Pennsylvania’s 2020 Title V Five-Year Needs and Capacity Assessment was composed of several phases broadly described as preparation, assessment of the health status of maternal and child health (MCH) populations, prioritization and assessment of capacity. Preparation for the assessment included development of a work plan and timeline, assembly of a needs and capacity assessment steering committee and identification of the goals and guiding principle of the assessment. The goals identified were: 1) Identify urgent priority needs of the MCH population domains that can be feasibly addressed given the state Title V Program’s capacity and workforce and; 2) Engage and collaborate with stakeholders to identify means of furthering the Bureau of Family Health’s (BFH) mission to provide comprehensive, equitable and community-centered health services to the MCH populations. Health equity was the guiding principle of the 2020 assessment. As such, in addition to analyzing data and gathering information from stakeholders to characterize the health issues facing all MCH populations in Pennsylvania (PA), the assessment also aimed to identify specific population groups that are disproportionately affected by adverse health outcomes and to evaluate underlying social, economic and environmental determinants of health. During the preparation phase, the BFH presented on the plan at meetings with Title V stakeholders and service recipients to raise awareness of the assessment and encourage robust participation in web surveys, focus groups and the prioritization.

In order to assess the health status of maternal and child health populations in PA, staff members from the BFH were assigned a set of indicators and asked to gather data from the past five years in order to determine whether MCH outcomes had improved, declined or remained the same. Data were gathered for the following datasets: American Community Survey (2015-2017), CDC Wonder Detailed Mortality and Linked Infant Death/Birth Datasets (2012-2016), National Center for Fatality Review and Prevention – National Reporting System (2011-2015), National Immunization Survey (2014-2018), the National Survey for Children’s Health (2016-2017), PA Youth Survey (2013, 2015 and 2017), PA Health Care Cost Containment Council (2008-2017), and the Youth Risk Behavior Survey (2009, 2015, 2017). Data from PA birth certificates and death certificates were summarized from the PA Department of Health’s online data platform, Enterprise Data Dissemination Informatics Exchange (EDDIE) for 2012-2017 and data files were also procured for Pregnancy Risk Assessment Monitoring System (PRAMS) Phase 7 data (2012-2015), PRAMS Aggregate Site Data from 34 PRAMS sites (2012-2015), and the Behavioral Risk Factor Surveillance System (BRFSS) (2011-2017). Additionally, qualitative data on the health needs of families and communities across PA were collected from stakeholders via focus groups and a web survey. Results from the quantitative and qualitative data analyses were summarized into a series of data briefs highlighting both the strengths and needs of each population domain. The data briefs were then distributed to stakeholders in order to inform the prioritization phase of the assessment.

In consultation with a team from the Center of Excellence in MCH Education, Science and Practice Program at the Johns Hopkins Bloomberg School of Public Health, the BFH developed an iterative prioritization process that was designed to incorporate feedback from stakeholders. The process was informed by a literature review of needs assessment methods and the experiences of other states. An initial list of priorities was identified and scored by the needs and capacity assessment steering committee based on the needs identified through the analysis of quantitative and qualitative data. The potential priorities were then ranked by stakeholders at a series of regional prioritization meetings and through an online survey. Stakeholders invited to participate in prioritization included all current MCH vendors and partners, service providers, service recipients and their families as well as other organizations, persons, and groups with an interest or stake in maternal and child health in PA. These rankings were then used by the steering committee to inform final priority selection. An outline of the prioritization process is provided in Figure 1.

Finally, the BFH completed several activities to assess their capacity to carry out the mission of Title V and to direct work related to the newly proposed priorities. In addition to evaluating existing infrastructure and capacity, Title V staff were surveyed on strengths, training needs and competencies. The BFH also held an in-person meeting with the Department of Health and other agency partners at which the BFH sought feedback on the health needs that stakeholders had identified as the highest priorities, discussed organizational capacity and opportunities for collaboration.

 

To ensure that the assessment was comprehensive and that the process of developing state priorities and the action plan was directed by data and input from stakeholders, the ultimate direction of the assessment was informed by the results of each preceding phase. The BFH identified seven state priorities and, once finalized and approved by the Department of Health’s leadership, the BFH developed its state action plan. While the BFH currently operates many existing programs and activities that address the new priorities, a component of action plan development was identifying gaps where new strategies could be developed. The development and implementation of new strategies will be informed by the data collected and summarized over the course of the needs assessment. Additionally, health equity remains at the forefront of action planning and programming and activities will be implemented in areas and among populations where health disparities and inequity were most apparent.

