to address transportation issues for this group. Families experience great difficulty in understanding, navigating through, and accessing the complex health system for CSHCN, including the Medicaid program, services and financing options available to them, technological issues including internet access and computer use, accessing available specialists and services, and finding respite care.

Part 2: Arkansas Children’s Hospital (ACH) Community Health Needs Assessment (CHNA):   

Every three years, ACH conducts a CHNA.  ACH’s CHNA gathered more than 100 parents, educators, and community members together to participate in focus groups throughout the state. ACH staff conducted 16 total focus groups, with 164 total participants, in three languages (English, Spanish, and Marshallese).  After all four data sources (focus groups, interviews, telephone survey, and secondary data) were analyzed and prioritized individually, the results of all data collection were combined into a single overall ranking. Data was grouped around top issues facing Arkansas children that already had natural existing workgroups or initiatives addressing them based on past needs assessments.

The themes, in priority order, are as follows: 1. Parenting Supports 2. Social Issues 3. Mental Health and Substance Use 4. Equitable Access to Care 5. Food Insecurity 6. Child Obesity 7. Reproductive Health 8. Oral Health 9. Child Injury 10. Immunizations

Part 3:  Title V Children’s with Special Health Care Needs (CSHCN) Program:  

The CSHCN NA work spanned two years (2018-2020), using a variety of modalities, and working directly with small focus groups of parents, service providers, and representatives of related agencies at the community level. This work began with 15 community and stakeholder needs assessment listening sessions facilitated by the Title V Parent Consultant and members of the Parent Advisory Council (PAC). The purpose of the listening sessions was to give parents and caregivers of CSHCN, service providers, and related stakeholders a voice and hear from them about strengths, needs, barriers, and priorities. Announcements regarding the community listening sessions were distributed to stakeholders via email, mailed by CSHCN staff to families on their Title V caseloads, and posted as a Facebook event. A total of 90 parents, providers, and agency representatives attended the sessions to provide insight and suggestions to aid the program in setting priorities for the next five years. A review of ACH’s CNA data revealed common themes across the population served: Parenting supports, mental health and substance abuse, and equitable access to care.

Priority Setting

Because of the extensive analysis conducted during the 2015 NA and input during the initial stakeholder meeting in November 2019, a decision was made to use the prior assessment priorities as the foundation on which to build for the ESM selection process. This decision allowed MCHPT to continue to focus on key areas that are showing progress in moving the needle and to refine priority areas.  A detailed report  of the NA process is attached.

Arkansas’s Title V Maternal and Child Health Services Block Grant

2019 Report/2021 Application

Women’s/Maternal Health: According to the U.S. Census Bureau, approximately 520,000 Arkansas women ages 18-44 reside in the state. However, data from the 2018 Behavioral Risk Factor Surveillance Survey (BRFSS) show one out of four women (74.8%) in this age group did not have a preventive medical visit in the past year. Lower rates of uptake for preventive visits were reported in women with less than a high school education (59.2%), women with no health insurance (50.9%), and women of Hispanic ethnicity (66.4%). Arkansas ranks 44th of 50 states (50 is the worst) for maternal mortality rate, which is 34.8 deaths per 100,000 live births. Although Arkansas has had some success with increasing prenatal care, reducing 1) the number of women aged 18-44 who smoke and 2) the percentage of women who smoke in the last 3 months of pregnancy has been challenging. According to BRFSS data for Arkansas, 21.6% of women aged 18-44 reported being current smokers in 2017. The number marks a decline of 5.4% percentage points since 2011 (27.0%). Data from the 2017 Pregnancy Risk Assessment Monitoring System (PRAMS) revealed that 14.5% of pregnant women reported smoking during the last three months of their pregnancy, a 7.9% decrease from the previous year’s rate (15.7%) and a 27.4% decrease from 2011 (19.1%).

Perinatal/Infant Health: Arkansas has higher rates of preterm births and low birth weights than the rest of the nation. The rate of low weight births in 2017 was 9.3% compared to 8.1% nationally. Arkansas tied with Georgia for having the 5th highest percent of preterm births in the nation in 2017. Arkansas continues to have a high infant mortality rate. In 2018, one in nine babies (11.6% of live births) were born preterm in Arkansas (March of Dimes, 2018). This can lead to infant mortality.  In 2018, 279 babies died in Arkansas before their first birthdays.  The infant mortality rate for that year was 7.5 deaths per 1,000 live births compared to the national infant mortality rate for the same year which was 5.7.  This places Arkansas 46th out of 50 (with 50 being the worst) in the nation on this measure. In 2017, 57.2% of infant deaths occurred in the neonatal period, and 42.7% occurred in the postneonatal period (March of Dimes, 2020). According to the ADH Health Statistics Branch, 2019 provisional data showed SIDS was the second leading cause of infant death (23.1%), after birth defects (24.5%). When looking at postneonatal deaths only, SIDS was the leading cause of infant deaths (54.9%).  Suffocation is the leading cause of injury-related deaths for children less than one year old.  

