Needs Assessment
Brief Description of Activities
As an ongoing effort to strengthen and develop the Idaho State Action Plan for the Title V application and annual report block grant requirements, multiple activities have been performed to help identify health care service limitations and capabilities in Idaho. The Idaho evaluation team (Boise State University Center for Health Policy) has focused on-going needs assessment (ONA) activities on refining evidence-based or -informed strategy measures (ESMs), collecting baseline information for Idaho opioid usage and neonatal abstinence syndrome (NAS) cases, and assessing MCH capacity to utilize partnerships and collaborations to enhance services for the MCH populations.
Assessing collaborations and partnerships, identifying their strengths and gaps, with the aim of advancing MCH stakeholder engagement and capacity was a focus of recent ONA efforts. In addition, the MCH leadership team and Boise State evaluation team participated in Title V supported technical assistance sessions for needs assessment planning.
Noted Changes in Health Status
In 2019, the Idaho Governor signed the Medicaid expansion bill into law which included 10 sideboards, including work requirements, family planning restrictions, and substance abuse assessment. It is estimated that Medicaid expansion could serve up to 91,000 people.
The Idaho Legislature also passed House Bill 109, which established a maternal mortality review committee (MMRC). The purpose of this review committee is to identify preventable maternal deaths, determine educational strategies for health care workers, and reduce the statewide incidence of maternal mortality.
In 2018, Idaho experienced a significant decrease (6.7%) in children enrolled in Medicaid and CHIP. While the cause is unknown, a major factor believed to contribute to the drop is the state’s strong economy and families accessing employer-based insurance.
The legislature appropriated another one-time funding amount of $1,600,000 to support the home visiting programs at the Public Health Districts (PHDs). The funds are meant to expand home visiting services to additional counties beyond the MIECHV service areas.
Additional data regarding Idaho’s MCH populations can be found under the “Health Equity Secondary/Archival Data Review” section.
Changes in Title V Capacity
With the passing of the MMRC legislation, the Title V Program will be leading the implementation, operation, and facilitation of the MMRC. State general funds were not attached to the legislation, so Title V will be covering the total cost of the MMRC. The MCH Section is currently using .15 FTE of the existing MCH RN’s time to lead implementation with assistance from a graduate-level intern. The MCH Program has requested an additional .5 FTE to assist with MMRC activities, which will increase capacity across the section.
In 2018, the Title V Program made significant budget changes to better align with state MCH priorities. Approximately $200,000 was shifted from general epidemiology activities to the Child Health domain to enhance work focused on obesity reduction in young children and to support a new partnership with the Idaho Suicide Prevention Program for suicide prevention programming in schools.
Partnerships and Collaboration
Within an environment of limited resources, health care shortages, and geographic challenges, the Title V staff are experts in a variety of MCH areas and are skilled at developing creative and nimble partnerships to address MCH issues. Most often MCH leadership and staff serve as a convener, collaborator, and/or partner to move the needle on MCH issues. One benefit of working in a small state is the tightknit community of public health professionals, social service programs, community organizations, and health care providers, and often, the same stakeholders are “at the table’ for many MCH matters. The MCH Program has close working relationships with the Idaho Medical Association, Idaho Chapter of the American Academy of Pediatrics, St. Luke’s Children’s Hospital, Idaho Parents Unlimited, Infant Toddler Program, Idaho Child Care Program, other public health programs, local public health districts, and a number of pediatric and pregnancy care providers. MCH and partner programs work together to identify evidence-based programming and monitor implementation of the funded activities. For example, Title V provides funding to the Idaho Oral Health Program, Family Planning, Idaho Tobacco and Prevention Program, and Idaho Physical Activity and Nutrition Program.
Further results from Idaho’s MCH partnerships and collaborations evaluation reveal baseline information on MCH’s strengths and opportunities for future statewide partnerships to enhance services for the MCH populations. These results are highlighted under the "Efforts to operationalize NA" section.