 

While the major health issues reflected in the state’s priority needs are described below, the aforementioned data briefs provide a summary of all the health indicators evaluated for each Title V population domain. The data briefs are available online at the following link: https://www.health.pa.gov/topics/Documents/Programs/Title%20V%20MCH%20Data%20Briefs.pdf.

 

Women/Maternal Health: Over the past five years, women in PA increasingly reported attending well-woman visits, discussing preconception health with medical providers, and taking a multivitamin containing folic acid prior to pregnancy. Additionally, the percentage of women who report smoking during pregnancy has decreased and women in PA also increasingly report attending postpartum care visits. The BFH has been successful in supporting women and mothers with gap-filling direct services by supporting home visiting for women who do not meet traditional eligibility criteria, providing interconception care programming and supporting Centering Pregnancy group prenatal care programs. Given that the scope of direct services is limited by program capacity and funding, the BFH sees an opportunity to develop system-level strategies addressing maternal health issues in PA.

Based on available data and feedback from stakeholders across the state, the BFH identified four key health issues affecting women and mothers in PA: 1) access to early and adequate prenatal care and preventive care; 2) increasing rates of maternal morbidity and mortality; 3) substance use and; 4) perinatal depression. The health issue ultimately reflected in the state’s priority needs is maternal morbidity and mortality. Stakeholders consistently reported that they viewed this as a major issue for the state. Many referred to the stark racial disparity in maternal mortality ratios and expressed a desire for more solutions that might help to address it. While maternal mortality rates may be decreasing in PA, Black and African American women were almost three times as likely to die a pregnancy-related death than white women from 2011-2015 in PA. The rate of severe maternal morbidity per 10,000 delivery hospitalizations has also increased in PA from 85.8 women with severe morbidity per 10,000 delivery hospitalizations in 2010 to 114.8 in 2015. Maternal morbidity is also most apparent among minority women, especially among non-Hispanic black women. An associated challenge is improving protective factors during and after pregnancy, such as receipt of prenatal care. From 2015 to 2017, approximately 1.6% of women in PA did not have any prenatal care and 26.2% did not receive timely prenatal care starting in the first trimester and, again, Black and African American women were least likely to receive prenatal care as compared to women of another race or ethnicity.

While awareness of maternal mortality may be increasing, the severity of the issue is only becoming more apparent as data collection and reporting improve. PA’s Maternal Mortality Review Committee (MMRC) was established in 2018 with the goal to systematically review all maternal deaths, identify root causes of these deaths and develop strategies to reduce preventable morbidity, mortality and racial disparities related to pregnancy in PA. Given its recent inception, recommendations from the MMRC have not yet been released. However, as reporting of maternal deaths continues and the quality of maternal mortality data in PA improves, there is an opportunity for the BFH to implement recommendations from the Maternal Mortality Review Committee as they become available and to develop new strategies, as needed, to address high-risk populations.

Infant/Perinatal Health: Over the past five years, the percentage of infants ever breastfeed has increased, infant mortality rates have decreased, and the percentage of infants placed to sleep on their backs has increased in PA. However, for each of these indicators there is still a significant disparity for Black and African American infants. As such, although some progress has been made, infant mortality and breastfeeding remain major health issues in PA. The BFH has successfully implemented gap-filling direct services for infants in the form of home-visiting for mothers and infants following birth and breastfeeding awareness/education programming. Additionally, Title V funds support an enabling safe sleep program aimed at reducing sleep-related infant death. This support is complemented by systems-level programming including the newborn screening and genetics program, child death review and breastfeeding support at the hospital level through Keystone 10. The BFH sees an opportunity to enhance existing strategies to continue to serve high-risk populations and to expand systems-level work.

Based on available data and feedback from stakeholders across the state, the BFH identified four key health issues affecting infants in PA: 1) pre-term birth; 2) infant mortality; 3) breastfeeding initiation and duration; and 4) timely reporting of results from newborn screens. The health issue ultimately reflected in the state’s priority needs is decreasing the infant mortality rate.

