This needs assessment was conducted from July 2019 through February 2020 in accordance with these statutory mandates and priorities, with a broad goal of ensuring that VT’s women, adolescents, children, children with special health needs, as well as all parents and families have what they need to be healthy and well, in accordance with VT’s State Health Improvement Plan, which envisions that “All people in VT have a fair and just opportunity to be healthy and to live in healthy communities.” The assessment focused on understanding strengths and needs across VT for MCH’s five identified population domains:

• women’s and maternal health
• perinatal and infant health
• children’s health
• adolescent health
• children with special health needs

Results will inform future MCH efforts to improve health and access to care for women, infants, children, adolescents, and families.

Goals, framework and methodology

 

Assessment activities were conducted independently by Noonmark Services, a Burlington-based consulting firm with expertise in public health assessment and evaluation, strategic planning, and organizational development. Noonmark worked closely with MCH staff leaders to establish the scope of the assessment inquiry, to develop assessment plans and instruments, and to reach a wide cross-section of MCH leadership partners, stakeholders, service users, and members of the community at-large. VT’s Title V assessment was conducted concurrently with a five-year needs assessment for the Maternal, Infant, Early Childhood Home Visiting (MIECHV) program, as many states have done, in accordance with federal guidance from both programs. VT stakeholders concurrently conducted a statewide needs assessment of VT’s early childhood systems under the Administration for Children and Families Preschool Development Birth through Five (PDG B-5) grant, which provided some additional data because MCH is a PDG B-5 stakeholder. Data from this assessment have been used for both the Title V and MIECHV needs assessment reports. The assessment received a VT Agency of Human Services Institutional Review Board (IRB) waiver.

Noonmark conducted interviews with VT state agency partners and leaders, as well as MCH division staff members. Data from these interviews were summarized and used to formulate plans to reach priority populations from all regions of the state, and to reflect MCH’s five identified population domains.

The assessment team collected and reviewed data from a variety of state-level public health surveillance systems to identify key topics for the assessment. The assessment team generated two open-ended focus group question lists for (1) service providers and practitioners and (2) consumers/service users and community members. A focus group plan was established to reach identified groups in each region of VT. Question lists are provided in Appendix 1.

An online community survey using Survey Monkey was developed, drawing on published MCH community needs assessments from other states to develop the survey questionnaire. The survey was disseminated via MCH partners and stakeholders, as well as by purchasing statewide distribution via Front Porch Forum, a statewide email listserv for community information exchange (Figure 1). These methods engaged individuals who reside in and/or who provide services for individuals in every VT county. The assessment included focused efforts to reach VT BIPOC residents, including immigrant and refugee parents and families, as well as youth (ages 13 to 18).

Stakeholder involvement, including families, individuals and family-led organizations

Using the methods described above, Noonmark collected assessment data from 466 individual contacts. In total, 28% of contacts were people who administer or provide services to MCH populations and 72% were people who use MCH services, have used services in the past, or are members of the larger community, including parents, grandparents, foster parents and guardians, and people who care for children with special health needs.

State agency and service provider stakeholders: Noonmark conducted interviews with 17 key stakeholders and ten focus groups with service providers, which engaged 85 individuals. State agency representatives, service providers, and practitioners who participated in interviews and focus groups included representatives from the VT Department for Children and Families, VT Department of Mental Health, One Care VT (the state’s Accountable Care Organization), VT Child Health Improvement Program (VCHIP), VDH Alcohol and Drug Abuse Programs (ADAP), Help Me Grow VT, VT Family Network, Burlington School District Diversity and Equity Team, the State Refugee Coordinator.

In addition, MCH Coordinators (public health nurses at the local level), Children’s Integrated Services (CIS) coordinators, MIECHV nurses, supervisors and other home visiting program staff, primary care and OB/GYN physicians and nurses, MCH Children with Special Health Needs staff, Parent Child Centers, school nurses, and community organizations (mental health, early childhood, youth) participated in the assessment.

Service users and community members: The community at large primarily participated via a statewide survey (described under Quantitative Data, below). Noonmark worked closely with MCH partners to conduct five focus groups with consumers and community members:

• Two groups of immigrant/ refugee parents in Burlington (grouped by language for translation) (20 participants)
• VT Rays high school youth (5 participants)
• Prevent Child Abuse VT Parent Support Group- Caledonia County (2 participants)
• Clarina Howard Nichols Center Moms Group- Lamoille County (5 participants)

Each focus group participant who was a service user or community member received a $20 gift card or cash incentive for their participation. Childcare and interpretation in multiple languages were provided as needed.

Qualitative data sources

Interviews, focus groups, and open-ended survey questions provided a substantial body of qualitative data. In these sessions, interviews/ facilitators asked open-ended questions about health and wellness, access to care, needs and concerns, and emerging issues using a pre-planned list of questions. Each focus group or interview had a designated note-taker who documented the session. The assessment team standardized transcripts from each session, removed identifying information, and generated a master transcript. From the master transcript, qualitative date was coded and grouped into domains and themes..

Quantitative Data Sources

Data collected via VDH annual, semi-annual, and special reports, and responses to survey data comprise the quantitative data collected and reviewed for this assessment. Survey results were analyzed using Survey Monkey, Microsoft Excel, and STATA to provide descriptive statistics including totals, averages, percentages, and medians. Raw population-level indicator data from public health surveillance systems was standardized, and Z-scores were calculated to indicate health risks for MCH domains at the state and county levels. Front Porch Forum’s analytics and Survey Monkey user data provided information about the survey’s reach across the State of VT.