Child Health: The 2020 annual Annie E. Casey Kids Count Data Book ranks Arkansas as the 40th state in child wellbeing.  Arkansas ranks 49th of 50 states for developmental screening: 13.7% of children 10 months through five years received screenings. In addition, the state continues to struggle with a high percentage of overweight children.  The most recent federally available data (2018) on the percent of Arkansas’s children ages 6 through 11 who are physically active at least 60 minutes per day indicates only 28.4% were physically active at least 60 minutes per day. Child injury rates in Arkansas have declined since 1990, but there is still work to be done. According to administrative data from the Arkansas Department of Human Services’ (ADHS) Division of Children and Family Services (DCFS), 172 of the 2,444 (7%) of families served by federally-funded home visiting programs had reports of child maltreatment in federal fiscal year 2018 (October 1, 2017 – September 30, 2018). Children who experience abuse and neglect are at high risk for problems with mental health.  In 2012, 12,591 children were victims of abuse or neglect in Arkansas at a rate of 17.7 per 1,000 children which is a 19.3% increase from 2009.  Of these children, 68.75 were neglected, 20.3% were physically abused and 20.7% were sexually abused.  In 2010, 19 children died in Arkansas as a result of abuse or neglect and in 2012, 33 died.  Arkansas has the highest child fatality rate in the U.S.: the state’s 2012 child fatality rate (4.64 per 100,000) was more than double the U.S. rate of 2.2 per 100,000 (e.g. 4.64 per 100,000 children).

Adolescent Health: In Arkansas, 32.2% percent of adolescents, ages 12 through 17, are bullied compared to 24.1% in the U.S. (YRBSS, 2017). The number of ninth grade students reporting being bullied is significantly higher than for students in 11th and 12th grades. Female students are significantly more likely than males to have experienced some form of bullying, name calling, or teasing in the past year. Although bullying was not identified as a new priority need, it is a problem  that was previously identified under the Child Safety priority area.  The most recent federally available data (2018) on the percent of Arkansas’s adolescents ages 12 through 17 who are physically active at least 60 minutes per day indicates that only 16.6% were physically active at least 60 minutes per day. The ADH’s Coordinated School Health Program provides professional development opportunities for school wellness coordinators in the areas of nutrition and physical activity. Tobacco use, particularly the use of vaping products, was identified by stakeholders as an emerging health need for adolescents. 2019 YRBSS data show more than half (51.5%) of Arkansas high school students have tried using an electronic vapor product, a statistic that has been on the rise the past three years.  The percent of students currently using an electronic vapor product (24.3%) is more than twice as high as the percent of students currently smoking cigarettes (9.7%). Electronic vapor products include e-cigarettes, e-cigars, e-pipes, vape pipes, vaping pens, e-hookahs, and hookah pens.

CSHCN Health: The transition of youth to adulthood, including the movement from a child to an adult model of healthcare, has become a priority issue nationwide. Over 90 percent of children with special health care needs now live to adulthood, but are less likely than their non-disabled peers to complete high school, attend college or to be employed. Effective transition from pediatric to adult health care is intended to ensure continuity of developmental and age-appropriate care for all CSHCN.  According to the Agency for Healthcare Research and Quality, around 750,000 children in the United States with special health care needs transition to adult care annually (AHRQ, 2014). Fewer than half receive adequate support and services for their transition to adult care. The 2017-2018 National Survey of Children’s Health reports 18.8% of adolescents with special health care needs in Arkansas received services necessary to make transitions to adult health care compared to 18.9% nationally. An effort to improve transition out of CSHCN care to adult care has been challenging, but is showing promise.  

Life Course: The Life Course domain is primarily affected by upstream determinant factors under the categories of social (e.g. health inequities), economic (e.g. poverty), and education (e.g. health literacy and lack of education).  (see State Overview)

Arkansas’s Title V Maternal and Child Health Services Block Grant

2019 Report/2021 Application

The ADH serves to protect and improve the health and well-being of all Arkansans with more than 100 services statewide and the support of over 2,100 diverse and dedicated employees and public and private partners. The ADH is a unified health department, with a main office in Little Rock and 94 LHUs in each of the state’s 75 counties.  The State Health Officer and Secretary of Health is Dr. Jose R. Romero.  Dr. Romero reports directly to the Governor as a Cabinet member.

ADH is organized into four primary Centers that carry out specific programmatic and administrative functions (See Organizational Charts):

• The Center for Health Advancement (CHA)
• The Center for Health Protection (CHP)
• The Center for Local Public Health (CLPH)
• The Center for Public Health Practice (CPHP)

The FHB is located within the CHA and contains three sections: Women's Health (Family Planning), Child and Adolescent Health; and MIECHV.  The FHB provides a unique opportunity for implementing the Title V Five-Year Action Plan through collaboration and coordination across a range of family-serving programs.

Title V CSHCN program activities have historically been housed within the Arkansas Department of Human Services (ADHS). ADHS is a large separate agency whose Secretary, Cindy Gillespie, also reports directly to the Governor. ADHS consists of eight major divisions and the Title V CSHCN Program is housed within the Division of Disabilities Services (DDS). DDS also contains administrative units for Early Intervention Services (Part C) as well as direct and coordinating services for children and adults with developmentally challenging conditions.

Arkansas’s Title V Maternal and Child Health Services Block Grant

2019 Report/2021 Application

The ADH emphasizes infrastructure-building and population-based activities through preventive health information and educational messages to public health care providers, referral, and linkage to service, and coordination of services.