While stakeholders felt that community members may not view infant mortality as a widespread concern unless they have been personally affected, they indicated that, among providers and public health professionals, infant mortality is an issue of high severity and importance. Stakeholders emphasized the stark disparity in mortality rates between White and Black or African American infants in PA. The infant mortality gap between Black and White infants in PA persists. Since 2012, the infant mortality rate in PA has decreased from 7.0 deaths per 1,000 live births to 6.1 infant deaths per 1,000 live births in 2016. However, the infant mortality rate for Black/African American infants in PA in 2016 is 14.6 deaths per 1,000 live births which is two times higher than the overall state rate, six times higher than the mortality rate for Asian/Pacific Islander infants (2.3) and three times higher than the rate for White infants (4.6). Many stakeholders also indicated that this priority is intertwined with pre-term birth and maternal well-being, suggesting that work on this priority may impact other areas of maternal and perinatal health.

Child Health: Over the past five years, children in PA are increasingly reported to attend child well visits and the rate of non-fatal injury hospitalizations has also decreased. Additionally, the percentage of children in PA who have had a preventive dental visit, have a parent-reported health status of “excellent” or “very good” and who reported experiencing bullying is below the national average. The BFH currently supports an enabling safe and healthy homes program aimed at reducing health risks and hazards in children’s homes, supports gap-filling direct services provided to children by County and Municipal Health Departments and supports the system-level Child Death Review (CDR) teams which operate statewide. In addition to enhancing the existing capacity of CDR teams, the BFH sees an opportunity to address behavioral, mental and developmental health needs among children and to develop systems-level strategies addressing childhood injury and trauma.

Based on available data and feedback from stakeholders across the state, the BFH identified four key health issues affecting child health in PA: 1) access to preventive visits and medical care; 2) child mortality and injury; 3) bullying and; 4) mental, behavioral and developmental health outcomes. The health issues ultimately reflected in the state’s priority needs are reducing child mortality and injury and improving mental, behavioral and developmental health outcomes. Data trends suggest that non-fatal injuries and related mortality rates are prevalent and a high severity issue, especially for youth and adolescents. In Pennsylvania, the leading causes of child and adolescent death include accidents, injuries and unintentional harm as well as suicide and intentional harm. Youth suicide rates have also consistently increased over the past several years. Stakeholders indicated that reducing child and youth mortality rates could be achieved, in part, by addressing mental and behavioral health. Additionally, in Pennsylvania, experiences with violence and hazards in the home contribute to the non-fatal injury hospitalization rate.

Health of Children with Special Health Care Needs (CSHCN): Given that there is minimal longitudinal data on CSHCN in PA, it is challenging to know to what extent improvement in health status has been made among this population over the past five years. Improving access and quality of data remains a challenge and an opportunity for the BFH for this domain. Based on available data and feedback from stakeholders across the state, the BFH identified four key health issues affecting the health of CSHCN in PA: 1) bullying; 2) access to and use of transition services to the adult health care system; 3) receipt of health care in a well-functioning system; and; 4) mental, behavioral and developmental health outcomes. The health issues ultimately reflected in the state’s priority needs are increasing CSHCN receiving care in a well-functioning system and improving mental, behavioral and developmental health outcomes.

Stakeholders reported that increasing CSHCN receiving care in a well-functioning system is viewed as a large concern by the community because there are not enough specialists and there is a lack of communication across systems. Similar sentiments emerged from the focus group discussions held with families, providers and children and youth with special health care needs. Many of the major themes that emerged from those discussions (i.e. doctor turnover, lack of continuity of care, transition services, caregiver respite) are related to a well-functioning system of care. A well-functioning system of care is imperative to optimizing the physical, mental, and behavioral health of PA’s CSHCN. Attempting to navigate a fragmented system can affect the health and well-being of both CSHCN and their families/caregivers. The BFH continues to administer programming aimed at providing children with a medical home and well-coordinated, family-centered care. Other components of a well-functioning system, including transition, may require the development of new system-level strategies. Additionally, CSHCN are more likely to have experienced ACES as compared to children without special health care needs. A new strategy aimed as supporting children, including CSHCN, with adverse experiences or experiences with trauma may need to be developed to address this.

