The NJ Title V program, has prepared the following Five-Year Needs Assessment Summary according to HRSA guidelines.  This year the COVID19 public health emergency has added a heightened examination of the needs for the MCH population. COVID-19 is an unprecedented public health threat that continues to rapidly evolve.  In the effort to transition many in-person programs and services to remote and virtual operations in order to limit exposures to COVID19, additional needs have been identified.  Food insecurity, domestic violence issues, unemployment issues, confusion and fear concerning labor and delivery issues, as well as many other health concerns have all been and continue to be identified.

The completion of a comprehensive needs assessment for the MCH population groups is a continual process that FHS performs in collaboration with families, providers, many other organizations and partners. The ultimate goals of the needs assessment process are to strengthen partnerships and collaboration efforts within FHS, the New Jersey Department of Health (NJDOH), the MCH Bureau, and other agencies and organizations involved with MCH and to improve outcomes for the MCH populations.

Figure 1 – NJ MCH Block Grant Needs Assessment, Planning, Implementation and Monitoring Process

The starting point (Stage 1) of the needs assessment process, is to engage stakeholders.  Coalitions involving stakeholders help FHS in the needs assessment process by identifying desired outcomes, assessing strengths, examining capacity, selecting priorities, seeking resources, setting performance objectives, developing action plans, allocating resources, and monitoring progress for impact on outcomes.

Maternal and Child Health Services (MCHS) has engaged stakeholders and strengthened partnerships to maintain a regional system of MCH services and programs in several priority areas. A system of regional MCH services and programs has been developed and provided through the Maternal Child Health Consortia (MCHC), an established regionalized network of maternal and child health providers with emphasis on prevention and community-based activities.

An example of partnerships to address a specific MCH priority involve NJs efforts to reduce infant mortality.  The Healthy Women, Healthy Families (HWHF) Initiative is focused on working to help community-based programs improve services and provide quality access to perinatal care to reduce disparities in birth outcomes. HWHF’s partners include the Departments of Labor and Workforce Development, Education, Transportation, Children and Families, Human Services, the Office of the Attorney General, community advisory boards and many others to strategically collaborate to reduce black infant mortality.

Nurture NJ is the First Lady of NJ’s statewide awareness campaign that is committed to reducing infant and maternal mortality and morbidity and ensuring equitable maternal and infant care among women and children of all races and ethnicities. Nurture NJ is focused on improving partnerships and collaboration between departments, agencies, and stakeholders to achieve its goal of making New Jersey the safest place in the country to give birth and raise a baby. In collaboration with other state agencies, including DOH FHS, The Nurture NJ strategic planning team is working to develop a comprehensive, actionable plan focused on equity and improved outcomes overall.

Another inter-Departmental initiative augmenting our efforts to reduce infant mortality, pre-term births and maternal morbidity and mortality is the Maternal and Infant Early Child Home Visiting (MIECHV) Program which has expanded Home Visiting (HV) across all 21 NJ counties with 5,805 families participating in HV during SFY 2018. The goal of the NJ MIECHV Program is to expand NJ’s existing system of home visiting services which provides evidence-based family support services to: improve family functioning; prevent child abuse and neglect; and promote child health, safety, development and school readiness.

Stakeholder engagement, strong partnerships and program funding have been developed in the following State Priority areas (see Table 1f - MCH Organizational Relationships with Partnerships, Collaboration, and Cross-Program Coordination in Attachment 1 for listed partnerships covering all 6 Health Domains and all 3 MCH Population groups by the following priority areas):

SPN1- Increasing Equity in Healthy Births,

SPN2- Reducing Black Maternal and Infant Mortality,

SPN3- Improving Nutrition & Physical Activity,

SPN4- Promoting Youth Development Programs,

SPN5- Improving Access to Quality Care for CYSHCN,

SPN6- Reducing Teen Pregnancy,

SPN7- Improving & Integrating Information Systems, and

SPN8- Smoking Prevention.

Special Child Health and Early Intervention Services (SCHEIS) works closely with its partners in early identification, pediatric specialty care, and case management, towards engaging stakeholders and strengthening partnerships to build and maintain a statewide system of access to care.  In addition, for over 30 years, DOH has formed a strong partnership with the Statewide Parent Advocacy Network (SPAN), home to NJ Family Voices (FV), that has been a model for promoting family-professional partnerships and family involvement in policymaking at all levels.  SCHEIS and the NJ Chapter of the American Academy of Pediatrics (NJ AAP), continue to collaborate on medical home implementation and transitioning CYSHCN. Through the Newborn Screening Advisory Review Committee (NSARC), first convened in 2005, SCHEIS partners with many stakeholders including parents, primary care physicians, specialty care physicians, nurses, allied health professionals, attorneys, scientists, as well as health insurance companies and hospital representatives in ongoing reviews of NJ’s newborn screening policies and activities.

The second stage in the process is to identify the community/system needs and desired outcomes by specific MCH population group and to identify legislative, political, community-driven, financial, or other internal and external mandates that are required.

Multiple processes contribute to the overall MCH Title V Block Grants needs assessment process including the NJ DOH planning and budget process, regional and county needs assessments, grant-driven needs assessments, surveys and public comment on the MCH Block Grant, and strategic plans completed by other state departments and organizations. Needs Assessments that focus on MCH topics such as maternal health and birth outcomes include: the Healthy New Jersey 2030 (HNJ2030) process, State Health Improvement Plan (SHIP) process, the NJ State Health Assessment process, the NJDOH budget process, Departmental strategic planning, the Public Health accreditation process, the NJ Preventive Health and Health Services Block Grant, Community Health Needs Assessments (CHNAs) and Community Health Improvement Plans (CHIPs), grant-driven needs assessments (MIECHV, MMRC, SMHIP, PREP), the Breastfeeding Strategic plan, the First Lady’s Nurture NJ initiative, as well as public comment on the MCH Block Grant Application, and the collaborative process with other MCH partners.  In the past year, the state legislature, Governor’s Office and the First Lady’s Office have focused significant attention on maternal child health issues. 

