Five-Year Needs Assessment Summary

FY 2020 Idaho Title V Five-Year Comprehensive Needs Assessment Summary

The MCH leadership team reviewed the final NA report, prioritization meeting summary, and 2016-2020 state action plan to determine the final 7 to 10 state priority needs that would guide the 2021-2025 state action plan development. To narrow down the priority needs, potential priorities were evaluated against the following criteria:

• Ability to make a measurable impact in the short- and long-term
• Feasibility of population-based approaches
• State and local capacity
• Incidence/prevalence
• Cost of potential strategies
• Alignment with existing programs and initiatives
• Alignment with National Performance Measures

During the Priority Setting Phase (March-July 2020), MCH staff and the BSU evaluation team met frequently to review data, refine ESM development, and discuss strategies relevant to those receiving MCH services in Idaho. MCH Leadership selected ten state priority needs, ensuring that needs of all six MCH population domains were represented. Please see the State Action Plan narrative for further discussions about the Idaho MCH Program’s goals, objectives, and selected ESMs and SPMs.

Key findings are organized by MCH population domain, with the methodology used to collect the data reflected either in the text or in parentheses (AFG = Adolescent focus group; ASD = Archival/secondary data; CS = Consumer survey; KSI = Key informant/Stakeholder interviews; MFF = MIECHV families’ findings; PS = Provider survey).

Women/Maternal Health

• In 2017, 49.7% of women aged 18-44 had an annual preventive medical visit compared to 66.5% nationwide (BRFSS).
• Between 2014-2018, 29.4% of Idaho women reported an unintended pregnancy (PRATS, 2019).
• 9.1% of women smoked at any time during pregnancy, with American Indian/ Alaskan Native women having the highest rate of smoking at 16.4% (PRATS, 2019).
• Between 2014-2018, Idaho’s maternal mortality rate was 24.2 per 100,000 live births (DHW, 2019).
• The top three issues for women of reproductive age in the CS were mental health issues and services (65%), adequate health care (45%), and contraception and reproductive health services (43%).
• The top three issues for pregnant women in the CS were parenting support and education (54%), depression/mental health screening and care (48%), and early and adequate prenatal care (47%).
• Common challenges identified for pregnant women and women aged 18-44 in the PS included financial barriers (26%), inadequate health insurance (16%), and access to health care (16%).
• The top health needs for women of reproductive age and pregnant women in the KSI were access to health care, adverse childhood experiences (ACEs), health education, mental health services, reproductive health care, and substance abuse services, care, and treatment.

Perinatal/Infant Health

• Between 2014-2018, 70% of new mothers reported their baby always slept alone. Hispanic women (49.8%) were less likely to report their babies sleep alone compared to their non-Hispanic counterparts (72.6%) [PRATS, 2019].
• The most important issues for perinatal and infant health identified in the CS were developmental screening and early intervention (49%), immunizations (48%), parenting support and education (39%), impacts of stress and ACEs (35%), and breastfeeding and nutritional needs (34%).
• The top health needs for newborns and infants in the KSI were access to health care providers, ACEs, breastfeeding, developmental screenings, education for parents and providers, and immunizations.
• The most common themes across parent interviews in the MFF were parent and family support, navigating health insurance, mental health and substance abuse, connecting to services, access to health care, financial concerns, and transportation.

Child Health

• During 2016-2017, 21.1% of Idaho children experienced two or more ACEs versus 20.5% nationwide (America’s Health Rankings, 2019).
• The most important issues for young children aged 1-5 in the CS were parenting support and education (53%), developmental screening and early intervention (50%), access to quality child care and preschool (45%), immunizations (42%), and impacts of stress and ACEs (33%).
• The most important issues for young children aged 6-11 in the CS were mental and behavioral health care (54%), healthy home environment/supportive parenting (52%), healthy peer relationships/bullying prevention (48%), and impacts of stress and adverse childhood experiences-ACEs (36%).
• Common challenges for pediatric patients in the PS included access to health care (18%), financial barriers (16%), and lack of parenting education (16%).
• The top health needs for children in the KSI were access to health care, ACEs, developmental screenings, parental education, immunizations, injury prevention, mental health, nutrition, and oral health.

Adolescent Health

• Between 2014-2018, the Idaho adolescent suicide rate for ages 12-17 was 13.0 per 100,000 residents. American Indian/Alaskan Native adolescents had the highest rate (24.2%), and the rural suicide rate (18.2%) is higher than frontier (11.5%) and urban (11.5%) suicide rates (YRBS, 2019).
• The most important health issues for teens as identified by adolescents in the AFG were mental health, substance abuse, self-esteem, bullying, and social media influence.
• The most important issues for adolescents in the CS were mental and behavioral health/suicide prevention (75%), supportive adult relationships (45%), bullying prevention (41%), and screen time and social media (36%).
• The top health needs for adolescents in the KSI were ACEs, activities/programs/ recreational opportunities, prevention education, mental health, reproductive health, and substance abuse.