Adolescent Health: Over the last several years, the teen pregnancy and birth rates have declined in PA, as has the rate of non-fatal injury hospitalizations. Based on available data and feedback from stakeholders across the state, the BFH identified four key health issues affecting adolescent health in PA: 1) morbidity and mortality; 2) bullying; 3) mental, behavioral and developmental health outcomes and; 4) teen pregnancy. The health issues ultimately reflected in the state’s priority needs are reducing rates of child mortality (including adolescents) and improving mental, behavioral and developmental health outcomes. The BFH currently supports gap-filling, direct teen pregnancy prevention and reproductive health services through the state’s Health Resource Centers and Family Planning Councils and provides direct behavioral health services to LGBTQ youth. Enabling programming developed to improve protective factors among youth and prevent bullying is also supported by Title V. The BFH sees an opportunity to enhance existing strategies and develop a system-level strategy addressing mental and behavioral health. 

Stakeholders reported that increased support of mental health and behavioral health services among adolescents is warranted in PA and could lead to overall improvement in adolescent health and in the transition from adolescence to adulthood. In addition to increasing suicide rates among adolescents in PA, the percentage of adolescents reporting sadness/hopelessness has increased and adolescents are also increasingly reporting trying substances such as electronic cigarettes and experiencing bullying and interpersonal violence, with LGBTQ youth being most affected. Increased access to mental health services and positive youth development programming is merited to address these issues.

 

The mission and efforts of the Department of Health (DOH) are guided by the Commonwealth’s leadership. Governor Tom Wolf was inaugurated as PA’s 47th Governor on January 20, 2015 and was re-elected for a second term in 2018. The Governor’s cabinet is comprised of the directors of various state agencies who are appointed by the Governor and confirmed by the Senate. All Cabinet members are responsible for advising the Governor on subjects related to their respective agencies. Dr. Rachel L. Levine was confirmed as Secretary of Health in March of 2018 and serves as a Cabinet member. Dr. Levine serves as the chief executive officer for the DOH and sets the policies, direction and mission. Dr. Levine also establishes strategic goals and objectives and advises the Governor on all medical and public health-related issues and policies. The mission of the PA DOH is to promote healthy behaviors, prevent injury and disease, and to assure the safe delivery of quality health care for all people in PA.

The DOH’s Bureau of Family Health (BFH) is the State Title V Agency in PA and is responsible for administering programming and activities funded by the Title V Maternal and Child Health Services Block Grant. The BFH’s Divisions of Child and Adult Health Services (CAHS), Community Systems Development and Outreach (CSDO), Newborn Screening and Genetics (NSG) and Bureau Operations (DBO) administer and oversee programming and activities that aim to improve the health and well-being of PA’s mothers, women, infants, children and youth, CSHCN and their families. The Department of Health and Bureau of Family Health organizational charts are included as supporting documents to the Title V annual application/report.

The BFH currently operates approximately 37 programs and activities using Title V funds. The BFH also administers other programs using federal grants and state funding. Collectively, these programs carry out the mission of Title V by establishing and supporting public health services and systems, enabling access to care and supporting the provision of gap-filling direct services. Table 1 provides a listing of all the Title V supported programs. The BFH continues to work toward strengthening the public health systems at the base of the pyramid in order to ensure that there is sufficient capacity and infrastructure for the essential maternal and child health services to be delivered statewide.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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In order to maintain infrastructure to support essential public health services and systems at the state level, BFH works with local Title V agencies and selects additional community-based partners throughout the state to provide public health, enabling or direct services to the MCH population. BFH uses population and public health data to target geographical areas or populations for interventions, and then selects qualified grantees. For all grant agreements, BFH staff develop objectives, work statements and budgets, and provide oversight and monitoring of grantee progress toward the stated goals. Through workforce development, technical assistance, and system change initiatives, BFH ensures its staff and partners have the capacity, expertise and resources needed to design, implement and evaluate public health programming that is evidence-based, family and community-driven, shaped by an awareness of the social determinants of health and the principles of health equity, and sensitive to the unique needs of the populations served by the Bureau.

 

Capacity to Serve Women and Mothers: PA’s Title V program provides a critical safety net for pregnant women and women of childbearing age. In partnership with providers at the local level, the Title V program works to meet the needs of women in the communities in which they reside. Women accessing Title V services are at higher risk for maternal morbidity and mortality due primarily to the impact of social determinants of health. The resources provided by Title V work to lower this risk at the individual, community, and state level by addressing social determinants, reducing racial disparities in health care, and increasing access to quality healthcare and health education throughout PA. The BFH collaborates with the 10 local health departments to provide home visiting services to women who do not fit the criteria for the traditional home visiting services, is working to expand Centering Pregnancy, and supports the Interconception Care (ICC) Project. Augmenting and supporting these collaborations is the Pregnancy Risk Assessment Monitoring System (PRAMS). See Table 1 for more information on PRAMS and each of the aforementioned programs.