Community and systems needs were informed by prior needs assessments from other State Departments and organizations which serve children and families including: DHS, DCF, DOE (Head Start), the Maternal Infant and Early Childhood Home Visiting Program (MIECHV), Advocates for Children of New Jersey (Pritzker Children’s Initiative), and the Preschool Development Grant Birth – 3 (PDG).

Recent legislative priorities including several statutory mandates have identified the desired need to improve birth and maternal outcomes. The numerous laws adopted by the New Jersey Legislature and enacted by the Office of the Governor in 2018 and 2019 are listed later in this Needs Assessment Summary. Nearly a dozen additional maternal health focused bills remain under consideration, reflecting a legislative focus on maternal mortality and morbidity.

The third stage in the process is examining strengths and capacity. This stage involves examining the State’s capacity to engage in various activities, including conducting the 5-year Needs Assessment and collecting annual performance data, and to provide services by each pyramid level. The pyramid, Figure 2 Core Public Health Services Delivered by MCH Agencies, is as below.

The fourth stage in the process is selecting priorities. FHS examines the needs identified and matches those needs to desired outcomes, required mandates, and level of existing capacity. The process of selecting priorities is also guided by the departmental strategic planning process, grant funding opportunities, Governor priorities, legislative mandates, budget process, survey results and public input into the MCH Title V Block Grant. Based on the results of this process, NJDOH then selects its most important, or highest priority, MCH strengths and needs, to receive targeted efforts for improvement and/or continuation of progress.

The selection of New Jersey’s priority needs is a product of FHS’s continuous needs assessment. Influenced by the departmental budget process, the MCH Block Grant’s needs assessment process and the collaborative process with other MCH partners has enabled FHS to select the eight priorities as identified in the third stage. 

The selected SPN reflect ongoing and new statewide public health initiatives. SPN #1 has been a recent focus of several new initiatives including the Healthy Women, Healthy Families Initiative, the MIEC Home Visiting Program, Nurture NJ, the Maternal Mortality Review Committee, and the State Maternal Health Innovation Program.

Based on NJ’s eight selected SPNs as identified in the Five-Year Needs Assessment, NJ has selected the nine of 15 possible National Performance Measures (NPMs) for programmatic emphasis over the next five-year reporting period.

The fifth stage is the identification of State selected national Performance Measures and Performance Measure targets and is summarized in Table 1.

Setting performance objectives consisted of two phases. In the first phase, action strategies to address their identified priority needs were developed. National Performance Measures (NPMs), Evidence-based Strategy Measures (ESMs) for addressing each of the selected NPMs and State Performance Measures (SPMs) were selected based on the priority needs and program strategies. SPMs were based on the state’s identified MCH priorities that are not fully addressed by the selected NPMs and their related ESMs.

In the second phase of the fifth stage, five-year targets (i.e., performance objectives) were set for the selected NPMs, the ESMs and the SPMs. The anticipated results of this stage are the identification of NOMs, NPMs, ESMs and SPMs that directly relate to the state priorities and establish a level of accountability for achieving measurable progress.

The sixth stage is to develop an action plan, which includes identifying activities to address priority strengths and needs at the four pyramid levels:  direct health care services, enabling services, population-based services, and infrastructure building services. This is an on-going process involving several workgroups and Action Plans (Strategic Plans, Needs Assessments) and is described in Section 3 of the full NJ MCH Title V Block Grant Needs Assessment and annually updated in the MCH Block Grant Annual Application/Report. Sometimes Action Plans start as workplans in grant applications or are developed by initiative in other organizations (NJ DOH Strategic Plan, Nurture NJ, MIECHV Needs Assessments, MMRC Grant).

Divisional and departmental strategic planning also contributes to the needs assessment process and the development of action plans. Many of the Healthy People 2030 objectives and the MCH Block Grant national and state performance measures are included in both the departmental and divisional plans. Strategic plans that are specific to targeted areas have also been developed and assist the Division in setting priorities.  Targeted plans include those developed for HWHF, MIECHV and The State Maternal Health Innovation Grant.

The development of Healthy New Jersey 2030, the New Jersey state equivalent of Healthy People 2030, is a major departmental planning and needs assessment process that incorporates the MCH population. Representation included the Departments of Health, Environmental Protection, Human Services, Education, Children and Families, and Law and Public Safety. One of the overarching goals for public health improvement is the elimination of health disparities. Public input was received through comments on a disseminated draft document and public hearings held in three sections of the State.

At the regional level the MCH Consortia conduct planning and needs assessment to promote a coordinated prevention-oriented approach to MCH services.  Their regional plans, due every 3 years, must address pediatric morbidity and mortality, risk-appropriate prenatal care, low birth weight, and teen births. The social, cultural, economic and demographic factors influencing the perinatal and pediatric needs of their communities must also be described. 

The seventh stage is focused on the funding of planned activities to address state priorities. Inputs include the five-year State Action Plan, current budgets, political priorities, and partnerships. The anticipated outcome is the development of a program budget and plan that directs available resources towards the activities identified in Stage Six as the most important for addressing the state's priorities. The funding of planned activities depends on the selected priorities and existing resources identified and may involve the identification of additional resources, funds, or authority from the State legislature or funding agencies in order to address priority areas.