Data sources used to inform the Needs Assessment process

MCH staff provided state-level indicator data from public health surveillance system sources such as the Behavioral Risk Factor Surveillance System (BRFSS), VT Youth Risk Behavior Survey (YRBS), the Pregnancy Risk Assessment Monitoring System (PRAMS), School Health Profiles, and other population-level data systems. Other data sources included recent publications and data summaries from state agencies such as the VT Child Health Improvement Program (VCHIP) at UVM and VT Department for Children and Families (DCF) annual and legislative reports, and from collaborative efforts such as the recent report from Building Bright Futures, “How are VT’s Young Children and Families?”, the VT Early Childhood and Afterschool Workforce Report, and the Stalled at the Start report from Let’s Grow Kids and numerous others.

Vermont is home to 257,000 adult women and 118,425 children and youth ages 0 to 18. In FY 18, VT’s Title V services reached 86% of pregnant women, 94% of infants, 98% of children and youth ages 1 to 21, and 98% of children with special health needs. Women, infants, children, and youth across the life course are generally found to be healthier than their U.S. counterparts across numerous health status indicators. At the same time, factors related to VT’s rurality, and the unique obstacles rural geography creates for low-income women and families provide a critical context for understanding and interpreting identified needs.

The role of rurality in maternal and child health: According to the U.S. Census, VT is the second least populated state and has the highest percentage of rural residents, with 82.6% of the population residing in rural areas compared to only 14% nationwide. VT’s rural geography and context give the state a distinct social and political character.

Low-income residents of rural counties encounter poorer health outcomes for all ages and sub-populations. VT’s mountainous geography, the limited availability of many kinds of services in small, geographically remote communities, lack of access to public transportation, and difficult winter driving conditions exacerbate the barriers vulnerable populations encounter in accessing services and support. Having access to a vehicle plays a critical role in the ability to receive health and social services.

For MCH populations, access to care, including access to prenatal, OB/GYN, maternity, and perinatal services are more limited in rural areas. In VT, declining and aging populations in rural communities contributed to two hospital maternity program closures in the last two years, meaning that women in some southeastern VT towns must travel an hour or more to reach labor and delivery services, with greater variability in their access to prenatal care.

 

Addressing Basic Needs

 

Addressing basic needs such as housing, food security, and transportation are integral to health and wellbeing. In focus groups and surveys, access to housing was the most commonly identified unmet need for families.

Housing issues centered around the lack of affordable housing in all regions of the state, where 46% of renters pay more than 30% of their income for housing,[1] and as do 33% of homeowners. The DCF Office of Economic Opportunity reported that it served 3,872 people at publicly funded homeless shelters in FY18, including 1,102 children. While the total number of people served has declined from a high of 4,303 in 2015, the number of homeless children was at its highest in 2018.[2]

Transportation barriers, including lack of public transportation in rural areas, no usable vehicle (including no winter tires, need for repairs, vehicle not insured or not inspected), difficulty accessing family-friendly transportation for low-income households where a child or adult has special health needs were common themes. In many instances service providers identified unmet housing needs, while community members/service users identified needs for employment or a stable source of income, reflecting their different orientation to fundamental basic needs concerns. For families, having a secure income may be viewed as a pathway to meeting all basic needs, including housing.

For low-income households, access to affordable, healthy food was a frequently identified challenge. Despite the decrease, one in seven children in VT is food insecure.[3]

The Annie E. Casey Foundation’s Kids Count report ranked VT 17th in the US in economic well-being, acknowledging the close connection between child and family health and economic well-being.

In many cases, the extent to which families can effectively address children’s and adolescents’ health needs was viewed as secondary to addressing basic needs. Families that struggle to maintain stable housing or adequate food viewed these concerns as the most significant issues they face. According to individuals who responded to the Access to Health and Wellness Survey, housing, food, and accessible and affordable healthcare were the three most “critically necessary factors for women, children, and families to thrive.” Because Title V services are especially focused on meeting the needs of low-income families, identifying creative and innovative strategies to increase equity and mitigate obstacles to meeting basic needs must continue to be a high priority.

Survey respondents were the least likely to view support for breastfeeding (56%), culturally relevant support and services (56%), and help navigating systems (63%) as critically necessary. Community members who responded to the survey frequently commented on a need to address “social isolation” and “connectedness.” The frequency of open-ended responses which named needs for interpersonal support, and those which described positive relationships as a significant contributing factor to health and wellness suggest that there are additional opportunities to strengthen approaches that nurture the interpersonal connections that promote health.

Access to services: MCH services before, during, and after pregnancy were the most commonly identified as “always” or “usually” accessible resources. Survey respondents were least likely to identify services to reduce stress, train parents on care coordination, and promote health and safety for youth.

“Where do you physically go in your neighborhood or community for health information or discussion about health issues or health information?”

Survey respondents overwhelmingly seek health information from health care providers and formal health settings, for all three populations. Informal spaces such as hair salons were the least likely resource for health information. Schools were the second most commonly identified health information resource for children and youth, but were less commonly identified for other groups.

Women/ Maternal Health

Summary: VT’s Title V women’s and maternal health programs and services address prenatal care, pregnancy planning and prevention, sexual and domestic violence, and maternal mental health, among others. Assessment participants generally identified prenatal and maternal health care services as a strength in VT. VT Medicaid covers pregnancy care up to 200% FPL, facilitating access for a substantial proportion of those with the greatest barriers to access.