 

Capacity to Serve Infants: Many of the services focused on perinatal/infant health are provided through collaborative work between the BFH and hospitals or midwifery practices. These services seek to promote infant health and well-being beginning at birth. The BFH’s Newborn Screening and Follow-up Program (NSFP) performs follow-up services for dried blood spot, hearing, and critical congenital heart defects screenings. Other hospital-based activities include prevention efforts related to Shaken Baby Syndrome and breastfeeding promotion through the Keystone 10 initiative.  The BFH also supports the development and ongoing implementation of an evidence-based, hospital-based model for safe sleep through staff and caregiver education. In addition to providing support to hospitals, the BFH also administers and supports programming at the community level. Supported programs include home visiting, the Breastfeeding Awareness and Support Program and the Neonatal Abstinence Syndrome (NAS) Follow-up Program. See Table 1 for more information on each of these programs. The BFH also operates the Healthy Baby hotline as a mechanism for pregnant and new mothers to access information and resources on insurance coverage, prenatal care and referrals to local healthcare providers.

Capacity to Serve Children: Child health programs provided by the BFH are community-based. An important component of the Title V program is to provide gap-filling direct services for uninsured children in PA. Title V nurses in the 10 local health departments staff clinics offered to children who are uninsured, underinsured or uninsurable and educate families on the importance of well child visits, development and nutrition. The BFH administers the Child Death Review (CDR) Program and also aims to improve the health and safety of families and homes in PA through the Safe and Healthy Homes Program and by working collaboratively with local partners to educate families on childhood lead poisoning prevention and lead hazards. For more information on each of these programs, see Table 1. Furthermore, the PA Department of Health tracks and monitors childhood lead activity through the PA National Electronic Disease Surveillance System (PA-NEDSS).  PA-NEDSS is a web-based application system that receives all lead reports on PA's children. The BFH utilizes available data through PA-NEDSS to identify possible high-risk areas, locate areas of under-testing and identify other potential service gaps. 

Capacity to Serve Adolescents: The BFH aims to serve PA’s adolescents through partnerships and initiatives, with a focus on youth in high-need areas. Title V and federal funds support teen pregnancy prevention, sexual health education, bullying prevention, mentoring and services for Lesbian, Gay, Bisexual, Transgender and Questioning (LGBTQ) youth. Personal Responsibility Education Program (PREP) and Sexual Risk Avoidance Education (SRAE) funding supports programs to delay sexual activity, increase condom or contraceptive use and reduce pregnancy. Health Resource Centers (HRC) provide sexual health education, counseling and referrals to youth in schools or other easily accessible locations. The BFH also supports Title X clinics by supplementing services for youth 21 years of age and younger with Title V funding. Several BFH programs aim to increase protective factors and decrease risk factors among youth including an evidence-based mentoring program and the Bullying Prevention Program. The BFH prioritizes providing services to LGBTQ youth in PA, who experience a higher rate of health disparities than their heterosexual peers. For more information on each program, see Table 1.

Capacity to Serve Children with Special Health Care Needs: Due to the broad range of care and coordination needed to meet the needs of CSHCN, the BFH supports direct, support and referral services across the state.  In the creation and implementation of programs, the BFH ensures that the National Consensus Standards for Systems of Care for Children and Youth with Special Health Care Needs (CSHCN) are incorporated. The BFH addresses domains directly within the purview of Title V funding, such as Identification, Screening, and Referral; Access to Care; Medical Home; Community-Based Services and Supports; and Transition to Adulthood. Other domains are addressed through partnership with state and federal agencies, stakeholder agencies and other partners. Services provided to this population are targeted towards individuals and families most in need; therefore, the BFH serves those blind and disabled individuals under age 16 who receive Supplemental Security benefits from Title XVI to the extent that those services are not provided by Title XIX (Medical Assistance).  Staff from the BFH collaborate with staff from the Department of Human Services Office of Medical Assistance Programs (OMAP) to avoid duplication of services and ensure that appropriate referrals and information are shared.