The seventh stage includes allocating resources and the development of a budget that directs available resources towards activities that have been identified as most important for addressing the State’s priorities. The annual State budget process includes several steps that are very similar to the stages and functions to the MCH Block Grant needs assessment.  In preparation for the annual State budget hearings where the Department’s budget priorities are presented to the Governor and legislature, FHS reviews and summarizes programmatic activities, service capacity, budgets, key performance indicators and emerging issues. Activities, budgets and priorities are justified in terms of standard health indicators, key performance indicators and program evaluation data.  This annual several month process takes place at the program level, the division level, then the department level, and finally is presented to the Governor and in turn the legislature. 

The grant awarding, renewal and monitoring processes continually assess local needs that are specific to geographic areas. FHS funds numerous grantees involved with MCH programs on a regional or local level.  The selection process includes a review of local identified need. Renewal and monitoring of grantees is based on measurable outcomes that are designed to address identified needs. Many of the agencies that are awarded health services grants by FHS use the MCH Block Grant performance measures or Healthy People 2030 objectives as their outcome measures. Examples of local grants include the Healthy Women, Healthy Families Initiative and the Personal Responsibility Education Program (PREP) grants.

The eighth stage (8. Monitoring Progress for Impact on Outcomes) examines the results of NJDOH’s efforts to see if there has been improvement in State Performance Measures, National Performance Measures, Outcome Measures, Evidence-Based Strategies, performance objectives, and other quantitative and qualitative information.

The quantitative surveillance and analysis of MCH data by FHS programs and the MCH Epidemiology Program provides continuous input into the assessing needs and the monitoring progress for impact on outcomes stage of the needs assessment.  The MCH Epidemiology Program produces standardized MCH health indicator reports for FHS, for the MCH Consortia, and for other public health related organizations by special request. The MCH Epidemiology Program works with the Vital Statistics Program, the Center for Health Statistics, other departments in NJDOH, and the MCH Consortia Data/TQI Workgroup to support data needs for regional planning. The MCH Epidemiology Program also conducts applied research projects which currently focus on issues related to breastfeeding, smoking and pregnancy, pregnancy intention, maternal mental health, and maternal morbidity.

The ninth stage (9. Report Back to Stakeholders) assures accountability to the stakeholders and partners who have worked with the MCH staff throughout the year and the Needs Assessment process. Public comment on regulations and publications is an ongoing process of needs assessment and input from both public and private constituents. Rules implementing laws sunset every five years, and therefore, programs must readopt rules every five years. Proposed rules are published in the New Jersey Registry (NJR) with a 60-day open comment period. Public comment on the development of the MCH Block Grant application is also encouraged through a public input process.

The NJ MCH Title V Block Grant Needs Assessment process is also consistent with the MCH Block Grant Logic Model in Figure 4 below which depicts how NJ’s priority needs “drive” the development of a five-year program plan that is responsive to the needs identified and is performance driven.

Figure 4. MCH Block Grant Logic Model

The current methods and procedures for the comprehensive needs assessment have both strengths and weaknesses.  The evolution of the MCH Block Grant to include standardized performance measures, outcome measures, and Evidence-Based Strategies has added structure and accountability to the needs assessment process.  Each year the state is able to build and add detail to prior needs assessment efforts.  Utilizing the departmental budget process is also an efficient use of time and effort. One strength that may be unique to New Jersey is the role the MCH Consortia play in contributing valuable information to the Title V comprehensive needs assessment.

A challenge of the needs assessment process is recording the breadth and diversity of activities that could be included under a comprehensive needs assessment.  New Jersey’s Title V activities intersect with numerous other federal and state programs, making it difficult to identify what most appropriately falls under the Title V needs assessment and what does not. Many activities that come to the attention of FHS staff are relevant to the MCH populations but may not be specifically administered or “formally” linked with Title V programs. There are numerous activities that other public or private organizations are involved with that affect the public health of MCH populations that are carried out without FHS involvement. Limitations in the scope of influence and accountability of FHS, limitations of staff, and limitations of funding must be recognized. However, we believe that the major activities and priorities effecting MCH services are being addressed.

The goals and vision that guide the Needs Assessment originate from the mission statement of the Division of Family Health Services (FHS).  Leadership for directing and completing a comprehensive needs assessment is provided by the Assistant Commissioner of FHS, Service Directors in FHS, and the Program Managers in FHS.  The overall needs assessment methodology is similar for each of the three population groups - preventive and primary care services for pregnant women, mothers and infants; preventive and primary care services for children; and services for children with special health care needs.  Though many of the functions occur simultaneously the sequential process is described below and in Figure 1.  This is a continuous and on-going process throughout the year.

Table 1a - Title V MCH Block Grant Five-Year Needs Assessment Framework Logic Model summarizes the selected nine national Performance Measures (NPMs) and aligns the impact of Evidence-Based Informed Strategy Measures (ESMs) on NPMs and National Outcome Measures (NOMs). The purpose of the ESMs is to identify state Title V program efforts which can contribute to improved performance relative to the selected NPMs. The Logic Model is organized with one NPM per row. The Logic Model is the key representation which summarizes the Five-Year Needs Assessment process and includes the three-tiered performance measurement system with Evidence-Based or Informed Strategy Measures (ESM), National Performance Measures (NPM), and National Outcome Measures (NOMs). The Logic Model represents a more integrated system created by the three-tiered performance measure framework which ties the ESMs to the NPMs which in turn influence the NOMs.

This year the COVID-19 public health emergency has added a heightened examination of the needs for the MCH population.  Necessary restrictions to promote social distancing have dramatically impacted NJ DOH staffing and staffing at grantee agencies.  The workforces of NJ DOH and grantee agencies have been forced a shift to work remotely from home in order to comply with state social distancing requirements. Title V staff are maintaining weekly communications with grantees and partners to monitor program administration and service provisions in this new virtual environment. “Town Halls” where Title V staff hold virtual meetings for grantees and other partners are scheduled on a monthly basis.  Ongoing needs are being assessed to assess what changes can be made to meet the needs of the MCH populations as well as to help ensure resiliency for the future.  Ongoing communications are occurring with Medicaid regarding telehealth reimbursements. 