Within the CLPH, ADH has 94 LHUs across the state and contracts with several communities based organizations, hospitals, direct service providers, family support organizations and others to address MCH priorities and state and national performance measures.

a) Preventive and primary care services for pregnant women, mothers and infants up to age one

Women’s Health Services are coordinated at the ADH state level through the CHA and the CLPH. ADH LHUs provide reproductive health services to adult and adolescent women, which enables them to choose freely and responsibly the number and spacing of their children and to prevent unwanted pregnancies.  These services include health history assessment, laboratory tests including PAP tests, physical assessment, contraceptive methods, health education, and treatment and referral.  Ninety-two  of the LHUs and three school-based satellite clinics provide family planning services, with at least one site in each county.  The ADH LHUs expanded well women capabilities and services in recognition of the importance of taking a preconception, interconception, and life span approach to women’s health.

The Women’s Health Program offers education materials and links to other resources on a wide range of topics that affect women, including healthy eating, physical activity, vitamins and nutrients, oral health, genetic illness, mental health and depression, safe relationships, family planning, pregnancy, sexually transmitted illnesses, and substance abuse.  Per culturally and linguistically appropriate service (CLAS) recommendations, publications are available in English and Spanish.

The clinical care component of the ADH Women’s Health Programs is directed by the ADH Medical Director, an ADH employee working 80% FTE. The MC spends an average of 50% of his time dedicated to the maternity program.  The MC is a Fellow of the American College of Obstetrics and Gynecology and a Diplomat of the American Board of Obstetrics and Gynecology. The MC is instrumental in directing research and the review of statistics for program planning and evaluation as well as establishing protocol and maintaining the quality control of the Cervical Cytology program, which includes the supervision of tracking abnormal Pap tests. The Advance Practice Nurse (APN) and the Registered Nurse Practitioners (RNP) who deliver health care services through ADH maintain a collaborative practice agreement to fulfill the requirements for prescriptive authority as set forth in the Arkansas Nurse Practice Act.  The APNs and RNPs work under protocols that are developed, reviewed, and authorized by the MC on an annual basis. The parameters of the APN/RNP’s practice scopes are defined by licensure and advanced education. The ADH FHB's Women’s Health Section oversees the Licensed Lay Midwife Program, which provides a choice for home delivery. There are currently 28 Licensed Lay Midwives and 15 Lay Midwife Apprentices in the state.  

With the focus on strengths for pregnant women and infants, all LHUs have public health nurses who have basic training and a supportive nursing policy to provide care to pregnant women. They provide basic nursing care and referral to local physicians and neighboring clinics.  ADH provides maternity services in 57 LHU sites in 53 counties. These clinics are attended by “circuit-riding” Women’s Health Nurse Practitioners (WHNPs) who serve as the prenatal clinician. The WHNPs develop close referral relationships with local physicians and provide Family Planning, STI, and Breast and Cervical clinic services. These WHNPs are administratively supervised by ADH Patient Care Leaders at the regional level and clinically supervised by a board certified ob-gyn, the MC in the Women’s Health Section.   The Women’s Health Medical Director is also a board certified obstetrician. The MC travels statewide to attend specialized clinics in LHUs and provide direct supervision to the five WHNP Coordinators in all regions. In turn, these Coordinators provide clinical supervision for the other 39 WHNPs.

The Maternal and Child Health Specialists (MCHS) in the LHUs work with multiple programs related to women and children including Maternity, Family Planning, Well Woman, Cervical Cytology, BreastCare, Laboratory and CLIA, and maltreatment/human trafficking. The MCH Specialists are RNs who have the responsibility of providing education and training for the medical staff in the 94 LHUs.  There are currently 11 MCH specialists (and 2 vacant positions) for the state divided among the five Regions. The MCHS are the policy experts for the policies listed for the nurses in the field.  Also, they perform and summarize the annual audits for the Family Planning and Maternity programs for each Region.

For infants, all LHU nurses are trained in basic child health nursing care and make referrals to local family physicians and pediatricians.  At the present time, LHU services for infants are provided in WIC and Immunization clinics, and all children who are covered by Medicaid’s ARKids A and B are referred to privately practicing primary care physicians (PCPs) and Community Health Centers (CHCs). ADH also offers resources and technical assistance to parents, child care, foster care, community action groups and others on how to prepare and keep children safe, healthy and in developmentally appropriate learning environments.  Topics include developmental screening and milestones, infant safe sleep practices, and feeding babies under one year old.  

b) Preventive and primary care services for children

The FHB CAH Section promotes health and well-being, health equity, early and ongoing learning and development, and safe environments and relationships for all children and their families.  It targets efforts toward African-American infants and women, in addition to MCHBG support, the section oversees grants from HRSA and CDC to improve the health, development, learning, and well-being of children and their families.  The Medical Director of CAH provides physician direction for child health programs, especially the population based services for children.

Specifically, the Adolescent Program works to ensure equitable opportunities for improved social, emotional, and physical health and wellbeing for adolescents and young adults. Program goals include providing access to quality appropriate health services, ensuring safe and supportive environments at home, school, and in the community and increasing sexual health services and information. The program has also worked across ADH on a collaborative strategy to focus on adolescent and young adult health within multiple program.

The ADH School Health program is the most promising program to address the health care needs of Arkansas’s adolescents.  ADH has 16 Community Health Nursing Specialists (CHNS) who are responsible for guidance and training for school nurses across the state. In addition, CHNS are required to participate in policy development and delivering/promoting tobacco prevention efforts within schools and communities statewide. School Based Health Clinics (SBHCs) are currently operated by local health providers in Arkansas and are funded through the ADE. The ADE’s School Health Services Office works in collaboration with the ADH and Arkansas Medicaid in the Schools to coordinate resources for the SBHCs.  Funding comes from the Arkansas Tobacco Excise Tax created by Arkansas Act 180 of 2009.  All SBHCs offer physical health services, mental and behavioral health services, and school health outreach programs based on student and community needs. Many offer other services, such as oral health and optometry and utilize the Coordinated School Health model. Adolescents are also seen in the LHUs for well women care or family planning.