The BFH ensures that children and families of CSHCN are active, core partners in decision making. The services and supports provided to CSHCN and their families are implemented and delivered in a culturally competent, linguistically appropriate, and accessible manner. The BFH offers support and advocacy programs such as Community to Home, Special Kids Network Helpline and Leadership and Development Training. The BFH also provides comprehensive, multi-disciplinary health related services to individuals with certain conditions. The Comprehensive Specialty Care Program provides care coordination and information and education provided by hospitals and community organizations. Through the BFH brain injury programs including Acquired Brain Injury Program, Traumatic Brain Injury (TBI) and Opioid, and BrainSTEPS, the BFH offers brain injury education, rehabilitation services and assistance with integrating back to a school environment following a brain injury. The BFH also partners with the Tuscarora Intermediate Unit to provide referral and follow-up services to infants who fail a hearing screening. BFH staff works with these partners to educate clinicians and parents on the importance of screening and early intervention for better hearing outcomes. Additionally, the BFH’s memorandum of understanding with the Department of Aging (PDA) allows the BFH to use PDA’s Pharmaceutical Assistance Contracts for the Elderly program’s claims processing and administrative functions to provide metabolic formula for CSHCNs, including Spina Bifida, Cystic fibrosis, MSUD, and PKU. The MOU allows the BFH to expand the number of accessible pharmacies and consolidate claims processing through a single administrative agency.

The County/Municipal Health Departments provide services to CSHCN including home visiting for at risk families, referrals to Early Intervention, a Medical Home Community Team for CSHCN in Philadelphia, and the Philadelphia Special Needs Consortium, which includes family members, providers, and other professionals to strengthen the system of care. For more information on each of these programs, see Table 1.

 

The state’s Title V program currently funds 59 full-time staff located in Harrisburg, PA and 53 local Title V staff who operate statewide through the County/Municipal Health Departments (Table 2). While most staff operate out of the BFH where the block grant is housed, other positions across the DOH which support the BFH or serve MCH populations are also supported by Title V. The BFH’s Director, Division Directors, Title V Block Grant Coordinator and MCH Epidemiologist serve as the lead positions that contribute to planning, evaluation and data analysis:

 

• Director of the Bureau of Family Health: Tara Trego was appointed as the director of the Bureau of Family Health in December of 2018 and serves as the state’s Title V MCH Director. Tara has worked for the BFH for over twelve years and has 16 years of public health experience. She holds a master’s degree in Health Education.
• Director of the Division of Child and Adult Health Services: Following the recent departure of former division director, Kelly Holland, this director position is currently vacant. Given the state employee hiring freeze in place due to the novel coronavirus (COVID-19), this position can only be filled if an exemption is approved. In the interim, the Bureau Director (Tara Trego) will oversee this division.
• Director of the Division of Bureau Operations: Erin McCarty has been the director of this division since April of 2017. Erin holds a Master of Public Health degree and has over 13 years of public health experience. Erin is also the Title V CSHCN Director.
• Director of the Division of Newborn Screening and Genetics: Stacey Gustin was named as the Director of this division in February of 2020. Stacey has worked in the BFH for eight years and has 13 years of public health experience. She holds a B.S.N degree in Nursing.
• Director of the Division of Community Systems Development and Outreach: Cindy Dundas has been the director of this division since November of 2016. Cindy has worked in the BFH for 18 years and has over 20 years of public health experience, in addition to ten years of experience in the mental health/intellectual disability field. She holds a bachelor’s degree in psychology and is the parent of a CSHCN.
• Maternal and Child Health Epidemiologist: Nhiem Luong was hired as the MCH epidemiologist for the BFH in October of 2018. As MCH epidemiologist, Nhiem conducts analysis on various MCH datasets and provides BFH staff with technical assistance and support related to accessing, analyzing and interpreting data and summarizing results. Nhiem holds a DrPH degree and has over twenty years of experience in medicine, public health and research.
• Title V Block Grant Coordinator: Caryn Decker was named the Title V Block Grant Coordinator in May of 2020. Caryn holds a Master of Public Health degree and has over five years of public health experience. Caryn has worked in the BFH for nearly two years and also coordinated the 2020 Title V Five-Year Needs and Capacity Assessment.