CSHCN

• From 2017-2018, 15.0% of adolescents with a special health care need aged 12-17 received necessary services to transition into adulthood compared to 18.9% nationally (National Survey of Children’s Health).
• The most common types of medical specialists seen by CSHCNs in Idaho in the past two years include speech therapists (56%), developmental specialists (53%), psychiatric specialists (50%), neurologic specialists (47%), and physical therapists (36%) [CS].
• The most important issues for CSHCN identified in the CS were training and family support for children with behavioral issues (66%), help with care coordination (40%), developmental screening and early intervention services (33%), access to mental and behavioral health care (31%), and inclusive school-based programs (28%).
• Common challenges identified for CSHCN in the PS included access to health care (12%), financial barriers (6%), and education on parenting skills and rights for CSHCN (6%).
• The top health concerns for CSHCN in the KSI were access to health care, ACEs, developmental delays, lack of education options, mental health, parent support, and substance abuse.

Successes, Challenges, and Gaps by Specific MCH Sub-Population Group

Questions about population-specific strengths were not asked in the NA surveys or interview methodologies. However, such strengths can be identified in the archival/ secondary data, from the stakeholder prioritization meeting, and through interviews with DHW administrators.

Women/Maternal Health

• A robust WIC system provides nutrition to pregnant women through more than 50 clinics throughout the state.
• A statewide Maternal Mortality Review Committee was created in 2019.
• There is increased insurance coverage for women through Medicaid expansion that went into effect January 2020.
• Many pregnant women and mothers have received home visiting services through the Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program.
• Prenatal care limitations include poor access to prenatal care in remote areas, level of literacy, preconception health, limited access to prenatal care for noncitizens, and misconception of home visiting programs as “big government.”
• Mental Health service limitations include short office visits with providers, mental health stigma, providers unsure of referral sources, and lack of universal screening.
• Substance use/abuse limitations include access to services, lack of providers, adequate provider training, and awareness of risks associated with substance use during pregnancy.

Perinatal/Infant Health

• Plans to screen for ACEs and remediate these problems are becoming more common and systematic.
• Many infants have received services through Idaho’s MIECHV Program.
• Immunization limitations include ease of opting out of immunizations, lack of knowledge and education, vaccine and physician mistrust, and relying on pediatricians to spread the information.
• Nutrition limitations include lack of breastfeeding awareness, employer support, and parent education; and difficulty reaching this group outside of pediatricians’ offices.

Child Health

• There have been increased efforts through child care centers, YMCAs, Boys and Girls Clubs, schools, and others to focus on healthy nutrition and exercise.
• The Idaho Oral Health Alliance has reconvened their Healthy Me is Cavity Free Steering Committee to focus on improving oral health for children ages 0-6.
• Childcare and school readiness limitations include lack of accessible early education, no state supported preschools or universal access to preschools, the need for after school care, and available and affordable daycares.
• Oral health limitations include geographic distance to providers, lack of education on the importance of dental health for long term health outcomes, and the undervaluation of starting dental health at early ages.

Adolescent Health

• Between 2006 and 2018, Idaho’s teen pregnancy rate decreased 27.2% and live births to teens decreased 23.4%.
• A suicide prevention hotline operates 24 hours per day, seven days per week.
• Idaho’s Independent Living Program assists youth ages 14 to 21 in developing the skills necessary to successfully transition from foster care to independent living.
• Mental health/suicide/bullying limitations include stigma, lack of funding, lack of mental health practitioners in rural areas, Idaho’s high rate of suicide, lack of high school counselors, cyber-bullying, and a lack of integration of mental health services into primary care settings.

CSHCN

• Key challenges, including access to specialists and the need for care coordination, have been identified as priorities and are being addressed.
• Community-based resources often exist, though they are not always known to parents of CSHCNs.
• Early identification of cognitive, social, and emotional problems is a key component of Idaho’s MIECHV program, as is sharing resources for families whose children are identified with developmental delays.
• Care coordination limitations include capacity, ownership, disparate systems that communicate poorly, administrative burden, no reimbursement or funding source, and lack of standardized processes, entry points, and referrals.
• Limitations to specialist access include lack of specialist choice, prolonged timeframes for assessment, lack of knowledge about referral sources outside of area, and cost for travel and care.

Analysis of MCH Block Grant Efforts to Address MCH Population Needs

The MCH leadership team met following a review of the results of the prioritization processes to decide upon the final seven to 10 state priority needs. These priority needs were presented to Division of Public Health leadership for review and approval. Leadership developed and selected ten state priority needs to ensure that needs of all six MCH population domains were represented.