In focus groups, providers referenced a variety of maternal health efforts that are working well, including the Women’s Health Initiative, home breastfeeding support, and perinatal depression services funded under VT’s STAMPP grant (described below). The MCH workforce was frequently cited as a strength, with many examples of stakeholders who view the nurses, social workers, home visitors, OB/GYNs, primary care providers and numerous others as exhibiting tremendous professionalism, dedication to their roles, and an investment in maintaining a high level of expertise within their fields.

“There are so many people in VT doing good work, and countless folks throughout the state wanting to make things work. This is the strength of the state.”

 

Strengths: The state has the highest 1st trimester prenatal care rates in the country, with 87.1% of infants were born to mothers who began prenatal care in the first three months of pregnancy (2017). VT exceeded its goal for providing free and low-cost family planning services.

Needs: VT’s overall rate of live births from intended pregnancies is the same as the national average (59.6% compared to 58.9%)[4]. However, according to 2018 PRAMS data, young women and low-income women in VT experience substantially higher rates of unintended pregnancies. The high rates of unintended pregnancies for those under 24 suggest that there continues to be a need for pregnancy prevention and family planning services for younger women.

In focus groups, immigrant and refugee women described numerous differences in their expectations about the prenatal and labor/delivery care they received, including cultural factors about motherhood and childbirth. For example, many immigrant and refugee women stated that they wanted longer hospital stays after delivery. Most agreed that they received a high quality of care.

The closure of the childbirth center at Springfield Hospital in 2019 was identified as a challenge for women in Southeast VT. Two hospitals with maternity services are located within a 45-minute drive from Springfield. This closure follows the closure of the maternity ward at hospital in Lebanon, NH in 2018. Women in this region may need to travel up to one hour for prenatal care.

Maternal/ prenatal substance use

Substance use and dependence during pregnancy is a significant problem in VT, where the rate of substance use during pregnancy (28.2/1,000 births) is four times higher than the U.S. rate (6.8/1,000 births).

The incidence rate of infants born with a diagnosis of drug withdrawal syndrome peaked in 2014.[5] The incidence remains more than double the 2007 rate of 12.8 cases per 1,000 live births, suggesting that substance use treatment intervention for pregnant women continues to be a high priority concern. QI data have shown that most women delivering an infant with neonatal abstinence syndrome are on Medication-Assisted Treatment. Among women who delivered an infant with NAS, 89% were insured under Medicaid.[6]

Few consumers who participated in the assessment raised topics related to maternal and prenatal substance use. MCH providers agreed that addressing substance use among pregnant women is difficult, largely because of significant stigma. Providers stated that pregnant women may be reluctant to identify and seek care for substance use, fearing negative responses from health care providers. Home visitors noted that they may receive and follow different guidance pertaining to substance use during pregnancy than the physicians who are providing prenatal care.

Providers identified the lack of specialized services available for low-income pregnant women who need substance use disorders treatment as a persistent challenge in many regions of the state. Providers generally agreed that when a postpartum mother with SUD treatment needs is effectively linked to services, the system works well. At the same time providers found that stress during the postpartum period can jeopardize SUD recovery, and that many families would benefit from more intensive support for a longer period of time.

Maternal Mental Health

All MCH populations identified mental health conditions and access to mental health care as important concerns.

Perinatal/Infant Health

 

Summary: VT offers far-ranging services for new parents and infants, touching the lives of approximately 94% of all newborns and 86% of all pregnant women, including high rates of breastfeeding and WIC eligibility.

Strengths and Assets: Both service providers and service users generally identified perinatal and infant health needs as being well addressed, and view these services as valuable to public health. MCH programs such as DULCE (see Formal and Informal Collaborations and Partnerships for a description), home visiting, breastfeeding support, immunization and well-child services were identified as “working well.” Service providers who were familiar with the DULCE model of integrated care cited a variety of benefits to the program and endorsed the idea of making this approach available statewide.

The quality of home visiting services available for eligible families, including those with newborns, young parents, low-income parents, and parents with a history of or risk for substance use, was identified as a strength. Home visiting providers agreed that there is less stigma about receiving home visiting services than they found in the past, and that families are generally respond positively to receiving home-based care.[7]

Needs: Providers who deliver perinatal and infant health services identified needs to improve the quality or accessibility of services, especially for low and middle-income mothers and those with complex circumstances and support needs. In general, providers noted that low-income families’ needs have become more complex, and that providers are rarely called upon to address only one category of need. Fully addressing families’ diverse needs requires substantial cross training among providers of services for families, and well-coordinated team approaches when multiple kinds of specialized expertise are needed.

In keeping with national trends, the number of WIC participants in VT has declined steadily, reaching roughly two-thirds of eligible households. Focus group participants noted that the 2016 transition to eWIC has facilitated better access for some households, but posed challenges for the most isolated, underserved, and remote families.

As with other MCH populations, access to mental health care, including mental health providers for women who experience postpartum depression, was identified as a significant unmet need throughout the state. Few consumers discussed maternal mental health concerns. One survey respondent used an open-ended survey field to describe her experience:

“More support-- and early on-- for postpartum depression would have been hugely helpful after giving birth. I felt there were limited resources given to me when I was struggling.”

Providers identified the current HRSA-funded Screening, Treatment and Access for Mothers & Perinatal Partners (STAMPP) project as a promising opportunity to improve responses to postpartum depression and address maternal mental health needs.