NJ DOH is adapting the way it provides the four types of services (Direct Health Care Services, Enabling Services, Population-Based Services, and Infrastructure Building Services) illustrated in the Figure 2 – Core Public Health Services Delivered by MCH Agencies (Pyramid Diagram). The DOH does not use Title V MCH funding to provide Direct Health Care Services. The provision of Enabling Services such as outreach, health education, family support and case management have all shifted to virtual services which are not conducted face-to-face unless absolutely necessary. Increased use of telecommunication tools have facilitated the shift with new development of protocols and practices to meet the needs of the programs. Population-Based Services are continuing as prior to the COVID-10 pandemic with changings in communications to the public to assure follow-up and ongoing outreach. The DOH has added multiple new communication channels to keep the public and MCH professionals informed of COVID-19 issues and changes to MCH Services including the NJ DOH COVID19 website, the NJ Parent Link website, and virtual town hall forums held with program constituents. Despite the disruption created by the COVID-19 crisis, the Infrastructure Building Services of DOH are continuing and have adapted to being conducted remotely.

Many of the Title V grantees are small community-based service organizations whose staffing and financial stability will be adverse impacted by the ongoing COVID-19 pandemic.  The uncertainty of federal, state and local private funding sources will challenge the sustainability of many grantees. Telecommunication tools are being adapted to provide Title V services to families such as family support services, health education and care coordination by Community Health Workers, Home Visitors and SCHEIS case managers.

Families have been dramatically impacted by the COVID-19 crises and challenged by the restrictions of social distancing reducing access to MCH funded as well as other needed services. Social distancing influences every aspect of family life, leading to significant changes in how MCH Title V programs can work with families. COVID19 has exacerbated many of the challenges and SDOH issues faced by our most vulnerable populations, including pregnant women, new moms, children, including those with special health care needs, and families. 

During this evolving public health emergency, NJ Title V programs are poised to provide infrastructural and leadership support to improve the health of mothers, children, and families.  One of the strengths of the Title V program is its role in conducting ongoing assessment of maternal and child health (MCH) population needs and in implementing science-based approaches to address current and emerging issues. 

Overall the majority of health measures concerning Title V as measured by national performance measures, state performance measures, outcome measures and the new health status indicators are stable or improving.  Table 1c - Summary of MCH Population Needs (See Supporting Document #1) displays the health status for each of the six population health domains according to the nine selected NPMs.  The table provides a summary of population-specific strengths/needs and identifies major health issues for each of the 6 population health domains which came from identified successes, challenges, gaps and areas of disparity identified during the needs assessment process. Statewide trend charts for key national performance measures, outcome measures, and health system capacity indicators mentioned in this section are presented in the Appendix (Charts 1-11).

The Organizational Structure of the NJ Department of Health and the Division of Family Health Services (FHS), the NJ Title V agency, remains unchanged. Lisa Asare MPH was appointed the Assistant Commissioner for FHS in 2016. Dr. Marilyn Gorney-Daley was appointed the Director of MCH Services for FHS in April 2017. Dr. Sandra Howell was appointed the Director of Special Child and Early Intervention Services in June 2018.  The Agency Capacity of FHS remains unchanged with the continuation of all major federal grants. Efforts continues toward Workforce Development and Capacity.

All Maternal and Child Health (MCH) programs including programs for Children and Youth with Special Health Care Needs (CYSHCN) are organizationally located within the Division of Family Health Services (FHS).  All Title V services are under the direction of the Assistant Commissioner for the Division of FHS.

The Division of FHS is the Title V agency for the state of NJ and is within the NJ Department of Health (NJ DOH). The NJ DOH is one of 11 departments under the Governor.

The Division of FHS is "responsible for the administration (or supervision of the administration) of programs carried out with allotments under Title V".

This section describes Family Health Service’s capacity to promote and protect the health of all mothers and children, including children and youth with special health care needs (CYSHCN). The Division of Family Health Services (FHS) supports the infrastructure to provide Title V services to each of the six population health domains. FHS supports the state’s capacity to provide services to CYSHCN and address its ability to provide rehabilitation services for blind and disabled individuals under the age of 16 receiving benefits under Title XVI (the Supplemental Security Income Program) to the extent medical assistance for such services is not provided under Title XIX (Medicaid). The Maternal and Child Health Services (MCHS) and Special Child Health and Early Intervention Services (SCHEIS) Units ensure a statewide system of services that reflect the principles of comprehensive, community-based, coordinated, family-centered care through collaboration with other agencies and private organizations and the coordination of health services with other services at the community level.

The statutory basis for maternal and child health services in NJ originates from the statute passed in 1936 (L.1936, c.62, #1, p.157) authorizing the Department of Health to receive Title V funds for its existing maternal and child services.  When the State constitution and statutes were revised in 1947, maternal and child health services were incorporated under the basic functions of the Department under Title 26:1A-37, which states that the Department shall "Administer and supervise a program of maternal and child health services, encourage and aid in coordinating local programs concerning maternal and infant hygiene, and aid in coordination of local programs concerning prenatal, and postnatal care, and may when requested by a local board of education, supervise the work of school nurses."

Other statutes exist to provide regulatory authority for Title V related services such as: services for children with Sickle Cell Anemia (N.J.S.A. 9:14B); the Newborn Screening Program services (N.J.S.A. 26:2-110, 26:2-111 and 26:2-111.1); genetic testing, counseling and treatment services (N.J.S.A. 26:5B-1 et. seq.,); services for children with hemophilia (N.J.S.A. 26:2-90); the birth defects registry (N.J.S.A. 26:8-40.2); the Catastrophic Illness in Children Relief Fund (P.L. 1987, C370); and the Sudden Infant Death Syndrome (SIDS) Resource Center (Title 26:5d1-4).  Recent updates to Title V related statutes are mentioned in their relevant sections. 