The following ten priority needs have been selected for the 2021-2025 state action plan:

1. Increase percent of women accessing prenatal and well-woman health care
2. Support services, programs, and activities that promote safe and healthy family functioning
3. Decrease substance abuse among maternal and child health populations
4. Improve breastfeeding rates
5. Decrease the prevalence of childhood overweight and obesity
6. Improve childhood Immunization rates
7. Improve maternal and child health population access to medical and dental homes
8. Promote smooth transition through the life course for CSHCN
9. Improve access to medical specialists for children and youth with special health care needs
10. Improve social determinants of health and promote health equity for maternal and child health populations

Current Title V-specific programmatic approaches were assessed by MCH leadership, including discussion of where current efforts are working well and should be continued, and areas in which new or enhanced strategies/program efforts are needed.

Women/Maternal Health

• Improvements have been made in the Family Planning Program by inclusion of federally-qualified health centers as Title X providers, by adding the support of a Health Program Specialist to assist with program coordination, and improving program operations through Title X policy clarification and development.
• Improved services and resources are now available to eligible pregnant women and mothers through the MIECHV program.
• Increased capacity to address maternal mortality has been added by dedicating a full-time employee (FTE) to oversight and coordination of the Maternal Mortality Review Committee.
• Enhancements could be made through improving collaboration between the MCH Program, MIECHV, and WIC Program as WIC services are accessed by women and children who are often eligible for Title X and MIECHV program participation.

Perinatal/Infant Health

• The Idaho NBS Program now screens for 47 conditions with the recent addition of universal screening for critical congenital heart defects (CCHD). This is well above the minimum core conditions as identified by the Recommended Uniform Screening Panel per the Advisory Committee on Heritable Disorders in Newborns and Children.
• Improved services and resources are now available to eligible pregnant women and mothers through the MIECHV Program.
• Improvements have been made in collaboration between the MCH Program and MIECHV Program in advancing safe sleep education and assessment.
• Enhancements could be made through improving collaboration between the MCH Program, MIECHV Program, and the WIC Program as WIC services are accessed by women and children who are often eligible for MIECHV Program participation.

Child Health

• Through collaborations with healthcare providers and schools, the DHW Idaho Immunization Program has helped increase the percentage of children vaccinated according to the recommended schedule.
• Idaho maintains a Child Fatality Review Team to complete systematic and collaborative reviews of all deaths of children under the age of 18.
• Improved services and resources are now available to eligible young children through the MIECHV program.
• Enhancements could be made through improving collaboration between the MCH Program, MIECHV Program, and the WIC Program as WIC services are accessed by women and children who are often eligible for MIECHV Program participation.

Adolescent Health

• The Idaho Suicide Prevention Hotline now operates 24 hours per day, seven days per week.
• Targeted substance use prevention programs are operated throughout the state by numerous organizations and many of these programs specifically serve adolescents.
• Title X Family Planning, Adolescent Pregnancy Prevention, and Sexual Violence Prevention programs all provide preventive services to adolescents.
• Enhancements could be made through improving coordinated adolescent programming across the Division of Public Health and considering other ways to enhance adolescent health.

CSHCN

• There are close collaborations between DHW and those who provide services to, advocate for, or are parents of CSHCNs. The CSHCN Director is a member of the IPUL advisory board and on the Idaho Council on Developmental Disabilities. The MCH Health Program Specialist is a member of Idaho Sound Beginnings. An effort to improve collaboration included the inclusion of two parents of CSHCNs at the 2020 Title V MCH State Prioritization Meeting.
• The Transition to Adult Health Care toolkits developed by DHW have been well received by users. As consumer preferences continue to shift toward digital resources and social media platforms, utilization of toolkits could be enhanced by exploring how to make them more user friendly and accessible.
• The Children's Special Health Program is a legislatively-defined, financial support program for children with certain diagnoses who do not have health insurance. Enrollment has decreased since 2015 due to families gaining insurance through Your Health Idaho. The MCH Program must explore ways to repurpose the program to continue serving CSHCN.
• While efforts have been made to improve collaboration with CSHCNs’ families and community partners, enhancements to these efforts are warranted. The MCH Program must continue to identify and develop strategies to include family input and feedback.

Cross-Cutting/Systems Building

• Idaho enacted Medicaid Expansion in January 2020, with an estimated 84,000 residents gaining insurance coverage so far.
• The Division of Public Health has developed a new approach to braiding funding to support building healthy and resilient communities through the Get Healthy Idaho initiative. This population-level plan aims to improve health outcomes, lower healthcare costs, reduce health disparities, and improve health equity through shared alignment and collective action across programs and with partners.
• Enhancements could be made between the MCH Program, other DPH programs, and external partners to support collaboration and workforce training efforts. Opportunities exist to support learning collaboratives, Project ECHO models, and similar training models to increase providers’ knowledge to serve MCH populations with special needs and complex conditions.