Providers identified regional differences in the availability and/or quality of prenatal and maternal health care. Specifically, some regions identified needs for more free or low-cost prenatal/ birth planning classes for women with Medicaid, access to same-day contraceptive care, and general gynecology resources and services for women who are not pregnant, including those addressing fertility concerns, as well as better support for middle income families who have less access to income-based services.

 

Child Health

 

Summary: VT children have high rates of developmental screening, immunizations, and health insurance coverage. Most VT children are enrolled in health insurance (98%) and 91% of young children saw a health care provider in the last year. All pediatric providers in VT accept Medicaid. For most children, factors related to health and well-being are directly connected to family stability and economic security.

 

Strengths: Children in VT have access to pediatric primary care and school-based health services such as screenings and prevention programs. Regions where primary care providers are operating as the child’s medical home were described as working well and effectively connecting children and families to the range of physical, emotional, behavioral, and developmental supports they need most. VT has one of the highest rates of child health care coverage in the United States, with 98% of children covered by a health insurance plan.

 

Help Me Grow VT is administered by MCH, and is part of the national Help Me Grow program, which seeks to ensure all young children receive developmental screenings to support healthy development by engaging families, pediatricians, childcare providers, and others in the early childhood system. Help Me Grow’s child development specialists provide information and referrals, provide developmental monitoring and screening, offer care coordination among multiple service delivery systems, and also assist women and families in accessing perinatal support. Help Me Grow’s work has generated important results[8]:

 

Needs: According to the NSCH 2017, approximately 23% of children and youth in VT have experienced two or more adverse experiences, compared to 19.3% nationally.[9] Family adversity may directly and indirectly impact children’s physical, social, and emotional development.

VT’s child protection system under the Department for Children and Families (DCF) has encountered rising caseloads and increasingly complex cases, including rising cases where parental substance use is a factor. In its Annual Report on Outcomes for VTers (2019), DCF reported conducting 20,758 child abuse and neglect intakes, with very little change from the prior year (20,985 intakes). [10] From 2014 to 2019, the number of children in DCF custody increased by 29%.

Need for pediatric mental health care and screening: School-based mental health services for school-aged children are available in some regions of the state but not others. Many MCH providers stated that mental health support for children, including screening, psychiatric evaluations, outpatient counseling, and intensive/inpatient treatment services are largely unavailable, or that there are long waitlists for pediatric mental health specialists. The number of children who accessed mental health services has increased substantially in the last two decades.[11]

Other children’s health needs that were identified via the survey and focus groups are addressed under the Adolescent Health and Children with Special Health Needs sections that follow.

 

Adolescent Health

 

Summary: VT youth fare better than their same-aged peers nationwide on numerous indicators. Many stakeholders commented on the relative invisibility of services for youth within MCH’s scope, noting that the transition points that come with aging out of programs for younger children make adolescent populations uniquely vulnerable.

Strengths: In 2017, 89% of students completed high school in four years. Over the past decade there has been a 50% decrease in the number of students who smoked cigarettes during the past 30 days. On most YRBS indicators, VT youth fare better than their peers nationally. While only 22% of high school students reported participating in 60 minutes of daily physical activity, 46% of students reporting physical activity at least five days in the previous week. VT’s adolescent health systems are well served by effective collaborations with a number of youth-serving efforts

Needs: In the Access to Health and Wellness Survey, 43.9% of respondents said developmental programs for youth are either “never” or “seldom” available, compared to only 34.4% of respondents who indicated that such programs are “usually” or “always” available. Most survey respondents were adults who are parents and caregivers, who may not be well aware of services that do exist or may have been responding based on a perception about what was available for themselves, their children or grandchildren. According to VT Afterschool, between 12% and 30% of VT middle and high school students do not participate in any sort of group activity supervised by trained adults when they are not at home or school. [12] Similarly, bullying prevention and support to transition to the adult health care system were identified as “never” or “seldom” available by most respondents. As the majority of respondents indicated that such programming is not accessible, these areas may warrant additional investigation.

A 2018 survey of more than 500 VT high school youth identified drug and alcohol use, sexism (body shaming and harassment), personal emotional safety, and bullying as major concerns.[13] Family poverty and lacking resources were identified as a top concern for older youth and for LGBTQ youth. At home, youth were concerned about stress, mental health for themselves and other household members, and emotional safety. This survey, YRBS data, and input from focus group participants identify mental health, substance use, sexual violence, and transitioning to adult systems of care as significant needs for youth.

Substance use: Youth and adults who work with youth who participated in focus groups expressed concerns about the rapid increase in rates of vaping and prevalence of electronic vaping products among youth, and the need for continued effort to reduce risk behaviors that are associated with substance use for youth.

At the system level, stakeholders acknowledged that addressing substance use for youth is under-resourced in VT. Treatment programs for young adults are specialized in nature, making it difficult for small communities to provide an adequate level of care. Providers noted that these services aren’t well integrated into the adult treatment systems.

Sexual and dating violence[14]:

Nearly one in five high school students (18%) have ever had unwanted sexual contact (kissing, touching, sexual intercourse), including 28% of female students and 8% of male students. More than one in three LGBT youth (38%) reported experiencing sexual harm. 27% of high school students reported emotional abuse in an intimate relationship; 8% reported physical violence in a dating relationship.