A number of divisions, branches and sections within the ADH, the ADHS, and the ADE work every day to improve the health and welfare of children in the state.  While the role of ADH in-direct service provision has decreased in recent years, the department is still the sole provider of WIC services and continues to administer a significant percentage of all immunizations to children and youth. ADH also operates screening programs at the state level.  The ADHS has organizational units dedicated to Medicaid services, child care and early education, foster children, and abused and neglected children.  ADE has is extremely involved in health through the Coordinated School Health Initiative and SBHC, as well as in ongoing wellness activities. Six Community Health Promotion Specialists (CHPS) provide resources to Arkansas School Wellness Committees to work toward reducing obesity in schools, as mandated by Arkansas Act 1220.

Among other things, the CHA oversees the Personal Responsibility Education Program (PREP), which works to lower teen pregnancy and sexually transmitted infections.  It focuses on activities for reducing the pregnancy rates and birth rates for youth populations, especially youth populations that are vulnerable or at the highest risk for pregnancies, or otherwise have special circumstances, including youth in foster care, homeless youth, youth with HIV/AIDS, pregnant youth under the age of 21, mothers under 21 years of age, minorities, and youth residing in areas with high birth rates for youth.

c) Children with special health care needs (CSHCN)

Arkansas is a small state with a relatively small Title V CSHCN program. Title V Program for CSHCN is housed in the ADHS, Division of DDS.  The program’s name was changed to Children with Chronic Health Conditions (CCHC) in June 2018. The program promotes an integrated system of services for infants, children and youth up to age 18 years who have or are at risk for chronic physical, developmental, behavioral, or emotional conditions and require health and related services beyond what is generally needed. CCHC works together with families, policy makers, health care providers agencies, and other public-private leaders to assist in addressing their concerns related to CSHCN by promoting assessment, intervention, education, and coordination of services including family support, care coordination, and health information.  Medicaid-covered Title V Targeted Case Management coordinates services that assist members in accessing all social, medical, educational, and other services appropriate to the individual’s needs.  Currently, DDS has fifteen CHC community-based offices in:  Arkadelphia, Berryville, Conway, Fayetteville, Fort Smith, Harrisburg, Huntsville, Hope, Jonesboro, Marshall, Mena, Mountain View, Pine Bluff, Pocahontas, Prescott, and Pulaski County (Donoghey Plaza).  Pediatric registered nurses serve as facilitators, educators, advocates, collaborators.  They provide local, state and national resources, clinical support staff with experience in assisting families to access needed services. All staff is certified by DDS as having completed a DDS Case Management Training Program. The professional staff includes registered nurses and social workers who have many years of experience working with the medical and social needs of the children and youth being served. Each office also has clerical staff to assist in the processing of applications and communicating with families.

In addition, the UAMS/ACH CoBALT Project has been working with community-based physicians and other pediatric health professionals to complete assessments, offer probable diagnoses, and make referrals for appropriate intervention services. The CoBALT Project trains and provides ongoing consultation to physicians and other pediatric health professionals in the triage of children with suspected Autism Spectrum Disorders. As a result, referrals to appropriate services have increased.

The specialty medical care provided by the staff at ACH and UAMS is excellent. A new campus of pediatric specialty services opened in northwest Arkansas and is filling a tremendous need in that area. Outreach clinics in other parts of the state for specialty care remain in place with support from the Title V CSHCN program staff.  As a small state, the network of professionals who serve CSHCN and their staff is smaller as well. This leads to the ability to develop relationships, work together on projects and initiatives, and provide general support for programs to meet needs.  

d) Lifecourse Capacity

Within the lifecourse domain, ADH supports five home visiting models that are funded through the HRSA’s Affordable Care Act - MIECHV Program. Four of the models in Arkansas are funded with competitive MIECHV funds: Healthy Families America (HFA), Home Instruction for Parents of Preschool Youngsters (HIPPY), Parents as Teachers (PAT), and a promising approach, Following Baby Back Home (FBBH). The NFP model is administered by the ADH using MIECHV formula funding. These programs are voluntary and provide education and information as well as resources and support to expectant parents and families with young children. The home visiting programs focus on different family needs: some programs focus on health and wellness, some on school readiness, while others focus on healthy development, child welfare, and care coordination.  All address parenting skills to some degree.  The different models may work with an expectant mother or a young family from birth into the child’s 4th year of life.

Arkansas’s Title V Maternal and Child Health Services Block Grant

2019 Report/2021 Application

The Arkansas Department of Health (ADH) provides maternity, family planning, and well woman services in each of the state’s five public health regions. These services are coordinated through the ADH’s patient care manager, maternal and child health (MCH) specialists, Hometown Health Improvement program administrator, and local health unit administrator at the specific clinic site. ADH has staff in a variety of specialty areas including epidemiology, public health administration, public health nursing, social work, oral health, CSHCN, obstetrics, perinatal care, adolescents, early childhood, health education, nutrition, genetics, immunizations, and psychology.  Title V MCH activities are the predominant focus of the Family Health Branch (FHB), shown below and in the attached organization charts.