 

To gauge the tenure of current Title V staff, BFH staff were surveyed on the amount of time that they have been in their current position as well as their public health experience. More than half of the BFH’s current Title V workforce (53%) have been in their positions for less than three years. When broken out by job title, it is evident that most newer hires are program-level staff (public health program administrators and public health program assistant administrators). This suggests that there has been some turnover over the past three years. In contrast, most managers and directors (89%) have been in their position for three years or more, suggesting that there is considerable institutional knowledge of Title V at the management level. The combination of experienced management and new program staff who may bring a fresh perspective to their work is a strength of the BFH’s Title V workforce. However, concentration of Title V knowledge and experience at the management level may suggest that continued training on the mechanics and framework of the MCHSBG at the program-staff level is warranted.

 

The BFH has two staff members who identify as parents of CSHCN and draws on the experiences and expertise of the consumers and family members who serve on the BFH’s program advisory boards and committees.

 

 

 

It is through partnership, collaboration and coordination with other entities that the BFH and the state’s Title V program can meet the needs of the women, mothers, infants, children, CSHCN and adolescents in PA. The BFH has productive collaborations with other governmental agencies at the state and local level as well as with other programs within the Department of Health and successfully augments its Title V funding with state and federal dollars in order to support the MCH system of care in the state. The BFH will continue to work with other programs within the Department to identify new opportunities for collaboration and to avoid duplication of efforts. Over the next funding cycle, the BFH also sees an opportunity to further collaborate with the Department of Human Services in order to coordinate efforts related to home visiting, CSHCN and child health.  Additionally, the BFH intends to continue to expand and strengthen its consumer/family partnerships.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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In order to develop the initial list of priorities, the BFH considered all of the National Outcome Measures (NOMs) and National Performance Measures (NPMs) put forward for Title V as well as the corresponding data that had been analyzed as part of the characterization of MCH population health status. Potential priorities were then scored by the needs and capacity assessment steering committee based on the list of pre-identified values (Table 3) and the BFH’s data briefs, which summarized the state and national health data that had been analyzed and data from the focus groups and web survey related to social determinants of health in PA.

The resulting list of 21 priorities (four priorities per Title V population domain and one cross-cutting priority) was then ranked by stakeholders at a series of regional prioritization meetings, in-person events and via web survey and by BFH staff and agency partners at an agency meeting. Following the conclusion of the regional prioritization events and the agency meeting, the steering committee reviewed the priorities that were top ranked by stakeholders at each of the events. Given that stakeholders were asked to make their rankings considering the values identified at the start of the prioritization process, the data presented in the data briefs and the unique needs in their networks of care, the BFH felt the priorities stakeholders had ranked in first place for each population domain should be considered as top priorities for the 2020 Title V MCHSBG cycle. Once the BFH confirmed that there was existing capacity to address the new priorities or the ability to build capacity, the first-ranked priority for each population domain was considered one of the final priorities. Afterward, the BFH considered those priorities that were ranked in second place in each domain and completed the same exercise of considering the capacity of the BFH. Given that several of the second-place priorities had tied, considerations related to capacity played a larger role. Once priorities for each population domain were finalized, the cross-cutting priority was adopted and a seventh priority explicitly addressing health equity was added given the feedback received from stakeholders throughout the prioritization process about the importance of advancing health equity and addressing social determinants of health in PA.

 

Several priority areas that were not on the list that the BFH put forward for consideration and ranking were raised by stakeholders at the prioritization events held across the state. Many of the priorities that were proposed can be broadly characterized as addressing social determinants of health – from deconstructing institutional racism, addressing social isolation and ensuring housing is safe to improving food security and transportation options. Proposed priorities that address social determinants of health were proposed across all prioritization meetings and for all the Title V population domains. Another need that consistently emerged was improved oral health and access to oral health care in PA. This proposed priority was suggested by at least one stakeholder for all the Title V population domains.  The need for improved access to and coordination of health care services was also frequently cited by stakeholders. 