In 2018, VT’s CDC-funded Rape Prevention Education (RPE) Program conducted interviews and focus groups with roughly 40 adults who work with youth, including prevention educators, youth specialists, and school personnel.[15] The assessment identified opportunities to strengthen sexual violence prevention (and other risk-behavior focused prevention) systems for youth.

 

Mental health needs: The percentage of students who reported feeling sad or hopeless in the past 12 months increased from 21% in 2009 to 31% in 2019. Among youth and adults who work with youth who participated in focus groups identified mental health concerns (and especially stress, anxiety, and depression) as one of the most important topics for VT youth. Youth spoke about the prevalence of mental health concerns among peers, while providers spoke about the scarcity of youth-friendly clinical resources, long waits for counseling, and need for more outreach and education to increase recognition of mental health concerns when they arise, and to decrease the stigma associated with seeking help. Relatedly, youth focus group participants agreed that more is needed to help young adults “find purpose,” learn about goal setting, and receive support as they enter adulthood.

Systems of support for the transition to adulthood: Adults who work with youth indicated that systems of healthcare and support are not seamless when youth reach adulthood, and that youth may not have sufficient health literacy to navigate the transition from pediatric to adult care systems. Adults who work with youth also frequently identified concerns about how well youth access services as they reach adulthood. This transition period presents a unique opportunity for service providers, who acknowledge that there are a variety of firm barriers and boundaries between programs and services for youth and those intended for adults.

LGBT youth reported more high-risk behaviors and worse mental health than their non-LGBT peers. LGBT populations are a priority for MCH programming. MCH partners with, and has received training from Outright VT, a statewide organization that serves LGBT-identified youth and their families.

Children with special health needs (CSHN)

 

Summary: VDH’s CSHN team coordinates care for approximately 700 children. Medical social workers provide care coordination to help families navigate the healthcare system; provide respite funding for parents and caregivers; bring teams of providers and educators together to coordinate care; and help families manage specialized care. VT’s high rate of children with Medicaid coverage is a strength, because it ensures that CSHN can access medical care, developmental and behavioral therapy, dental care, and other needed support.

Strengths: Providers and consumers find that the level of coordinated care families with CSHN receive, systems for early identification/ developmental screening, and “collaborative teaming” to provide care are “working well.” Statewide, approximately 61% of children ages 0 to 3 received recommended developmental screenings, which are one of the tools that identify CSHN.[16]

Needs: Unmet needs and areas where the system is not working well for CSHN were among the most frequently discussed topics focus group participants identified, even in instances where the group was not specifically focused on CSHN populations. MCH providers identified needs for a stronger CSHN workforce, with a more robust system of training and support for personal care assistants (PCAs) and paraprofessionals. Providers expressed concerns about the stress that inadequate workforce resources place on providers and on families, citing a lack of available respite providers even when a family receives funds to support respite care.

Providers stated that in most regions of VT families with CSHN encounter difficulty when children reach any transition point, including as CSHN age (from 0-3 to pre-K/school-age services, across grade levels, and from pediatric to adult systems), as well as when families are “handed off” from and/or served by multiple systems. In focus groups, providers gave several examples of ways transition points are difficult for families.

Providers and consumers described difficulty finding local childcare providers who are trained and registered to provide care for CSHN; issues with providers “expelling” young children with CSHN (and especially CSHN with spectrum disorders) from care; and a lack of providers for specialized services such as physical therapy, speech language therapy, occupational therapy, and other services outside of Chittenden County.

All survey respondents who identified as the parent/ guardian/ caregiver of a child with special health needs identified transportation, eligibility, and physical access as barriers that they or their child has experienced. “Needed services not covered by insurance” (95%) and “access to information” (94.7%) were also commonly identified barriers.

Crosscutting/ Priority Populations

 

Immigrant and Refugee Populations

Summary: VT welcomed 7,956 refugees from 1989 through 2019, majority of whom reside in Chittenden County. The largest numbers of migrants have come from Bosnia, Vietnam, Bhutan, the Democratic Republic of Congo, and Somalia. There is limited health data about these populations because most systems only ask about race and ethnicity, which aggregates migrant and non-migrant populations. In addition, some migrant populations from a single ethnic or cultural group may have only a few hundred people, making it difficult to provide accurate summary data because of the small sample sizes.

Needs: Needs that were identified included limited access to dental care, needs for more culturally responsive mental health care services, and needs for culturally responsive prenatal, maternity, and perinatal services and supports. For the most part, mothers stated that the maternity care they received was good, despite differences in what they expected. Even when services exist, members of these communities may be reluctant to access them because of cultural and linguistic barriers, and described a lack of self-advocacy skills within medical care settings. When a doctor, nurse, or social worker gives information that is not well understood, many focus group participants described a reluctance to ask questions, and stated that they often feel that “something is not right,” but feeling uncomfortable raising concerns.

Establishing relationships with medical homes, including by using community liaisons and nurse home visitors, was identified as a promising approach, when medical homes can provide services that are culturally responsive, have adequate access to translation, and can provide for patient confidentiality given the small size of VT’s immigrant and refugee communities.

Some immigrant and refugee focus group participants and program providers expressed concern that demonstrating “self-sufficiency” is critical to refugees’ immigration status, creating a reluctance to seek care if they perceive that doing so will jeopardize their immigration status or has the potential to undermine the appearance that they are able to maintain self-sufficiency.

Among the concerns that immigrant and refugee adults named for themselves and their children, stress and anxiety, meeting basic needs, and having adequate time and places to build positive social connections were high priorities.