Title V Program Capacity

Organizational Structure

(i) The State Title V Agency in Idaho exists within the Division of Public Health, Idaho

Department of Health and Welfare (DHW). The DHW was formed in 1974 pursuant to Idaho Code 39-101 to “promote and protect the life, health, mental health, and environment of the people of the state.” The Director is appointed by the Governor and serves “at will.” S/he serves as Secretary to the state’s Health and Welfare Board

which is charged with formulating the rules and regulations for DHW. Administrative oversight of the MCH block grant is vested with the Bureau of Clinical and Preventive Services (BOCAPS). Other programs in BOCAPS are HIV Care/Prevention, Viral Hepatitis, STD, Syringe Exchange, WIC, and MCH programs. The MCH Section includes the Children’s Special Health Program, Newborn Screening, MIECHV, MMRC, Family Planning, and Adolescent Pregnancy Prevention.

(ii) The following comprises a listing of programs and activities that Title V MCH funds in support of the administration (or supervision of administration) with allotments under Title V [Section 509(b)]: MCH Needs Assessment/contractor; MCH Epidemiology; Oral Health Program; Physical Activity and Nutrition; Title X Family Planning Program; Idaho Careline (2-1-1); Idaho Poison Control Center; Children’s Special Health Program; Newborn Screening Program; Pediatric Specialty Clinics; Perinatal Surveillance; Suicide Prevention Program, and Tobacco Prevention and Control Program. Other special projects include: medical provider learning collaboratives and Project ECHO models, Safe Sleep training and education; Transition to Adult Healthcare toolkits; WIC Breastfeeding Summit; and Maternal Mortality Review Committee.

(ii) While the Title V Program does not provide rehabilitation services for blind or disabled children who receive Title XVI benefits, there are other areas in which the program has capacity to serve CSHCN. Outlined below are the areas in which the program is addressing the National Consensus Standards for Systems of Care of CSHCN:

• Identification, Screening, Assessment, and Referral. The NBS Program addresses this domain by ensuring all Idaho newborns have access to screening of conditions on the Recommended Uniform Screening Panel (RSUP), except for X-LAD and SMA.
• Eligibility and Enrollment in Health Coverage. Title V funds the Children’s Special Health Program, a state-governed financial assistance program for uninsured children with significant health problems or chronic illnesses/conditions requiring long-term medical treatment and rehabilitative measures.
• Access to Care. The Title V Program financially supports travel and services for various specialty clinics throughout the state, including: genetic, cardiac, endocrinology, cranial/facial, orthopedic, and rehabilitative clinics.

• Community-Based Services and Supports. The MCH program has an established relationship with the state’s Family to Family Health Information organization to help enhance the organization’s capacity to provide technical assistance and systems navigation to families of CSHCN.
• Transition to Adulthood. The MCH Program utilizes its partnership with IPUL to develop comprehensive digital resources for transition to adulthood for CSHCN.
• Quality Assurance and Improvement. The MCH Program has financially supported learning collaboratives focused on pediatric improvement and care delivery for CSHCN across a range of topics. The MCH Program is exploring implementation of Project ECHO with the goal of increasing knowledge and capacity of Idaho primary care providers to link to pediatric specialists and help increase specialty care to CSHCN. 

MCH Workforce Capacity

The State Title V MCH Program strives to implement the core public health functions and to achieve increased accountability through ongoing performance measurement and monitoring by supporting an adequately-sized and skilled workforce.

(i) The MCH Program has two Full Time Equivalent (FTE) professionals holding administrative positions (Katherine Humphrey, Maternal and Child Health Programs Section Manager 1.0 FTE; and Sarah Lopez, CSHCN Director 1.0 FTE). Additionally, the MCH program has five support staff (Xenya Poole, Health Program Manager 1.0 FTE; KD Carlson, Health Program Specialist 1.0 FTE; Ana Vidales, Health Education Specialist 0.5 FTE; Dana McKee, Registered Nurse 0.5 FTE; and Carrie Weaver, Administrative Assistant 0.7 FTE).

(ii) Senior level management who serve in lead MCH-related positions include Katherine Humphrey, Title V MCH Director, and Sarah Lopez, CSHCN Director. Ms. Humphrey’s professional experience includes HIV prevention, adolescent health and pregnancy prevention, and family planning services. Ms. Lopez’s professional experience consists of early childhood development, newborn screening, and children with special healthcare needs. The MCH Program’s data analysis capabilities are supported by Andrew Bourne and Ward Ballard, who fulfill Research Analyst Principal positions.

The State Title V Program’s planning and evaluation capacity is supported by a contract for services with Boise State University’s Center for Health Policy.

(iii) The Title V program has had the privilege of forming a working relationship with Angela Lindig, the executive director of Idaho Parents Unlimited (IPUL), the state’s designated Family to Family Health Information Center. Ms. Lindig is also a parent of a child with special health care needs, a well-known advocate for CSHCN and their families, and serves as the Title V Family Leader. The MCH Program maintains a contract with IPUL to fulfill these important functions for the Title V block grant.