Efforts to Operationalize Needs Assessment
Opioid Use and Neonatal Abstinence Syndrome
Idaho does not have a centralized repository to access hospital data, including NAS data; therefore, there is a paucity of knowledge regarding the severity of NAS in the state. The most recent national data available for NAS incidence in Idaho is from 2013 which indicated the rate as 6.0 per 1,000 hospital births. Idaho is particularly high in Medicaid prenatal opioid prescriptions, with 35.6% of pregnant women being prescribed an opioid.3 This is second in the country only to Utah.3 Although there is a pressing need for more information, there are minimal data available. In Idaho, 35 of the 44 counties are considered rural and these counties account for a majority of Idaho’s land mass.4,5 There is strong evidence to suggest that rural communities in the U.S. experience higher NAS rates than their urban counterparts.6 This is likely due to maternal opioid use being 70% higher in rural counties than urban ones.
According to Idaho Division of Medicaid data, there was increase in diagnosed NAS cases from 7.4 per 1,000 members in 2013 to 9.8 per 1,000 members in 2017. The five-year average for the same time was 8.1 NAS cases per 1,000 members. The data also revealed that infant care costs associated with a NAS diagnosis were significantly higher than infants without a diagnosis. Medicaid payments from 2013 to 2017 for infants with NAS exceeded those for non-NAS infants by an average of $48,564. From 2013 to 2017, infants with NAS required an average of 17.7 more inpatient days than infants without NAS.
Additionally, data from a major health system in Idaho revealed that the NAS rate more than doubled between 2014 and 2018 from 5.38 per 1,000 hospital births to 11.2 per 1,000 in 2018 (preliminary data). More than half of the state’s births occur at hospitals within this system.
Evaluation of Idaho Partnerships and Collaborations
As part of the ONA, the Boise State research team conducted a MCH partnership and collaboration evaluation to assess the level of engagement the MCH program has with organizations that share a similar goal of improving the health of MCH populations. Strategic efforts used to identify the organizations were: 1) an environmental scan; 2) a HRSA TA stakeholder brainstorming activity; and 3) an interview with the MCH leadership team.
The level of engagement and interaction between these partner organizations and MCH was measured on a continuum modeled on the American Academy of Pediatrics Family Engagement Continuum.9 Specific areas measured were: 1) the current MCH interaction level (core, program, and funded partner program); 2) continuum of engagement (no interaction, coexistence, networking, cooperation, collaboration, and partnership); and 3) the current capacity and reach to help identify the next steps for future engagement (strengthen, appropriate level, and no potential).
- A total of 86 organizations were identified and included as part of the evaluation.
- Each organization identified with respect to its continuum category: 16 fell within the no interaction category, 14 in the coexistence category, eight within the networking category, 13 within the cooperation category, nine within the collaboration category, and 26 within the partnership category.
- The MCH level of interaction with the various organizations was identified. Two organizations’ interactions occur across all MCH categories; 49 organizations’ interactions take place at the core level; six organizations’ interactions occur at both the core and program levels; four organizations’ interactions exist at the funded partner program level; eight organizations’ interactions take place at the program level; one organization’s interactions occur at the program and funded partner program levels; and 16 organizations are designated as not applicable because their interactions do not occur at any of the levels indicated.
- There were 40 organizations found to have an appropriate level of interaction with MCH, one organization was deemed as having no potential for collaboration with MCH, and 45 organizations were identified as having relationships with MCH that may benefit from strengthening.
Planning and Development of the Title V Five-Year Needs Assessment
The MCH team and the Boise State evaluation team participated in HRSA TA session. The TA training was conducted by Dr. Colleen Huebner, an expert consultant who offered training on the NA components, including framework background information, data source identification, data collection methods, and stakeholder identification. The TA allowed participants to identify working frameworks and models, ascertain primary and secondary data collection techniques, brainstorm current and potential new stakeholders, and examine priority setting techniques for future NA efforts.