ADH Title V  MCH Leadership       

**NOTE:  The Women’s Health Section Chief, Rhonda Brown resigned in June 2020.  Courtney Livingston was appointed Interim.  Hiring for the position was delayed due to hiring freeze. FHB anticipates appointment of new Women’s Health Section Chief by the end 2020.

Within the FHB, the Women’s Health Medical Consultant (MC) and the Women’s Health Section Chief assure that needed services are provided according to state and federal rules and regulations. The ADH Women’s Health Section develops, coordinates, and establishes the policies and procedures for the perinatal and family planning programs; responds to LHU staff as needed for interpretation of policy, management of problems, or responding to other needs of the field or patients. The FHB’s Child and Adolescent Health Section (CAH) provides similar support to the field, with the Child Health Medical Director providing clinical leadership.

Our agency and office leadership teams are currently prioritizing employee retention and succession planning in an effort to keep skilled employees by offering learning and advancement opportunities, and to experience successful transitions when long-term employees retire or leave their positions.  When we have a position vacancy, we pause to examine whether to fill the position as it is currently organized and funded, or whether a long-term workforce strategy might warrant a change. As part of agency accreditation, a Workforce Development plan is in process, but has been on hold due to COVID19.

The ADH nursing staff, is aging and looking at retirement in the near future. The typical ADH public health nurse is female (98%) and over 40 (70%).  Over the years, the ADH has experienced difficulty with recruitment and retention of public health nurses. In addition to the shortage of primary care physicians in rural areas, the LHUs are adversely impacted by a statewide nursing shortage. The ADH’s Center for Local Public Health (CLPH) currently employs 33 nurse practitioners (6.6% vacancy), 301 registered nurses (12% vacancy), 39 nurse coordinators (6.5% vacancy) and 31 Licensed Practical Nurses (LPNs) (5.2% vacancy). These nurses staff the 94 LHUs in Arkansas’s 75 counties.

In 2018, ADH put forth a new pay scale that greatly impacted many nurses.  With the new pay scale, the nurses fall under medical professionals and as such raised the starting salary of all registered nurses to help aid in recruitment and retention of our nursing staff.  In 2020, the agency instituted a new LPN salary grid.  With this grid, it raises the compensation/salary of LPNs working at the ADH.  It allows us to hire LPNs and raise their starting salaries to compensate for their experience.  This means we can hire above the starting salary for the grade making our positions more appealing to qualified, experienced LPNs which enhances our recruitment efforts. The agency also utilizes compensation differential plans to assist with recruitment and retention of nurses. Differential compensation plans are to pay additional compensation for qualified applicants and/or employees in designated positions or classifications who meet specified criteria. Continuation of differential pay plans must be requested and approved legislatively on an annual basis. Various ADH nurses currently receive the following differentials depending on the role they serve in (up to an additional 6, 8 or 10%): Geographic Area Differential Pay, Hazardous Duty Differential Pay, and Differential Pay for serving in specific administrative or coordinator roles.

Maintaining appropriate staffing levels is a priority of the agency.  ADH will continue to evaluate and assess areas of opportunity to implement recruitment and retention strategies as well as engage with the State Primary Care Office and Primary Care Association for technical assistance as needed. 

Title V CSHCN

Arkansas’s Title V CSHCN Program is housed within the Arkansas Department of Human Services (ADHS), Division of Developmental Disabilities Services (DDS). The program was renamed in June 2018 and is now called the Children with Chronic Health Conditions Program (CCHCP). The program is overseen by a Title V CSHCN Program Director who provides general oversight for the CCHCP. The program director splits her time between Title V CSHCN and the First Connections Part C program (under the Individual’s with Disabilities Education Act).

The CCHCP maintains staff in 15 community-based offices statewide and in the central office. The professional staff in the counties are registered nurses and administrative specialists, who are overseen by three area managers who are also registered nurses. These three area managers are supervised by the Title V CSHCN Program Director. The leadership staff meets monthly to discuss emerging issues and ensure continued cooperation among the 15 community-based offices. The goal of these monthly meetings is to establish a single vision and mission for the CCHCP.

CCHCP Senior Management

The CCHCP is comprised of a total of 28 full-time employees and one employee in a part-time position. Fifteen of the full-time employees are registered nurses. The remaining employees are administrative support for clinical staff. Arkansas CSHCN workforce is comprised of a vast range of professionals that possess knowledge and skills to support the CSHCN population.  

Like many public health programs, the CCHCP faces the challenge of an aging workforce. The CCHCP has developed strategies to ensure the institutional knowledge possessed by the current workforce is carried forward to the next generation of CCHCP leaders. For example, the CCHCP’s northwest area manager served on the University of Arkansas at Fort Smith’s Carolyn McKelvey School of Nursing’s Advisory Board, which provided the opportunity for nursing students to shadow him to learn about CCHCP as a public health agency for CSHCN.

The CCHCP’s senior management continues to monitor caseloads and service gaps around the state. The existing workforce, sub-grants, and contracts are used to fill these gaps to provide services in underserved areas. For example, the CoBALT contract, paid for by Title V, is used to train physicians on how to identify and diagnose developmental disabilities, including autism. Additionally, Project Delivery of Chronic Care (DOCC), funded by the CCHCP through a sub-grant to the Arkansas Disability Coalition, trains pediatric residents on interviewing and meeting the needs of families with CSHCN.