(iv) Over the past year, the MCH Section has undergone many staff changes. Jacquie Watson, the Title V MCH Director, and Yvonne Niedergesaess, the CSHCN Director, both left the organization. Katherine Humphrey, former Title X Family Planning Program Manager, accepted the Title V MCH Director role, and Sarah Lopez transitioned from the MCH Program Specialist to the CSHCN Director. Other changes include the addition of Xenya Poole as the new MMRC Program Manager, KD Carlson as the MCH Program Specialist, the addition of Ivie Smart as the new Title X Family Planning Program Manager, and Jen Liposchak as the MCH State Adolescent Health Coordinator in addition to her duties as Adolescent Pregnancy Prevention Program Specialist.

In September 2019, the MCH Program was allocated a 1.0 FTE Health Program Manager position, which increased capacity across the section. This position will lead MMRC implementation and Perinatal Quality Collaborative (PQC) development, along with other MCH activities in support of the state action plan. The MCH Program anticipates funding a Medical Claims Examiner 0.25 FTE position in fall 2020 in place of an external contractor in this role.

Title V Program Partnerships, Collaboration, and Coordination

Most often, the MCH Program serves as a convener, collaborator, or partner to move the needle on MCH issues. The following partnerships, collaborations, and coordination exit between the MCH Program and other programs as identified by category.

 (a) Other MCHB investments in Idaho:

• State System Development Initiative (SSDI) Grants
• MIECHV Grants
• Early Childhood Systems of Care (ECCS) Grants
• Universal Newborn Hearing Screening and Intervention grants
• Family to Family Health Information Center grant
• Emergency Medical Services for Children grant
• Community Integrated Services grant

 (b) Other Federal investments in Idaho:

• WIC services at more than 50 clinics provide these services statewide
• CDC-funded programs, including Women’s Health Check Breast and Cervical Cancer Screening, HIV Prevention, and Sexually Transmitted Disease Programs
• Title X Family Planning Program
• Idaho Immunization grant
• Adolescent Pregnancy Prevention grants funded by ACF/FYSB

(c) Other HRSA investments in Idaho:

• The Idaho Emergency Medical Services for Children (EMSC) Project, which provides for essential pediatric equipment and supplies to EMS providers
• The Idaho Ryan White Part B Program, which provides medical case management for persons with HIV disease
• Federally Qualified Health Centers (FQHCs) to provide family planning services in underserved areas

(d) Other MCH programs in Idaho:

• Idaho Perinatal Project
• March of Dimes
• Idaho Sound Beginnings
• Idaho Voices for Children
• Idaho Chapter of the American Academy of Pediatrics (AAP)
• Idaho Early Childhood Advisory Council
• Idaho Head Start
• Idaho Oral Health Alliance
• Hunger Relief Task Force
• Idaho Academy of Nutrition and Dietetics

(e) Other DHW programs in Idaho:

• Child Care Program
• Child Protection Program
• Children’s Mental Health Program
• Developmental Disabilities Program
• Early Hearing Detection and Intervention (Idaho Sound Beginnings)
• Adolescent Pregnancy Prevention Program
• Substance Use Disorder Services Program
• Suicide Prevention Program
• Infant Toddler Program
• Tobacco Prevention Program
• Idaho Immunization Program
• Idaho Medicaid
• Idaho Physical Activity and Nutrition Network (IPAN)
• Idaho Oral Health Program
• Public Health Integration Team (PHIT)
• Get Healthy Idaho
• Idaho Vital Records and Statistics
• Comprehensive Cancer Alliance of Idaho

(f) Other government agencies in Idaho:

• Idaho Commission on Hispanic Affairs.
• Idaho Department of Juvenile Corrections
• County Probation Departments
• County Juvenile Detention Centers
• Idaho State Department of Education

(g) With Tribes or Tribal organizations in Idaho:

• As specified under the Indian Child Welfare Act of 1978, DHW works closely with Idaho’s six federally-recognized tribes.
• DHW maintains a health equity/cultural liaison with the tribes on health issues

(h) With public health, health professional educational programs, and universities:

• Idaho Child Welfare Research Training Center
• Title IV-E child welfare student stipends support students at EWU
• Boise State University
• Idaho State University
• Lewis and Clark State College
• University of Idaho

(i) Other State, public, and private organizations that serve MCH populations in Idaho:

• Local Public Health Districts
• St. Luke’s Children’s Hospital in Boise
• Family Medical Residency of Idaho
• Idaho Coalition on Sexual and Domestic Violence
• Centro de Comunidad y Justicia

Identifying Priority Needs and Linking to Performance Measures

The MCH Leadership team focused on assessing collaborations and partnerships along with synthesizing the needs assessment (NA) data and the stakeholder prioritization meeting outcomes for identifying priority needs and linking them to national performance measures. It is worth noting that the emergence of the COVID-19 pandemic in spring 2020 presented many challenges in meeting with partners and fostering the inclusive input and collaboration desired by the MCH Program. Efforts to increase stakeholder engagement and collaboration will continue to be a focus in the years to come.