Table 1d – Title V Program Capacity and Collaboration to Ensure a Statewide System of Services

(See Supporting Document #1) summarizes according to the six MCH population health domains the collaborations with other state agencies and private organizations, the state support for communities, the coordination with community-based systems, and the coordination of health services with other services at the community level.
 

III.C.2.b.ii.b.  Preventive and Primary Care for Pregnant Women, Mothers and Infants
 

The mission of Maternal and Child Health Services (MCHS) within FHS is to improve the health status of NJ families, infants, children and adolescents in a culturally competent manner, with an emphasis on low-income and special populations. Prenatal care, reproductive health services, perinatal risk reduction services for women and their partners, postpartum depression, mortality review, child care, early childhood systems development, childhood lead exposure prevention, immunization, oral health and hygiene, student health and wellness, nutrition and physical fitness and teen pregnancy prevention are all part of the MCHS effort. The population Domains addressed by MCHS include 1, 2, 3, 4, and 6.

Reproductive and Perinatal Health Services (RPHS), within MCHS, coordinates a regionalized system of care of mothers and children in collaboration with the Maternal and Child Health Consortia (MCHC). The MCHC were developed to promote the delivery of the highest quality care to all pregnant women and newborns, to maximize utilization of highly trained perinatal personnel and intensive care facilities, and to promote a coordinated and cooperative prevention-oriented approach to perinatal services. Continuous quality improvement activities are coordinated on the regional level by the MCHC.

Under RPHS, the goal of the Healthy Women Healthy Families (HWHF) Initiative is to improve maternal and infant health outcomes for women of childbearing age and their families and reduce disparities, especially with black families, though a collaborative and coordinated community-driven approach. Participants in the HWHF program receive individual support from a Community Health Worker (CHW). CHWs link families to community resources through a centralized referral system of Central Intake Hubs.

NJ successfully applied in 2010 for the Maternal, Infant and Early Childhood Home Visiting Program (MIEC HV) Formula and Competitive Grants to the Health Resources and Services Administration.  The goal of the NJ MIEC HV Program is to expand NJ’s existing system of home visiting services which provides evidence-based family support services to: improve family functioning; prevent child abuse and neglect; and promote child health, safety, development and school readiness.  Full implementation of the grant project is being carried out in collaboration with the Department of Children and Families (DCF).  Currently evidence-based home visiting services are provided by 65 Local Implementing Agencies (LIAs) providing three national models (Healthy Families America, Parents As Teachers and Nurse Family Partnership) in all 21 NJ counties serving 5,805 families in SFY 2019. 

III.C.2.b.ii.b.  Preventive and Primary Care for Children and Adolescents

The Child and Adolescent Health Program (CAHP), within MCHS, focuses on primary prevention strategies involving the three MCH domains of Child Health, Adolescent/Young Adult Health, and the Life Course.

Adolescent Health (AH) supports three main focus areas: Teen Pregnancy Prevention (PREP, SRAE), the WSCC School Health NJ project and Pediatric (inclusive of adolescents) Mental Health (PMH).  Additionally, areas of adolescent mental health, other than access, address positive youth development and/or teen suicide prevention. CAHP grantees (PREP, SRAE and WSCC School Health NJ) have been trained in developing safe, caring, and inclusive environments for teens by the Transgender Training Institute and the Society for the Prevention of Teen Suicide (SPTS),  Evidenced-based models (Teen PEP and TOP®), grounded in social and emotional learning (SEL), positive youth development (PYD), and motivational interviewing, are implemented among middle and high school students.  Eleven CAHP grantees are required to maintain a youth advisory board (YAB).  Through these YABs, youth work with trained adult advisors at their local level.  Each YAB nominates two members to be represented on a Statewide YAB who meet with State staff annually to provide program input.  For their SFY2020 focus, youth chose teen suicide awareness and prevention.

III.C.2.b.ii.b.  Preventive and Primary Care for Children with Special Health Care Needs
 

NJ maintains a comprehensive system to promote and support access to preventive and primary care for CYSHCN through early identification, linkage to care, and family support. Title V partially supports this safety net that is comprised of pediatric specialty and sub-specialty, case management, and family support agencies that provide in-state regionalized and/or county-based services. It is designed to provide family-centered, culturally competent, community-based services for CYSHCN age birth to 21 years of age, and to enhance access to medical home, facilitate transition to adult systems, and health insurance coverage. The Specialized Pediatric Services Programs (SPSP) agencies are a significant resource of pediatric specialty and subspecialty care in NJ, and are used widely by CYSHCN including Medicaid recipients. Although clients are screened for their ability to pay for clinical services, the support provided by Title V enables all CYSHCN to be served regardless of their ability to pay. There is no charge for SCHS CM and family support.

Administratively housed in the Family Centered Care Services (FCCS) Unit these services include 21 county-based Special Child Health Services Case Management Units (SCHS CMUs), one Family Support project, multiple Specialized Pediatric Services Programs (SPSP) which include 8 Child Evaluation Centers (CECs) of which 4 house Fetal Alcohol Syndrome/Fetal Alcohol Spectrum Disorder Centers, and 3 provide newborn hearing screening follow-up, 3 Pediatric Tertiary Centers, and 5 Cleft Lip/Palate Craniofacial Anomalies Centers and a small State operated Fee-for-Service program.  Likewise, State and federal collaborations among the FCCS programs and non-Title V funded programs such as the Ryan White Part D Family Centered HIV Care Network (RWPD), Early Intervention System (EIS), Federally Qualified Health Centers (FQHC), medical home initiatives, Supplemental Security Income (SSI), Catastrophic Illness in Children Relief Fund (CICRF) and other community-based initiatives extend the safety net through which Title V links CYSHCN with preventive and primary care.