The Boise State evaluation team, in conjunction with the MCH leadership team, attended the MCH Federal/State Partnership TA meeting and Association of Maternal and Child Health Programs (AMCHP) 2019 Annual Conference and attended sessions focused on needs assessment methodology. The Boise State evaluation team also participated in multiple webinars and trainings related to the needs assessment process.
These NA efforts are essential to ONA activities as they provide opportunities for remaining current regarding MCH policies, making continuous process improvements, networking with MCH personnel in other states, and identifying successful strategies that can be tailored to Idaho’s unique health care environment and state priority needs.
Changes in Structure/Leadership
In 2018, the MCH Section was reorganized to better align staff skills and workload. As a result, Jacquie Watson (previously the CYSHCN Director) became the new Title V MCH Director and Yvonne Niedergesaess became the new CYSHCN Director. Sarah Lopez transitioned from the Newborn Screening (NBS) Program to the role as MCH Program Specialist to provide increased support for MCH-specific activities. Other changes include the addition of Kelsey Hofacer as the new MIECHV Program Manager, Jen Liposchak as the Adolescent Pregnancy Prevention Program Specialist, and Dana McKee as the RN, Senior to provide support to the NBS/CYSHCN, Family Planning, and MMRC Programs. The request for an additional .5 FTE for a RN, Senior is still pending.
Emerging Issues and Capacity to Address Issues
During the 2019 legislative session, a bill was signed into law requiring a Maternal Mortality Review Committee (MMRC) be established in Idaho. This multidisciplinary committee will study cases of maternal deaths and make recommendations to prevent future adverse outcomes. The Title V Program will be leading the implementation, operation, and facilitation of the MMRC and will make plans to translate the data and recommendations into population-based strategies to eliminate preventable maternal mortality and morbidity. Additionally, Idaho is part of a Region X effort to apply for HRSA’s Maternal Health Innovation Grant opportunity. If awarded, Idaho would leverage this funding to implement a perinatal quality collaborative, seek data sharing for maternal and perinatal data with hospitals, explore and pilot telehealth solutions for enhancing care to pregnant and postpartum women, and link high-risk pregnant women with home visiting services.
The MCH Program is committed to taking action to prevent substance-exposed pregnancies and to improve outcomes of infants born with Neonatal Abstinence Syndrome (NAS). To address reporting of NAS and substance-affected infants, MCH leadership has partnered with the Child Welfare Program to assist in implementing changes to the Comprehensive Addiction and Recovery Act (CARA) which aims to address opioid additions and various aspects of other substance use disorders. Idaho Public Health, Medicaid, and Behavioral Health partners reviewed and considered the recent CMS Maternal Opioid Misuse (MOM) Model grant. Ultimately, it was decided not to apply for the grant, but new connections across the agencies were formed with future plans to address opioid use disorder during pregnancy and Medicaid coverage changes to support postpartum insertion of LARC.
Over the past year, there has been increased interest and momentum around addressing adverse childhood experiences (ACEs). The MCH Program kicked off the pediatric ACEs and Resiliency Learning Collaborative with St. Luke’s Children’s. St. Luke’s Health System has since adopted community health initiatives to address ACEs and build resilient communities. A variety of organizations and community partners have come together to create the Idaho Resilience Project to build upon common goals to support education and outreach, prevention strategies, healing and coping, and build community support related to ACEs and trauma. Further, the Division of Public Health will be rolling out a plan to braid and layer funding to create a unified plan to address ACEs and build resilient communities through the public health lens. For the 2021 – 2025 Title V State Action Plan, the Idaho MCH Program intends to link ACEs to life course theory to ensure that strategies to address population needs build protective factors and incorporate screening for and mitigating ACEs.
In June 2019, Idaho experienced the first measles cases in 18 years. In preparation for potential future outbreaks, the Division of Public Health maintains an All Hazards Response Plan and a specific protocol for handling measles public health investigations.
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