Methodologies

The methodologies utilized to arrive at the final selection of ten priorities for the state action plan included: 1) a review of the 2020 needs assessment data and final report; 2) alignment with outcomes from the stakeholder prioritization meeting; 3) discussions with DPH and MCH leadership; and 4) an assessment to identify strengths, opportunities, and capacity for partnership and collaboration with organizations serving MCH populations. Each priority, along with the selected national performance measure (NPM) or state performance measure (SPM), is discussed by MCH domain.

Emerging Issues and Needs

The emergence of coronavirus (SARS-CoV-2) and subsequent COVID-19 disease continue to be developing issues that have long-term health impact and evolve daily. As a result, it is challenging for MCH staff and MCH EPI staff to stay on top of the volume of related communications and guidance. Idaho’s economy has been influenced by this crisis as well. While the pandemic continues to strain government and health care systems, the final implications on MCH capacity and MCH populations is yet to be determined. As of September 1, 2020, Idaho had 32,368 cases and 368 deaths due to COVID-19, and these numbers are being continuously updated.

Two additional cross-cutting issues highlighted in the 2020 NA were the challenges of substance use/abuse and improving mental health among MCH populations. The MCH Program has made progress in building relationships and capacity to address these priorities since the 2015 NA. The 2021-2025 state action plan addresses these issues predominantly by supporting systems-building, workforce development strategies such as topical learning collaboratives, Project ECHO models, and community-led, population health initiatives as flexible strategies that can pivot to address emerging needs. The development of a perinatal quality collaborative (PQC) will serve as another avenue for addressing emerging issues such as these in the years to come. The MCH Program continues to develop its relationships with the Suicide Prevention Program and external partners as another way to support strategies for address these priorities in the Adolescent Health domain.

Selected Priorities and Performance Measures by MCH Domain

Following assessment by the MCH Leadership team, Idaho has developed the following ten priority areas as outlined by domain:

Women/Maternal Health

• Increase percent of women accessing prenatal and well-woman health care
• Support services, programs, and activities that promote safe and healthy family functioning
• Decrease substance abuse among maternal and child health populations

Based on the 2020 NA, the first priority is centered on results indicating the need to focus on routine care for women, including prenatal care for pregnant women. In 2018, 79.7% of pregnant women initiated prenatal care during the first trimester. In 2017, 49.7% of Idaho women had a well-woman visit in comparison to 66.5% of women nationally (PRATS). Therefore, the priority to “Increase percent of women accessing prenatal and well-woman health care” was continued from the previous state action plan and linked with NPM 1: Well-Women Visits.

Preconception health, mental health/substance abuse treatment, access to health care, self-care, parenting education, and prenatal care were also identified as significant priorities for women of reproductive age and pregnant women. The priority of “Support services, programs, and activities that promote safe and healthy family functioning” was continued from the previous state action plan and continues to be linked with NPM 1: Well-Women Visits to support new strategies as outlined in the Women/Maternal Health application plan.

The 2020 NA indicated 9.1% of women smoked at any time during pregnancy statewide from 2014-2018. American Indian/Alaskan Native women had the highest rate of smoking during pregnancy at 16.4%. Non-Hispanic women had over two times the rate (10.1%) of smoking at any time during pregnancy than their Hispanic counterparts (4.0%). Frontier women had the highest rate (14.6%) of smoking any time during their pregnancy when compared to rural (9.5%) and urban women (8.6%) in Idaho. The priority to “Decrease substance abuse among maternal and child health populations” was also carried over from the previous state action plan and linked with NPM 14.1: Percent of women who smoke during pregnancy.

Perinatal/Infant Health

• Improve breastfeeding rates
• Support services, programs, and activities that promote safe and healthy family functioning

Based on outcomes from the 2020 NA and stakeholder prioritization process, Idaho intends to continue with the same priorities and NPMs that were identified in the state action plan for the Perinatal/Infant Health domain in previous years. This includes improving breastfeeding rates (NPM 4), increasing the percent of infants placed to sleep on their backs (NPM 5), and injury prevention for children under 5 years of age (SPM 3).

While Idaho women (90.1%) compared favorably in 2017 to the national percentage for percent of infants ever breastfed (83.2%), breastfeeding duration is significantly lower at 63% for the 2014-2018 time period (Idaho PRATS). Breastfeeding initiation is lowest among American Indian/Alaskan Native women (86.9%) and highest among Black women (96.8%). Breastfeeding duration is also lowest among American Indian/Alaskan Native women (58.7%) and highest among Black women (79.1%). Hispanic women in Idaho had higher prevalence of both breastfeeding initiation (94.6% versus 90.0%) and duration (64.5% versus 50.7%) than their non-Hispanic counterparts. “Improving breastfeeding rates” will continue as a priority in the 2021-2025 state action plan.