 

[1] ACS, 5-year estimates United States Census Bureau, Table B25070, Table B25091

[2] VT Department for Children and Families. 2019. Annual Report on Outcomes for VTers. VT Agency on Human Services.

[3] Feeding America. (2019). Child food insecurity in VT 2014-2017.

[4] cdc.gov/prams/prams-data/mch-indicators/states/pdf/2018/All-PRAMS-Sites-2016-2017_508.pdf

[5] VT Uniform Hospital Discharge Data Set (VUHDDS) (2019). Data analysis was performed on the VT Uniform Hospital Discharge Data Set (VUHDDS) 2007-2017, as published in the 2019 How Are VT’s Young Children and Families report.

[6] VDH. Neonatal Abstinence Syndrome Surveillance Pilot Project, 2015 VT results. August, 2019. healthVT.gov/sites/default/files/documents/pdf/HS_Stats_NAS_pilot_project.pdf

[7] Home visiting assessment results are addressed in VT’s Maternal, Infant, and Child Home Visiting Program (MIECHV) Needs Assessment report, prepared concurrently with the Title V Needs Assessment.

[8] Help Me Grow Annual Report. 2019. helpmegrowvt.org/

[9] Kasehagen, L. 2015. Adverse Family Experiences: The VT Story, Power Point Presentation. VT Care Partners and VT DMH.

[10] VT DCF. 2019. The Annual Report on Outcomes for VT Families. VT Agency on Human Services.

[11] VT DMH (2019). Data provided by the VT Care Partners Data Repository through the Department of Mental Health Interagency Planning Director.

[12] Schwab, E. “VYP Data Shows Lack of Third Space Activities for MS/HS Youth.” Blog post dated February 10, 2020 retrieved from VTafterschool.org/fall2019-vypdata.

[13] VT Network Against Domestic and Sexual Violence. 2018. Askable Adults: A survey of VT’s Youth. VT Network Against Domestic and Sexual Violence.

[14] VDH. 2019 VT Youth Risk Behavior Survey Statewide Results. March 2020.

[15] VDH. 2019. VT RPE Sexual Violence Prevention Stakeholder Assessment.

[16] DVHA, VT Blueprint for Health (2018). Community Health Profiles.

Situated within the Agency on Human Services, Department of Health (VDH), MCH Division, VT’s Title V is actively engaged in ensuring a statewide system of services, which reflect principles of comprehensive, community-based, coordinated, family-centered care. VDH is the single public health agency, with its central offices and lab in Burlington, and 12 district offices located around the state. State health reform efforts have included a focus on promoting health and preventing chronic illness. Public Health is written into the state’s health reform law.

VDH and all public health efforts, including Title V, are overseen by Commissioner of Health, Dr. Mark Levine. VDH is one of six departments within the AHS. Within AHS, VDH is closely connected to the leadership and resources of the Departments of Mental Health, Health Access (Medicaid & health reform), Disabilities, Aging, & Independent Living, Children & Families, & Corrections. The AHS Secretary reports directly to VT Governor Phil Scott. The Governor’s administration has prioritized increasing early childhood and higher education funding as a critical continuum of support for VT’s children and youth. The AHS Secretary and Governor have a strong interest in prevention and have identified home visiting as a promising strategy for supporting statewide health improvement goals.

The MCH Division has been led by Dr. Breena Holmes since 2010 and oversees all Title V programming. In September 2020, Dr. Holmes will be transitioning to a new part-time role as MCH Medical Advisor and Ilisa Stalberg, MCH Deputy Director since 2013 will be taking on the role of MCH Director. Other federal initiatives housed within the MCH Division include WIC administration, MIECHV, Title X, PREP, EPSDT/school health and significant pieces of the Preschool Development Grant. VT’s CSHN program is under the MCH Division.

VT’s State Health Assessment (SHA) and State Health Improvement Plan (SHIP) are used to prioritize goals and objectives for health, monitor trends, identify gaps and track progress. The SHA/SHIP use a health equity framework, evaluating MCH (and other health) data by key populations that have experienced historical injustice or have documented health disparities. VDH used a collaborative process to develop the SHA/SHIP; key department and external stakeholders reviewed health status indicators. Several the outcomes identified for the five-year SHIP are MCH focused, including: Optimal Child Development and Resilience. Title V/MCH is perfectly positioned to take a leadership role in the development and implementation of strategies to achieve this outcome.

VT public health planning relies on the Prevention Model, an adapted five-level Social-Ecological Model framework. This model recognizes that, although individuals are ultimately responsible for making healthy choices, behavior change is more likely and more sustainable when the environment supports individual efforts. VDH leaders recognize that public health efforts need to influence not only health care and health systems, but also areas such as education, early care and education, housing, law, economic opportunity, community planning, transportation and agriculture.

VDH emphasizes that public health actions are based in researched strategies and in measurement and accountability. Resources from national agencies, such as the CDC, SAMHSA, and MCHB are used to guide staff and policymakers to select successful evidence-based interventions.

The VT Department of Health (VDH) Division of MCH provides programming across the life course: before, during and after pregnancy, and throughout infancy, early childhood and the school years, with an emphasis on adolescents and young adults, recognizing that the health and wellness of VT’s women, children and families is fundamental to the health of all Vermonters, under the its vision that “strong, healthy families power our world,” and mission to “invest in people, relationships, communities and policies  to build a healthier VT for future generations.”