State Title V staffs, SCHS CMUs and SPSP providers, and SPAN Family Resource Specialists receive training from State agencies such as the NJ Department of Human Services, and the Department of Children and Families to become Informal Application Assistors for Medicaid/NJ FamilyCare programs as well as to learn about Managed Long Term Services and Supports, how to obtain care through the Marketplace, and behavioral services through PerformCare. These trainings build capacity among Title V agency providers to enhance access to primary and preventive care for CYSCHN. For example, an SCHS CM reported being able to assist a parent to problem solve a denial of home health aide services for a 12-year-old with autism and significant developmental delays by advocating on Mom’s behalf with PerformCare, her child’s school district, and her Family Support Organization. Repeated phone calls, home visits, and written appeals by the SCHS CM supported Mom’s efforts to clarify the missing information and resolve her child’s needs.

NJDOH has identified through the State Health Assessment, the State Health Improvement Plan and the Departments’ Five-Year Strategic Plan, the need to improve the public health workforce in the areas of access to care, quality improvement, systems integration and population health management. MCH workforce development and capacity is also a priority for the Division of Family Health Services (FHS). As such, the FHS developed and has initiated a MCH Workforce Development and Capacity Plan with the overall goal to prepare present and future maternal and child health workers with the skills and knowledge to succeed in the transformed public health system. Without an adequately trained MCH staff, vital Title V services and functions would not be provided to meet the needs of the current and future MCH population. Recognizing the value of an experienced and trained staff, the FHS has taken action to improve the capacity of the MCH workforce despite a long-standing hiring freeze.

The FHS implemented the development of succession planning to assure essential functions were considered in long-term planning. During this past fiscal year, cross-training of staff was implemented to assure the ability to maintain key roles in the event of short-term staffing shortages. A Division-wide survey was conducted to identify gaps and needs related to skills development and training. Staff identified several areas such as the need for further training and the development of metrics that are specific to the long-term outcome measurement of maternal and child health in order to maintain the momentum of quality improvement already begun by the NJDOH.  Additional training is needed for staff to become skilled in collecting data appropriate for accountability documentation and to develop accountability metrics. FHS also recognized the need for incorporating the perspectives of families and family representatives into the MCH workforce under the broader umbrella of systems integration. Continued family involvement in health transformation is essential for effective program and policy development related to newly aligned systems.

Given the diversity of our state, cultural competency trainings continue to be provided to staff as an essential component of their continuing education activities. Other available opportunities have been pursued through trainings offered at national conferences including AMCHP, the MCH Epidemiology Conference, and the MCH Public Health Leadership Institute. Departmental trainings have been offered on Ethics, grant writing, and grants management. Opportunities to supplement staffing through student internships, special temporary assignments, fellowship programs and state assignees have also been successful.

The following section describes the strengths and needs of the state MCH and CSHCN workforce:

III.C.2.b.ii.c Preventive and Primary Care for Pregnant Women, Mothers and Infants

Maternal and Child Health Services (MCHS) is comprised of one program manager, nine professionals and three support staff.  All staff members are housed in the central office.  Dr. Marilyn Gorney-Daley was appointed the Director of MCH Services for FHS in April 2017.  

Reproductive and Perinatal Health Services (RPHS) is staffed by five professionals. The Program Manager, Coordinator, and three other professional positions are currently vacant.  RPHS responsibilities include: the HWHF Initiative; Black Infant Mortality reducing activities including breastfeeding, fatherhood support, Centering programs and a doula pilot program; regional MCH Consortia; Certificate of Need rules and MCH Consortia regulations; Maternal morbidity and mortality reviews; Fetal Infant Mortality Reviews; Title V Liaison with the Healthy Start projects; perinatal addictions and fetal alcohol syndrome prevention projects; postpartum mood disorders initiative; and the Sudden Infant Death Syndrome prevention program.

III.C.2.b.ii.c Preventive and Primary Care for Children and Adolescents

The Child and Adolescent Health Program (CAHP), within MCHS, focuses on primary prevention strategies and is comprised of 3 full-time professional staff, one support staff and one program manager.  There are two vacant full-time positions, one each being covered by the Health Projects Coordinator and the CAHP Manager. The CAHP receives only federal funding through the MCH Block Grant, HRSA, and DHHS, FYSB, ACF.  The CAHP Manager has oversight responsibilities for child and adolescent health programs including PREP, SRAE and, the Pediatric Mental Health Care Access Program and covers the vacant grant management position for the CDC WSCC School Health NJ grant in 26 schools; and, the Mercer County Traumatic Loss Coalition grant on youth suicide prevention.  CAHP staff have varied professional backgrounds in nutrition, physical education, sexuality education and social work.  In January 2019, the Childhood Lead Exposure and Prevention Program (CLEPP) was transferred from CAHP to the Office of Local Public Health. Lead exposure and its management is still a NJ DOH priority and FHS continues to collaborate on this issue.

The Children's Oral Health Program (COHP) is comprised of 1 professional staff, Yvonne Mikalopas, a Registered Dental Hygienist, who reports to the New Jersey State Dental Director, Dr. Darwin K Hayes, in the Division of Community Health Services, Oral Health Service Unit.

The Maternal and Child Health Epidemiology Program (MCH Epi) provides MCH surveillance and evaluation support to MCHS.  The mission of the  MCH Epi Program is to promote the health of pregnant women, infants and children through the analysis of trends in maternal and child health data and to facilitate efforts aimed at developing strategies to improve maternal and child health outcomes through the provision of data and completion of applied research projects.  The MCH Epi Program promotes the central collection, integration and analysis of MCH data.  The Pregnancy Risk Assessment Monitoring System (PRAMS) survey is coordinated by the MCH Epi Program. MCH Epi is staffed with one professional and one support staff. Two research professional positions are currently vacant.