Safe sleep education, especially in rural areas and among Hispanic populations, continues to be a priority based on the 2020 NA and key informant interviews. While Idaho (84%) compared positively in 2017 to the national percentage (79.5%) of infants placed to sleep on their back, only 70% of Idaho infants were reported as sleeping alone between 2014-2018. Hispanic women in Idaho were less likely to report that their babies sleep alone than their non-Hispanic counterparts (49.8% versus 72.6%). Frontier (61.9%) and Rural (65.2%) women had a lower prevalence of placing babies to sleep alone than Urban women (71.8%).

Key informant interviews indicated that, “Safe sleep or unsafe sleep practices still are quite high among the fatalities we see in Idaho.” The priority of “Support services, programs, and activities that promote safe and healthy family functioning,” will be used to justify strategies that focus on promoting safe sleep practices and activities that seek to lower the unintentional death rate of children under 5 years of age.

Child Health

• Decrease the prevalence of childhood overweight and obesity
• Improve childhood immunization rates
• Improve maternal and child health population access to medical and dental homes

In 2019, Idaho’s children fared better then children nationally for maintaining a healthy weight, 25.2% compared to 31%. In the same year, 32% of Idaho’s children between the ages of 6 and 11 were physically active for at least one hour. Despite these low numbers, Idaho identified decreasing the prevalence of childhood overweight and obesity as a priority need. The 2020 NA highlighted a significant difference in the selection of nutrition and physical activity as a health need for young children ages 1-5 in urban counties (23%) in comparison to rural/frontier counties (0%). Similarly, nutrition and physical activity as a health need for children ages 6-11 was identified at a higher rate in urban counties (34%) than rural and frontier counties (7%). Therefore, the priority to “Decrease the prevalence of childhood overweight and obesity” will continue from previous years, however, the strategies will shift focus to reaching older children in more populated areas where measurable improvement can still be made. This priority is connected to NPM 8.1: Percent of children, ages 6 through 11, who are physically active at least 60 minutes per day.

Based on the 2020 NA and key informant interviews, the MCH team has chosen to continue the priority need to “Improve childhood immunization rates.” The MCH Program will use the state-created performance measure SPM 1: the percentage of children at kindergarten enrollment who are adequately immunized to measure progress on this effort. Key informants cited cultural resistance to immunizations and indicated that they encounter many families that refuse immunization. One interviewee stated there is a high level of “vaccine mistrust, physician mistrust is a really big deal and I have been really shocked at how many of the newborns do not get vaccinated and (parents) won’t even have a conversation about it.” For 2014-2018, Hispanic mothers in Idaho had a lower prevalence (87.9%) of having their baby’s immunizations up to date than their non-Hispanic counterparts (95.4%). Urban women (89.8%) had the highest prevalence of having their baby’s immunizations up to date when compared to Rural (85.65%) and Frontier (85.25%) women.

During the 2020 Needs Assessment, Idaho also identified oral health and dental care as a top health need that will continue from the previous state action plan. The priority to “Improve maternal and child health population access to medical and dental homes” will be connected to NPM 13.2: Percent of children, ages 1 through 17, who had a preventive dental visit in the past year. Oral health arose as a top health need among provider survey respondents for young children (ages 0-5) with comments regarding dental care, access to oral health, preventive dental care, regular checkups, early childhood caries, oral health screenings, and assistance finding dental homes as aspects of this need. Oral health was also a top need identified for children ages 6-11, with the need for oral health in general, sealants, proper brushing, school outreach for proper brushing habits, dental screening, and affordable dental care were specifically mentioned by survey respondents. Oral health/dental care was more often selected as a need by survey respondents in the eastern (28%) and southwestern regions (22%) than by those in the north regions (0%) of Idaho. Additionally, 37 out of 44 Idaho counties are designated as population group Dental Health Professional Shortage Service Areas. Another 6 six out of 44 counties are considered geographic Dental Health Professional Shortage Service Areas.

Adolescent Health

• Support services, programs, and activities that promote safe and healthy family functioning

In the 2021-2025 state action plan, the MCH Program is shifting away from NPM 10: Adolescent Well-Visits to NPM 9: Bullying. The 2020 NA results continued to indicate a lack of access to mental health services as a priority across the life course. Bullying was also specifically identified as an important health issues for teens in the results of the youth focus groups conducted as part of the NA. The 2019 Idaho YRBS included six questions on bullying and 21.1% of students reported they were bullied one or more times on school property. Students who are bullied are more likely to be depressed, lonely, anxious, have low self-esteem, and think about suicide.