MCH provides direct services, linkages and referrals, population-based supports, education and monitoring, quality oversight, and policy and systems development. MCH supports professionals who work with children and families in health care, early care and education settings, and with human service agencies, and collaborates with partners across VT and nationally to achieve high quality health and health care for children and families. These efforts are family-centered, evidence-based and data-driven.

The Title V funds VT receives are applied across all of MCH’s efforts, directly or indirectly serving thousands of Vermonters each year. Title V funds are frequently used to seed novel and innovative efforts and partnerships, explore emerging topics for MCH service populations, and to assure that MCH leaders are represented in collaborative multi-agency and interdepartmental efforts.

Details about the ways funds are applied in each domain are included in the Findings section, as well as in the Program Partnerships, Collaboration, and Coordination sections.

VDH’s CSHN team coordinates care for approximately 700 children. Medical social workers provide care coordination to help families navigate the healthcare system; provide respite funding for parents and caregivers; bring teams of providers and educators together to coordinate care; and help families manage specialized care. VT’s high rate of children with Medicaid coverage is a strength, because it ensures that CSHN can access medical care, developmental and behavioral therapy, dental care, and other needed support. Details about VT Title V-funded CSHCN services are detailed in the Findings section.

Vermont’s MCH workforce includes professional staff who hold degrees in medicine, nursing, public health, social work, and numerous allied health and social service professions. During FFY18, 13.9 FTEs, representing 49 staff worked directly on behalf of Title V programming. These staff are located at the VDH central office in Burlington, in the local health offices across the state, within the division of Health Surveillance (immunization, health research and statistics), and within the division of Health Promotion and Disease Prevention. There are 56 staff in the MCH Division (including CSHN). Vermont leverages Title V funding along with other federal grants and Vermont’s Global Commitment Waiver to support these staff.

MCH Coordinators (MCHCs) are public health nurses working at within Office of Local Health to provide direct connections to every region and community of the state. The MCHCs positions are not funded by Title V but play a critical role in administering Title V activities. School Liaisons work with schools to promote the MCH mission and further EPSDT mandates. MCHCs and School Liaisons are administered under the organizational structure of the Offices of Local Health and are not managed by MCH, but MCH directs their workplans.

MCH Senior management and program staff

 

Strengths: MCH direct service providers, including nurse home visitors and CSHN staff, are highly dedicated to their profession and to the families and children for whom they care, and have personal and professional values that strongly align with the work they perform. Providers recognize that working in the public health arena (and outside of hospital settings) affords them greater flexibility and autonomy than positions in inpatient settings.

Needs: Staffing and workforce issues were among the most frequently discussed topics for focus group participants. Nurse home visitors, CSHN staff, and other MCH providers identified workforce shortages as a significant issue. Concerns related to this theme included high turnover, limited professional pathways, need to protect staff from burnout, lower pay in public nursing settings when compared to hospital-based positions, and a desire for greater flexibility and autonomy within their roles. Many direct service providers stated that their roles require “too much paperwork,” and that the time burden of administrative tasks detracts from their professional satisfaction.

For nurse home visiting, supervisors expressed concern that many nurse home visitors have an income below the median in VT, and face similar basic needs concerns as they families they work with. At the same time, many nurse home visitors spoke about the benefits available to them including strong support from supervisors and peers, feeling like their work makes a meaningful contribution, and greater flexibility.

For CSHN services, assessment participants identified needs for more personal care assistants, better systems to train, support, and compensate PCAs; more specialized care providers with pediatric specialties and more accessible providers throughout the state; and more respite care providers who can alleviate burnout.

There are several recent reports describing workforce concerns among MCH stakeholder groups, including those within the CIS system, early childhood care (and primarily early childhood education), and other DCF systems.

MCH works very closely with other divisions within VDH to carryout activities under and connected to Title V. VT is served by a statewide network of local offices. MCH Coordinators and School Liaisons in each district office carry out Title V and other MCH activities within communities. The chronic disease division houses programmatic activities related to tobacco control and prevention, oral health, physical activity and nutrition. MCH works with the Division of Emergency Preparedness, Response and Injury Prevention to address childhood injury, Environmental Health around toxic exposure, and the Alcohol and Drug Abuse Programs on shared planning around substance use in pregnancy and among youth. MCH epidemiology, data analysis, and surveillance is conducted by staff within the Division of Health Surveillance, as is our immunization program.

As a small rural state, VT has proportionally small state government agencies. Committed staff at children and family-serving state agencies and nonprofit organizations collaborate to address the needs of VT children and families.

MCH holds strong partnerships with the professional organizations that serve women of childbearing age, pregnant women, children, and families, including the VT chapters of the AAP, AAFP, ACOG, AMA, the VT NP Association, and multiple statewide organizations.

VT MCH works with a large number of state agency and community partners, too many to name them all here. Below are a few examples:

Children’s Integrated Services provides support to families, children, and childcare programs through specialized childcare, early childhood and family mental health, early intervention and nursing/family support programs.

Department for Children and Families (DCF) Family Services Division (child welfare). Efforts are underway to ensure the medical and dental needs of children in custody are known to Caseworkers and foster parents, as well as the clear identification of children with special health needs. Additionally, MCH and DCF are jointly planning around Family First prevention.

Department of Mental Health (DMH). MCH partners with DMH on numerous projects. Most recently joint work includes the HRSA-funded maternal depression and other related disorders grant, suicide prevention, the child and family trauma workgroup, and a host of projects related to promoting resilience and strengthening families.