Arkansas’s Title V Maternal and Child Health Services Block Grant

2019 Report/2021 Application

Within an environment of limited resources, health care shortages, and geographic challenges, the Title V staff are experts in a variety of MCH areas and are skilled at developing creative and nimble partnerships to address MCH issues. Most often MCH leadership and staff serve as a convener, collaborator, and/or partner to move the needle on MCH issues. One benefit of working in a small state is the tightknit community of public health professionals, social service programs, community organizations, and health care providers, and often, the same stakeholders are “at the table’ for many MCH matters. The MCH Program has close working relationships with the UAMS, Arkansas Medical Association, Arkansas Chapter of the American Academy of Pediatrics (AAP), ACH, Arkansas Hospital Association (AHA), Arkansas Advocates for Children (AACF) and Families, Arkansas Foundation for Medical Care (AFMC), Arkansas Minority Health Commission (AMHC), March of Dimes, LHUs, and a number of pediatric and pregnancy care providers. Over the past couple of years, MCH leadership has been the primary convener with stakeholders to drive policy development, decisions, and activities related to newborn screening program operations, infant mortality reduction (safe sleep and hospital regionalization), and vetting of implementation the MMRC review team.

As the only medical school in the state, the role of UAMS in Arkansas's health care system is difficult to overestimate. Development of the College of Public Health within UAMS since 2001 has led to much stronger links between the state's health-engaged agencies and the university. UAMS is also the sponsoring entity for the ACHI, a collaborative effort designed to promote public health research and translation into practice. UAMS supports eight Regional Campuses around the state, which provide direct patient care and training of family medicine residents. UAMS's pediatrics and obstetrics/gynecology departments are very strong partners with ADH in the provision of direct care to women and children. These departments also partner with ADH to carry out ongoing public health programs and other initiatives to improve systems of care.

The 83 general hospitals in the state provide the bulk of in-patient care. ADH works closely with these local providers to assure that standards of care are met. Apart from this regulatory relationship, ADH also regularly partners with the AHA on issues of common interest at the systems level.  Professional boards of medicine, nursing, and other disciplines are examples of other state agencies that provide support to the health system. These disciplines, along with dentistry, pharmacy, chiropractic, and hospital administration, are all represented on the Arkansas Board of Health.

Although not state-supported per se, the role of ACH in the health system deserves special mention. ACH is one of the largest children's hospitals in the U.S., attracting patients from around the region and other countries. ACH provides a large proportion of the pediatric critical care in the state. Apart from direct care provision, the hospital's administration is also committed to involvement in community- and state-level public health concerns such as infant mortality reduction, injury prevention, and school health initiatives. ACH is a major partner for MCH and one of the most important collaborations is the MCH Directors participation in the Natural Wonders Partnership Council (NWPC), which ACH has led since its inception in 2007.  More than two dozen leaders from various fields meet monthly to share information and prioritize action steps that will improve the health and wellbeing of children in Arkansas. Members of the NWPC have taken ownership of various areas and share progress with the Council at meetings and in reports.  Specific areas of focus for MCH participation have been prenatal care, infant mortality, teen pregnancy, immunizations, oral health, injury prevention, tobacco prevention, and obesity prevention. The Injury Prevention Center at ACH is vital to childhood safety efforts.  Inextricably linked to all of ACH’s initiatives are the faculty members within the Department of Pediatrics at UAMS.

The ADH partners with Nurse Family Partnership (NFP) within the Center for Local Public Health (CLPH) and ACH to implement the Arkansas Home Visiting Network (AHVN). At-risk families in 46 Arkansas counties are being served by the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) - funded home visiting programs. The Network is made up 32 local implementing agencies and more than 400 home visitors working in 80 community agencies in all 75 counties. The Network supports four evidence-based home visiting models and a promising program, Following Baby Back Home, which follows babies in Neonatal Intensive Care Units (NICUs) back into their home community. There are currently 125 MIECHV-funded home visiting staff members in 38 program sites across the state. These programs provide direct services to the 1,253 families enrolled in home visiting programs. ADH partners with ACH to provide the AHVN. In addition, the Home Visiting Network’s Training Institute provides supplemental training and professional development for all home visitors and supervisors involved in home visiting services in Arkansas.  To date, the Training Institute has developed 38 training modules and trained a total of 4,536 home visitors, supervisors, and coordinators (participants attend more than one training) in 242 instructor-led training sessions.

ADH has an established collaboration with UAMS and ACH to conduct Infant and Child Death Reviews on unexpected infants and pediatric deaths in Arkansas. Currently, there are 11 review teams covering all 75 counties around the state to investigate deaths that are not conclusively determined.

Arkansas Advocates for Children and Families (AACF) is a key player in promoting policies and practices that enhance the health status of children, particularly those who are most vulnerable.  The state has a well-trained work force of pediatricians whose medical society, the Arkansas Chapter of the AAP, also takes an active stance in promoting child-friendly health policies.

The ADH partners with the Arkansas Perinatal Outcomes Workgroup Education and Research (POWER) to develop strategies to improve perinatal outcomes in the state. POWER is an initiative with a focus of collaborating with 39 delivering hospitals in Arkansas to reduce maternal mortality and morbidity by implementing maternal safety bundles in postpartum hemorrhage and severe hypertension. POWER has recently launched a safety bundle to reduce postpartum racial/ethnic disparities. The ADH Family Health Branch (FHB) Medical Director and Medical Consultant for Women’s Health provide public health information and perspective to the workgroup.