Although completed suicide is statistically rare, Idaho continually has some of the highest suicide rates in the United States. According to the 2019 Idaho Youth Risk Behavior Survey (YRBS), suicide was the second leading cause of death among youth aged 10 to 19 in Idaho. The percentage of Idaho high school students who seriously considered attempting suicide in 2019 was 21.6% and 9.6% of students attempted suicide one or more times. The priority area to “Support services, programs, and activities that promote safe and healthy family functioning” will be used to support this important work in the state action plan.

Children with Special Health Care Needs

• Promote smooth transition through the life course for CSHCN
• Improve access to medical specialists for children and youth with special health care needs

In the 2021-2025 state action plan, the MCH Program is shifting away from NPM 11: Medical Home to NPM 12: Transition. This is due, in part, to shifting resources as a result of the COVID-19 pandemic, the needs indicated in the 2020 NA, and a capacity assessment to carry out the work with key stakeholders and partners.

Due to the progression of the COVID-19 pandemic, the existing medical home coordination project in PHD 1 reallocated their resources to focus on pandemic-related duties and terminated their agreement to provide care coordination services in their region. The medical home project in PHD 7 also concluded this year after reaching a clinic saturation point in their local area due to continuous project implementation since 2013.  Additionally, the PHD 7 coordinator who acted as the mentor and trainer for onboarding new projects left employment with the local public health district in summer 2020, and the district has indicated they do not plan to fill this position. The MCH Program does not have the capacity at this time to pursue another partner, nor the expertise to provide training on model implementation. For the 2021 application year, the MCH Program has developed a new priority and strategies that align with the 2020 NA for the CSHCN domain.

The 2020 NA found that 59% of CSHCN caregivers with children 12 years and older did not feel prepared for their child’s/children’s transition to adulthood, and only 18% stated they did feel prepared. Over 68% of survey respondents indicated they do all of the work to prepare for their child’s transition to adulthood alone, and 18% stated that no one has helped them prepare for this transition. Key informant interviews support that there are unmet needs related to transition to adulthood for children with disabilities and special health care needs. Almost 41% of parent survey respondents indicated they have not prepared for any transitions topics, and some of the most cited topics of need included addressing social needs, transportation needs, medical needs, legal needs, and independent living plans. The priority need to “Promote smooth transition through the life course for CSHCN” was developed to encompass these needs and support new strategies that will be carried out as part of the state action plan.

The 2020 NA outcomes continue to indicate access to specialty care providers as the top priority and major health care concern for CSHCN. Idaho has fewer primary care physicians per 100,000 people than any other state. Every county in Idaho, except two, are federally-designated Primary Care Health Professional Shortage Areas. On average, over 26% of parents of CSHCNs reported having to travel over 100 miles, with nearly 18% having to travel over 200 miles, to access health care services outside of their community. Access to specialty care, especially trained providers for CSHCN, was frequently cited as an unmet need in the 2020 NA. For this reason, the MCH Program will continue the priority to “Improve access to medical specialists for children and youth with special health care needs.” SPM 2: Specialist Access: Percent of children with special health care needs who needed or received specialist care in the past 12 months and experienced some problem accessing care, will also continue in the state action plan.

Cross-Cutting/Systems Building

• Improve social determinants of health and promote health equity for maternal and child health populations

Idaho MCH has identified a new priority area in the Cross-Cutting/Systems Building domain to address the 2020 NA findings and stakeholder input during the prioritization process. Stakeholders consistently identified the impact of adverse childhood experiences (ACEs) on the health outcomes for MCH populations across all domains. Some of the most frequently experienced ACEs among children included: economic hardship, parent or guardian separation or divorce, living with someone suffering from mental illness, and the impact of toxic stress. As a result of childhood ACEs, trauma-informed care was cited as one of the top five needs for women of reproductive age. 

ACEs negatively affect a child’s health and social outcomes, including increased risk for lower educational attainment, unemployment, poverty, and chronic disease. To address this, the priority to “Improve social determinants of health and health equity for maternal and child health populations” has been established to guide the 2021-2025 state action plan strategies. The creation of this priority aligns with the Idaho Division of Public Health’s (DPH) 5-year plan, Get Healthy Idaho: Building Healthy and Resilient Communities (Get Healthy Idaho). This population-level plan aims to improve health outcomes, lower healthcare costs, reduce health disparities, and improve health equity across Idaho through shared alignment and collective action across programs and with partners. One of the key ways Get Healthy Idaho seeks to do this is by addressing social determinants of health. This priority will allow flexibility to implement a variety of systems-building and workforce development strategies such as topical learning collaboratives, Project ECHO models, and community-led, population health initiatives as flexible strategies that can pivot to address emerging needs. State performance measure (SPM) 3 has been developed to measure the number of health care professionals who serve MCH populations that receive training with the goal of improving delivery and quality of care.