VT Child Health Improvement Program. VCHIP is a population-based child & adolescent health services research & QI program of the UVM. Since 2000, the partnership between the MCH and VCHIP has resulted in measurable improvements in child health outcomes across the pediatric age spectrum and a variety of health service areas.

University of VT Medical Center/University of VT Children’s Hospital. VT MCH works very closely with UVMMC to improve the system of care for children and families.

Agency of Education. MCH collaborates with AOE to align skills and content in our state’s approach to health education in public schools. MCH also works closely with AOE around essential school health services through the state school nurse consultant, and more recently around COVID.

Parent Child Centers are a network of 15 non-profit organizations across VT that provide support and education to families with young children.

VT Family Network (VFN) is committed to a mission that promotes better health, education and well-being for all children and families, with a focus on children and young adults with special needs. VFN regularly participates in our annual Title V submission, needs assessment, and attends the block grant review yearly.

VT Afterschool is a public-private statewide partnership dedicated to supporting and sustaining innovative learning opportunities that extend beyond the school day. Activities are directed toward increasing the quality and availability of education programs during non-school hours.

Developmental Understanding and Legal Collaboration for Everyone is an innovative intervention embedded within pediatric primary care. DULCE proactively screen for and address SDOH to promote the healthy development of infants from birth to six months and provide support to their parents.

Planned Parenthood makes up VT’s network of family planning centers. VT recently made the decision to decline federal Title X funding due to recent rule changes that were in direct conflict to VT’s approach. Although this could have created significant challenges to meeting the family planning needs of low-income Vermonters, officials made the decision to use state funds to fill this gap until the federal rule is overturned.

Outright VT is a statewide organization whose mission is to build safe, healthy, and supportive environments for LGBTQ youth. Outright worked with MCH to increase knowledge and skills among employees around gender-inclusive language and identify opportunities to use more inclusive language in programming and communication.

Women’s Health Initiative Women receive primary care and preventative care services in both Patient-Centered Medical Homes, obstetrics and gynecology practices, and Planned Parenthood.

Overall, the services MCH provides under Title V are well aligned with the needs that were identified across VT, and the generally strong health outcomes MCH indicators reveal are strong evidence of all that is “working well” in MCH systems of care. The needs assessment found several important themes that cut across all of MCH’s work that relate to the domain-specific themes and findings:

1. Addressing basic needs and social determinants has a direct impact on the health of MCH populations. Especially in light of COVID-19, the primacy of meeting basic needs as a cornerstone of public health was well founded throughout this assessment. For low-income families, meeting basic needs is the highest priority, and when these needs are not well addressed, it is difficult to engage in any other kinds of service.

2. Consumers and providers are concerned about the prevalence of mental health issues and the availability of care. Topics related to depression, anxiety, suicide and postpartum/ maternal mental health issues came up in every focus group. Participants were especially concerned about the limited availability of mental health providers who specialize in serving families, young children, and adolescents and postpartum mental health conditions.

3. Regional differences in levels of care may undermine equity and positive results in some areas of VT. VT’s rural nature means that many kinds of health and human services are concentrated in a few larger towns. In VT’s most remote counties, residents may have to travel outside of their region to receive services.

4. Building relationships and informal connections contributes to health and wellness for MCH populations. A surprising finding of the needs assessment was the large number of individuals who expressed a desire for more opportunities to connect. Concerns about the negative impact of isolation on health and wellness came up across all MCH population domains.

5. Seek opportunities to replicate effective programs and services. MCH stakeholders especially value the DULCE model, home visiting, and many traditional Title V/ MCH programs such as those that support breastfeeding, provide postpartum and well-baby care, and pregnancy prevention. STAMMP and the Women’s Health Initiative were named as strategies that consumers and/or providers have especially valued.

6. Address the full scope of MCH health needs among Black, Indigenous, and People of color (BIPOC) communities. Amid VT’s shifting racial demographics, and in light of historic health disparities and structural inequities, all health and human services must consider how well they are equipped to provide high quality care for BIPOC communities.

Linking to Performance Measures

Priority needs were identified by reviewing needs assessment findings and data from all sources in light of VDH performance measures and agency-wide plans. The decision regarding Priority Areas and performance measures was completed by the MCH Leadership Team, with input from key stakeholders through the process.

Over the course of several months, the MCH Leadership Team comprehensively reviewed the quantitative data and findings from the key informant interviews. Each member ranked priority areas/performance measures according to 1) impact; and 2) feasibility. Following this individual ranking process, scores were compiled and a list of top priorities emerged. The MCH Leadership Team was largely unanimous in our decision making. Only small shifts in the priority areas were made in cases where there wasn’t complete agreement among Team members or where there wasn’t alignment with the population domains.

Identified Priority Needs

1. Ensure optimal health prior to pregnancy
2. Promote optimal infant health and development
3. Achieve a comprehensive, coordinated, and integrated state and community system of services for children
4. Children live in safe and supported communities
5. Youth choose healthy behaviors and thrive
6. Reduce the risk of chronic disease across the lifespan
7. Promote protective factors and resiliency among VT’s families.

National Performance Measures

1. Breastfeeding
2. Developmental screening
3. Physical activity in children
4. Adolescent well visits
5. Transitions to care for CSHN populations
6. Preventive dental visits in children
7. Smoking during pregnancy

State performance measures

1. Early childhood flourishing
2. Adolescents who feel they matter to people in their community
3. Alcohol use in pregnancy
4. Suicidal ideation
5. Family and consumer partnership