 

The proposed priorities related to specific determinants of health, such as food security, were not adopted. However, a priority that broadly addresses social determinants of health was developed. While the BFH does not have the bandwidth to address all the social, environmental and economic factors that influence health individually, the BFH does see a role for Title V in supporting efforts that advance health equity. Similarly, the need around improved access to care was noted but not adopted as a unique priority given that access to care and care coordination are components of many of the priorities included in the final list. Finally, the need around improving oral health and access to oral health services was not adopted as a Title V priority given that there is existing capacity, funding and programming addressing oral health within the Bureau of Health Promotion and Risk Reduction (BHPRR) in the Department. However, given the breadth of the final Title V priorities, the BFH is committed to considering the extent to which the frequently cited needs, including improving oral health, may be addressed through new collaborations and the development and implementation of strategies over the next five-year cycle.

 

The BFH developed and implemented a prioritization process that was transparent and deliberately committed to incorporating the input of stakeholders and the needs of their communities. As such, it was important to the BFH that the input and rankings received from stakeholders across PA directly informed the selection of the final priorities. The final set of seven priorities are responsive to the high priority needs identified over the course of the assessment. This resulted in the PA Title V Program identifying seven new priorities for the new five-year reporting cycle.

 

Each of the new priorities is connected to an NPM or State Performance Measure (SPM) with the goal that strategies and programmatic activities encompassed within each priority will drive improvement in national performance and outcome measures. The priority aiming to reduce or improve maternal morbidity and mortality is connected to NPM 1 on ensuring women receive a preventive medical visit. While access to health care is only one factor contributing to a woman’s health, women with the highest rates of severe maternal morbidity and mortality are also among the women who are less likely to receive preventive care. Strategies implemented to address risk factors associated with maternal morbidity and mortality will encompass an emphasis on regular receipt of preventive care to address co-morbidities and other health issues before, during and after pregnancy. The priority aiming to reduce infant mortality is directly connected to NPM 4.1 and 4.2 on improving breastfeeding initiation and duration as well as NPM 5 on safe sleep practices. Given the known association between breastfeeding, infant health outcomes across the life-course and maternal health and connection with their infant in the postpartum, strategies associated with improving breastfeeding awareness and duration will be implemented to address the priority and, in turn, the NPM. Sleep position and environment are also modifiable risk factors. When safe sleep practices are promoted and implemented, they can reduce infant mortality that may result from sleep-related unexpected infant death.   The priority aiming to improve mental health, behavioral health and developmental outcomes for children and youth with and without special health care needs connects to NPM 10 on adolescent preventive medical visits. Strategies associated with improving mental, behavioral and developmental outcomes will include an emphasis on the importance of seeking care when navigating the physical, cognitive and social transitions that are characteristic of adolescence and improved access to care in alternative settings such as in schools and in community-based organizations, particularly those dedicated to serving historically marginalized people. The priority aiming to reduce rates of child mortality and injury is connected to NPM 7.1 on reducing rates of hospitalization for non-fatal injury. Given that the priority mirrors the NPM, associated strategies which aim to reduce child injury in PA will address the NPM as well. The priority aiming to connect CSHCN to a well-functioning system of care is connected to NPM 11 on Medical Home. Given the priority’s focus on developing a system that integrates each of the components of a well-functioning system, including Medical Home, this priority should directly drive improvement in NPM 11.The priority aiming to strengthen Title V staff’s capacity for data-driven and evidence-based decision-making and program development is connected to an SPM focused on increasing the number of programs or policies created or modified. This SPM aims to measure the extent to which data and evidence are utilized to direct and inform Title V work. Given Title V’s framework of implementing strategies across MCH domains that are effective and have a strong evidence base – improvement made under this priority will serve to advance the identified SPM as well as the NPMs associated with the other priorities.

In addition to the relationship between the priorities and the NPMs described above, several of the priorities and their corresponding strategies link directly to an NOM. Given that there are many factors not represented in the NPMs which influence the NOMs, in these scenarios the BFH has developed SPMs. The BFH developed an SPM that mirrors NOM 12 (Percent of newborns receiving an on-time report out and follow-up by an appropriate physician), which is still under development nationally. While there is no national data source to date for the NOM, PA has programmatic data for this indicator which can be used to track progress and improvement at the state level. Similarly, the priority aiming to advance health equity and address social determinants of health is connected to an SPM which aims to reduce the gap in mortality rates between Black/African American and White infants, children and women. This SPM will serve the dual purpose of driving change in the mortality rates described in NOM 3 (maternal mortality), NOM 9.1 (infant mortality) and NOM 15 (child mortality) while also addressing the persistent state disparity in mortality rates by race. The BFH will continue to consider the addition of other SPMs as the action plan is further developed.