III.C.2.b.ii.c  Special Child Health and Early Intervention Systems (SCHEIS)
 

NJ maintains a comprehensive system to promote and support access to preventive and primary care for CYSHCN through early identification, linkage to care, and family support. Title V partially supports this safety net that is comprised of pediatric specialty and sub-specialty, case management, and family support agencies that provide in-state regionalized and/or county-based services. It is designed to provide family-centered, culturally competent, community-based services for CYSHCN age birth through 21 years of age, and to enhance access to medical home, facilitate transition to adult systems, and health insurance coverage. The Specialized Pediatric Services Programs (SPSP) agencies are a significant resource of pediatric specialty and subspecialty care in NJ and are used widely by CYSHCN including Medicaid recipients. Although clients are screened for their ability to pay for clinical services, the support provided by Title V enables all CYSHCN to be served regardless of their ability to pay. There is no charge for SCHS CM and family support.

Administratively housed in the Family Centered Care Services (FCCS) Unit these services include 21 county-based Special Child Health Services Case Management Units (SCHS CMUs), one Family Support project, multiple Specialized Pediatric Services Programs (SPSP) which include 8 Child Evaluation Centers (CECs) of which 4 house Fetal Alcohol Syndrome/Fetal Alcohol Spectrum Disorder Centers, and 3 provide newborn hearing screening follow-up, 3 Pediatric Tertiary Centers, and 5 Cleft Lip/Palate Craniofacial Anomalies Centers and a small State operated Fee-for-Service program.  Likewise, State and federal collaborations among the FCCS programs and non-Title V funded programs such as the Ryan White Part D Family Centered HIV Care Network (RWPD), Early Intervention System (EIS), Federally Qualified Health Centers (FQHC), medical home initiatives, Supplemental Security Income (SSI), Catastrophic Illness in Children Relief Fund (CICRF) and other community-based initiatives extend the safety net through which Title V links CYSHCN with preventive and primary care.

State Title V staffs, SCHS CMUs and SPSP providers, receive training from State agencies such as the NJ Department of Human Services, and the Department of Children and Families to become Informal Application Assistors for Medicaid/NJ FamilyCare programs as well as to learn about Managed Long Term Services and Supports, how to obtain care through the Marketplace, and behavioral services through PerformCare. These trainings build capacity among Title V agency providers to enhance access to primary and preventive care for CYSCHN.

Expanded partnerships, collaborations, and coordination of MCH programs continue especially involving HWHF. FHS is working very closely with the NJDOH newly created Office of Population Health, where the Maternal Mortality Review Commission and the State Maternal Health Innovation Program are both housed. Together FHS and the Office of Population Health work collaboratively to improve birth outcomes and reduce disparities. 

Building the capacity of women, children and youth, including those with special health care needs, and families to partner in decision making with Title V programs at the federal, state and community levels is a critical strategy in helping NJ to achieve its MCH outcomes. FHS has several initiatives to build and strengthen family/consumer partnerships for all MCH populations, to assure cultural and linguistic competence and to promote health equity in the work of NJ's Title V program.

Efforts to support Family/Consumer Partnerships, including family/consumer engagement, are in the following strategies and activities:

• Advisory Committees;

• Strategic and Program Planning;

• Quality Improvement;

• Workforce Development;

• Block Grant Development and Review;

• Materials Development; and

• Advocacy.

This section summarizes the relevant family/consumer and organizational relationships which serve the MCH populations and expand the capacity and reach of the state Title V MCH and CYSHCN programs. Table 1f - MCH Organizational Relationships with Partnerships, Collaboration, and Cross-Program Coordination (See Supporting Document #1) summarizes the partnerships, collaborations, and cross-program coordination established by the state Title V program with public and private sector entities; federal, state and local government programs; families/consumers; primary care associations; tertiary care facilities; academia; and other primary and public health organizations across the state that address the priority needs of the MCH population but are not funded by the state Title V program.

The public health issues affecting MCH outcomes generally affect low-income and minority populations disproportionately and is influenced by the physical, social and economic environments in which people live. To address these complex health issues effectively, the FHS/Title V program recognizes that a spectrum of strategies to build community capacity and promote community health must include parents and consumers representing the affected populations as integral partners in all activities in order to have full community engagement and successful programs. In order to carry out these functions and address the public health disparities affecting NJs maternal child health population, the FHS/Title V program has incorporated consumer/family involvement in as many programs and activities as appropriate.

NJ has prided itself on its regional MCH services and programs, which have been provided through the Maternal Child Health Consortia (MCHC), an established regionalized network of maternal and child health providers with emphasis on prevention and community-based activities. Partially funded by FHS, the MCHC are charged with developing regional perinatal and pediatric plans, total quality improvement systems, professional and consumer education, transport systems, data analysis, and infant follow-up programs. The three MCHC are located in the northern, central and southern regions of the state. It is a requirement of the statute governing the MCHC that 50% of their Board of Directors be comprised of consumers representing the diverse population groups being serviced by their organizations.

Recognizing the importance that parent/consumer involvement has in the design and implementation of a program to address issues related to preterm births and infant mortality, the MCH Program incorporated focus groups into several programs under the HWHF initiative including those for doulas, breastfeeding, and addressing disparities.  Similarly, the Home Visiting Program (MIECHV) also requires funded grantees to implement County Advisory Boards.