In many ways the ADH is it's own best partner.  Programs focused on chronic disease, tobacco cessation, breast and cervical cancer, HIV and STIs, oral health, immunizations, vital records, health statistics, and healthy communities all reside in the ADH, with most being in the same center as the MCH program. Programs are always working with each other to maximize resources and expertise.  The MCH epidemiologist position actually resides in the Health Statistics Branch, as does the States Systems Development Initiative (SSDI) program that provides much of our data. The FHB (in which MCH is housed) is also the recipient of the Title X Grant, Infant Hearing Grants, and MIECHV Grant.  Additionally, through state funds and fees, the FHB is also home to the Newborn Screening Program and funds the Infant and Child Death Review.

MCH and partner programs work together to identify evidence-based programming and monitor implementation and progress of the funded activities. The Title V Program is skilled at community engagement and has a number of formal and informal partnerships with community-based organizations across the state to assist with MCH efforts. Formal partnerships include those cemented via contract, subgrant, or memorandum of understanding (MOU). Informal partnerships are those in which MCH works closely with another program or organization to provide information, technical assistance, or referrals. For example, MCH has a MOU with ACH to support safe sleep education efforts.

The Arkansas CSHCN/Title V program partners with various agencies and groups that provide services to the specialized population that are being served. The Parent Advisory Council (PAC) to Title V CSHCN is comprised of 19 family members who attend quarterly meetings in Little Rock to receive training. There are currently two vacancies within the PAC. The PAC’s diversity includes families that are African American, Caucasian, and mothers and fathers.  PAC representatives are required to hold at least one parent support group meeting or workshop in their region of the state each year.  Our PAC parent consultant also serves on the Family-2-Family (F2F) steering committee, which meets monthly. The F2F steering committee helps to provide: general health-related assistance to families and professionals;  referral services that connect families to other families, professionals, and health-related programs;  outreach to under-served/under-represented areas of Arkansas, including a statewide minority outreach program; and  family/professional training seminars and workshops. The Arkansas CSHCN population is represented by a PAC parent who serves on the Association of Maternal and Child Health Programs (AMCHP) Board as a Director at Large.  The CSHCN Program staff also participate on the following committees/workgroups:  The ACH Genetics Committee, Leadership Education on Neuro-developmental and Related Disorders Training (LEND), and the Governor’s Commission on People with Disabilities.

Arkansas’s Title V Maternal and Child Health Services Block Grant

2019 Report/2021 Application

Arkansas ranks 48th out of 50 states in terms of overall health and 49th in health of women and children.  An extremely broad range of health measures in the state rank unfavorably when compared to other states. With 50 being the worst and one being the best, Arkansas ranks:

• 50th – adult obesity in women and teen births
• 49th – physical inactivity, diabetes, and smoking in adult women
• 47th – adverse childhood experiences, and infant mortality.
• 46th – maternal mortality
• 44th  – child mortality
• 42nd – low birthweight live births

There is significant overlap between the ACH NA, the MCH Community Survey, and the Title V CSHCN NA. The process of triangulation/integration of the three into the state’s NA process helped the ADH select the ten national performance measures chosen for programmatic focus by Arkansas’s Title V program. The following is a brief discussion as to why they were selected and their linkage to the selected state priorities.

State Priority:  Improve access to health care for women

NPM 1: Well-woman visit - (women 18 through 44 years)

Arkansas’s Title V program has focused on both preconception and interconception health for a number of years, fully recognizing the importance of improving the health of all women of reproductive age to ensure better birth outcomes and healthier babies. LHU’s well woman/preventive visits continue to provide the best opportunity for at-risk women to receive recommended clinical preventive services, including screening, counseling, and immunizations, which can lead to the appropriate identification, treatment, and prevention of disease to optimize the health of women before, between, and beyond potential pregnancies.

State Priority:  Improve preterm, low-birth weight, and pregnancy outcomes

NPM 3: Percent of very low birth weight (VLBW) infants born in a hospital with a Level III+ Neonatal Intensive Care Unit (NICU)

Arkansas is developing a coordinated regional system to help ensure that pregnant women and infants at high-risk of complications receive care at a birth facility that is best prepared to meet their health needs. Infants born before 32 weeks gestation should be cared for at facilities with specialized health care providers and equipment to care for infants who are born too early or who are critically ill.  The AMROQRC has adopted a new process to assess the hospitals’ perinatal levels of care using the CDC’s levels of care assessment tool (LOCATe). LOCATe will guide efforts to improve the state’s perinatal care system and help align the state’s recommendations with the most recent national standards.

State Priority:  Promote breastfeeding

NPM 4: A) Percent of infants who are ever breastfed, and B) Percent of infants breastfed exclusively through 6 months 

Promoting breastfeeding has been an important focus of Arkansas’s Title V program. It has also been recognized as a major health benefit to both infant and mother, as well as an enhancement of maternal/child bonding. The ADH provides breastfeeding support activities through a number of different programs, including the WIC program, Healthy Active Arkansas, Sisters United, and the Chronic Disease Branch that develop policies/tools to promote breastfeeding as the preferred method of infant feeding.