The NJ Title V CYSHCN Program, SCHEIS, partners, collaborates, and coordinates with many different governmental and nongovernmental entities, on federal, state, and local levels, as well as parents, families and caregivers, primary care physicians, specialists, other health care providers, hospitals, advocacy organizations, and many others to facilitate access to coordinated, comprehensive, culturally competent care for CYSHCN. SCHEIS works with programs within the NJ Departments of Human Services (DHS) and Children and Families (DCF) in addressing many needs facing CYSHCN including medical, dental, developmental, rehabilitative, mental health, and social services. DHS administers Title XIX and Title XX services and provides critical supports for ensuring access to early periodic screening detection and treatment for CYSHCN. The State DHS Medicaid, Children’s Health Insurance Program Reauthorization Act (CHIPRA) NJ FamilyCare Program, and the Division of Disability Services afford eligible children comprehensive health insurance coverage to access primary, specialty, and home health care that CYSHCN and their families need. SCHEIS utilizes patient satisfaction survey as a means to improve and refine. All trainings provided to grantees are also open to parents/consumers as either participants or speakers. All CYSHCNs educational materials and informational brochures receive input and are reviewed by parents/consumers for health literacy and cultural competence.

SCHEIS collaborates with many offices and programs in DHS to develop and implement policy that will ensure that children referred into the SCHS CMUs and their families are screened appropriately for healthcare service entitlements and waivered services. SCHEIS programs including case management, specialized pediatrics, and Ryan White Part D, screen all referrals for insurance and potential eligibility for Medicaid programs, counsel referrals on how to access Medicaid, NJ FamilyCare, Advantage, and waiver programs, and link families with their county-based Boards of Social Services and Medicaid Assistance Customer Care Centers. Program data including insurance status is collected into a report that is compared with Medicaid data in determining CYSHCN need. Referrals are made to Boards of Social Services, NJ Family Care, Advantage, Charity Care, Department of Banking and Insurance, and Disability Rights NJ for support and advocacy.

The Early Hearing Detection and Identification (EHDI) program within the SCHEIS also recognizes the pivotal role that consumers and parents play in the effective administration of the program. EHDI has an Advisory Council composed of parents of Deaf and hard of hearing children and consumers who themselves are Deaf or hard of hearing. Participants on the council take part in literature reviews, advise the NJDOH regarding innovations in the programmatic area and assist in the review of operations of the program.

In accordance with the 1993 Family Support Act the NJ CDD established the Regional Family Support Planning Councils (RFSPCs) to provide a way for parents and family members of people with developmental disabilities to come together to exchange knowledge and information about family support services and to advocate for families and individuals with developmental disabilities at the local and state level on issues that directly impact their lives. They also collaborate with the state Division of Developmental Disabilities (DDD) on how to better serve individuals and their families.

The Medical Assistance Advisory Committee (MAAC) operates pursuant to 42 CFR 446.10 of the Social Security Act. The 15-member Committee is comprised of governmental, advocacy, and family representatives and is responsible for analyzing and developing programs of medical care and coordination. State SCHEIS staffs participate at MAAC meetings and share information on access to care through Medicaid managed care with Committee members as well as with SCHEIS programs. Likewise, information shared by the MAAC is incorporated into SCHEIS program planning to better assure coordination of resources, services, and supports for CYSHCN across systems. The quarterly MAAC meetings continue to provide a public forum for the discussion of systems changes in DHS's Medicaid program as well as invite collaboration across State programs. Updates keep stakeholders including the public and providers informed of NJ's progress in implementation of Managed Long Term Services and Supports (MLTSS), and the restructuring of services to children and youth with the developmental disabilities through DDD, DCF, DOE and DOL, Vocational Rehabilitation.

The SPAN Parent Advocacy Network, and the NJAAP are key partners with the Title V Program in NJ in many initiatives and projects to better serve CYSHCN and empower families. The Statewide Community of Care Consortium (COCC), a leadership group of SPAN, dedicated to improving NJ’s performance on the six core outcomes for CYSHCN and their families, includes three co-conveners from Title V, SPAN and NJAAP. This group also includes DHS, DCF, the NJ Primary Care Association, and over 60 statewide participating stakeholder organizations. The COCC partners are continuing to work to improve the access of children with mental health challenges to needed care, and to improve the capacity of primary care providers to address mental health issues within their practice. A Family Guide to Integrating Mental Health and Pediatric Primary Care has been developed and shared with families. COCC co-conveners continue to meet with NJ's child protection agency, DCF Division of Protection and Child Permanency, about addressing challenges for children with mental health needs under their care. As an organization consisting of parents or families of CYSHCN, SPAN’s guides, publications and presentations are consistently developed, by design, with family and consumer involvement.

As evidenced by the multitude of advisory council, consumer groups, coalitions, interdepartmental work groups, and committees, the NJDOH places a great emphasis on the active and meaningful participation of parents and consumers in the development, design and implementation and evaluation of Title V programs. This is a core strength of the NJDOH Title V programs.

The findings from the Five-Year Needs Assessment drive the identification of MCH priority needs for the five-year reporting cycle consistent with Figure 4 of the MCH Block Grant Logic Model. The selected priorities reflect the unique needs of NJ and address the defined MCH population groups and cross-cutting/ systems building areas. In addition, the identified priority needs address areas for which targeted interventions will result in needed improvements to its health care delivery systems. The identified priority needs have informed the selection of nine NPMs, one in each of the MCH population health domains, and the development of 4 SPMs. Collectively, the NPMs and SPMs address the state’s identified priority needs. The narrative discussion organized by NPMs supplements the listing of the final priority needs by providing a rationale for how the priority needs were determined and how they link with the selected national and state performance measures. The selected state priority needs drive the selection of NPMS and the development of SPMs which align the impact of Evidence-Based Informed Strategy Measures (ESMs) on NPMs and National Outcome Measures (NOMs). Table 1a - Title V MCH Block Grant Five-Year Needs Assessment Framework Logic Model (see page 49 and Supporting Document #1) summarizes the process of identifying priority needs and linking them to performance measures.