State Priority:  Promote safe and healthy infant sleep behaviors and environment

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 C) Percent of infants placed to sleep without soft objects or loose bedding

Arkansas’s Title V program is significantly involved with the CoIIN, and safe sleep for infants is one of the selected priority strategies for CoIIN. The ADH continues to facilitate a monthly meeting of the Breastfeeding Promotion Taskforce. The Taskforce brings together stakeholders from the WIC program, Office of Health Equity, and Child and Adolescent Health Section as well as representatives from the Arkansas Breastfeeding Coalition, Arkansas Injury Prevention Center, and the Baptist Health System to provide input on the state work plan to reduce sleep-related infant deaths. Arkansas’s MIECHV program also has focused efforts to support breastfeeding. In Arkansas, SIDS remains a significant contributor to infant mortality. Focusing on a safe sleep environment can reduce the risk of all sleep-related infant deaths, including SIDS. 

State Priority:  Increase the percent of infants and children receiving a developmental screening

NPM 6 – Percent of children ages 9 through 35 months, who received a developmental screening using a parent-completed screening tool in the past year

Studies suggest that many children do not receive regular, standardized developmental screening. Such screening helps identify children who need special attention, so we can give them that attention earlier, which greatly improves their long-term well-being.  Early identification of developmental disorders is critical to the well-being of children and their families.  The American Academy of Pediatrics (AAP) recommends developmental screening for all children ages 9, 18, 24, or 30 months. The ADH continues to provide education on early detection supports to new families across a number of programs such as: Infant Hearing, Newborn Screening, WIC, and MIECHV.

State Priority: Reduce the burden of injury among children

NPM 7.1- Rate of hospitalization for non-fatal injury per 100,000 children, ages 0 through 9

Social connectedness, healthy relationships, violence-free environments, and family and community engagement together provide children with safe, stable, and nurturing relationships and environments. This includes providing individuals, families, and organizations with knowledge, skills, tools, and opportunities to make safe choices that prevent injuries and create safe communities.  Arkansas’s evidenced-based home visiting models MIECHV continues to demonstrate the best hope for working directly with Arkansas parents and children.  Each home visiting model works with a specific population and promotes positive parenting skills, helps parents become self-sufficient, and addresses MCH issues.  The Injury Prevention Center at ACH continues multiple programs such as:  baby safety showers, motor vehicle safety, drowning prevention, and a statewide Safe Sleep Campaign. 

State Priority: Decrease the prevalence of childhood and adolescent obesity

NPM 8: Percent of children ages 6-11 and adolescents ages 12-17 who are physically active at least 60 minutes per day

The importance of physical activity to reduce obesity and improve health is a major focus within the ADH. Studies have shown that for many children, a decline in physical activity begins in middle school, and those children who continue to be physically active through middle school and high school have a much better chance of being physically active adults. ADH’s CAH Program continues to increase opportunities for physical activity for children and adolescents. This objective is attained by developing and implementing new policies; using frameworks to identify opportunities and build capacity, building strong stakeholder relationships, and providing professional development opportunities and technical assistance to those doing the work. The School Health Services Programs at ADH and the Arkansas Division of Elementary and Secondary Education continue efforts to create healthier environments for children through the implementation of coordinated school health and Act 1220 activities.

State Priority: Reduce the burden of injury among children

NPM 9: Percent of adolescents, ages 12-17, who are bullied or who bully others

The most recent federally available data (2018) on the percent of adolescents ages 12 - 17 who are bullied or who bully others indicates the following: 47% of adolescents ages 12-17 were bullied and 17% of adolescents ages 12-17 bullied others. Bullying greatly increases the risk of self-injury and suicide. Bullying is a continued priority for Arkansas’s Title V program. The School-Based Mental Health program works with schools to provide and promote access to mental health services, allowing for prevention and early intervention. The ADH Injury and Violence Prevention Section’s Suicide Program continues to provide educational opportunities to increase the awareness of suicide prevention.  ACH Injury Prevention Center continues to promote suicide prevention by providing resources and supports for families with children exhibiting suicidal ideation.

State Priority: Increase the number of adolescents who successfully transition to adult health care

NPM 12: Percent of adolescents with and without special health care needs who received services necessary to make transitions to adult health care

Transition from pediatric to adult health care has become a priority nationwide and effective health care transition is especially important for children with special health care needs as they are less likely to finish school, go to college, or secure employment. When transition is successful, it can maximize lifelong functioning and well-being. Proactive coordination of patient, family, and provider responsibilities prior to becoming an adult, better equips youth to take ownership of their health care as adults.

State Priority:  Improve poor pregnancy outcomes

NPM 13.1: Percent of women who had a preventive dental visit during pregnancy

According to the CDC, 60 to 75% of pregnant women have gingivitis. Periodontitis has also been associated with poor pregnancy outcomes, including preterm birth and low birth weight. Studies indicate that the medical community may not be prepared to discuss the importance of oral health with patients, specifically during pregnancy.  The ADH Office of Oral Health and Women’s Health Program are partnering to educate primary care physicians and LHUs on the impact of oral health outcomes for pregnant women, patients will in turn be better informed of the significance of perinatal oral health and will be more likely to seek dental care during the perinatal period. 

SPMs to monitor progress with priority needs not addressed by NPMs.

SPM 1: Hearing Screening – Percent of newborns with timely follow-up of failed screening:  Linked to NPM 6

SPM 2: Nicotine Use – Percent of adolescents, ages 12 through 17, who report using nicotine products (emerging need)

SPM 3: Well-Functioning Health System – Percent of children with special health care needs (CSHCN) receiving care in a well-functioning system:  Linked to NPM 12

SPM 4: Percent of Family Health Branch and Arkansas Home Visiting Program staff who complete the National Center for Cultural Competence’s - Unconscious and Conscious Bias in Healthcare Course (emerging need)