2.b.(i) MCH WORKFORCE DEVELOPMENT

Nebraska Title V has put in place a variety of activities to develop a workforce in the state competent to carry out essential public health services and benefit the MCH population.  Recruiting and retaining trained state-level staff supporting Nebraska's Title V activities are listed below, with title and % of FTE supported by Title V funds:

*Both Title V co-Directors oversee larger units within the DHHS organization, of which the Title V MCH Block Grant is only a part.  Their salaries are paid from a “pooled cost” account which is funded from a portion of the funds from programs under their purview.

A number of other state-level staff support Nebraska's Title V activities in a partial but valuable capacity, as listed below:

External to the Department, the MCH and CYSHCN workforce is varied and employed in a wide range of agencies and organizations, including local and Tribal health departments, Federally Qualified Health Centers (FQHC), schools, and various non-profit organizations such as family planning and WIC clinics.  Nebraska has a de-centralized public health system, meaning that regional health departments cover the state's 93 counties independently of the state health department.  While not all health departments receive funding through the Title V Block Grant, all of them have identified MCH issues as priorities through a local needs assessment process, and thus maintain the staff to work on and address them.  Agencies such as Community Action Partnerships, FQHC, and the Nebraska Children and Families Foundation are among the important partners providing MCH services at the local level.  This workforce also extends to schools, community hospitals, family planning agencies, WIC clinics, and Tribal/IHS clinics.  Importantly, there is an extensive network of private clinics and facilities offering direct care services to Nebraskans daily.

To help support the broader, statewide maternal and child health workforce, Title V has extensive activities that include provision of training, continuing education, and financial support.  The six-person team in the Maternal Child Adolescent School Health (MCASH) program provides a significant volume of continuing education to health professionals, as measured in events and audience attendance.  During COVID, transition to virtual platforms for educational delivery has gone relatively smoothly.  While training participants are frequently licensed health professionals, particularly nurses, training opportunities also are delivered to youth-serving professionals and home visitors.   In 2019, the MCASH team began developing MCH-specific training for Community Health Workers (CHW), as well as partnering with stakeholders to host in-person regional events for CHW for learning and networking within this diverse and emerging workforce.  The role of CHW is promoted as valued and respected members of effective integrated health care teams in clinical and community settings, helping to achieve population level outcomes for maternal and child health. 

Additionally, Title V participates in developing new roles for MCH workers, such as home visitors, parent resource coordinators, and the TOP ® educators working in positive youth development. Title V staff supports development and proficiency of the school nurse workforce as well as providers in birthing hospitals and clinics.  In addition to peer-approved continuing education events for health professionals, Title V facilitates Communities of Practice (with tribal health on maternal and perinatal health topics; with stakeholders interested in data-driven decision-making).

Recent training and growth opportunities for Title V program staff and family leaders include the following:

Title V:

         Great Plains Public Health Leadership Institute

         State Government Leadership Certificate program

         National conference participation including: the Title V Federal State Maternal & Child Health Partnership meeting; the national Maternal Mortality Review Information Application users conference; American School Health Association annual meeting; the National Association of School Nurses (virtual); National Association of City/County Health Officials (virtual); Association of Maternal Child Health Programs (virtual); the 17th National Shaken Baby Syndrome Conference (virtual); the Pediatric Mental Health Care Access program all-grantees meeting (virtual; NE a presenter);  Maternal Infant Early Childhood Home Visiting all-grantees meeting. 

        Title V provides capacity building training for evidence based practice, specifically including Teen Outreach Program and Healthy Families America.  In 2020 the Adolescent Health Program hosted a virtual training called “Sex Ed 101 for Nursing Professionals” originally intended for Nebraska audiences that attracted audience participation from several states.  Title V leads the LEARN project, Lactation Education Across Rural Nebraska, now in its fifth consecutive year of offering training opportunities, particularly to minority women, to become certified lactation counselors.

        Title V also participates in planning and hosting statewide conferences of significance: Recharge for Resilience 2020 (hosted and presented); Current Practices of Maternal Behavioral Health (deferred in 2020 due to COVID); the Nebraska Prematurity Summit (planning committee with March of Dimes); the annual statewide Minority Health Conference; regional training and networking events for Community Health Workers; the Annual School Health Conference (virtual in 2020), and Summer Splash (School Nurse Conference – virtual in 2020).

• In all, the MCASH team delivered 202.5 hours of training to diverse MCH audiences during the period September 30, 2018 to October 1, 2019. 

Family leaders:

• Family leader participation in Title V Steering Committee,
• Support for Parent Resource Coordinators (peer supports) at MMI. 
• Support for CHW workforce development.
• Title V is lead agency for Nebraska’s Pediatric Mental Health Care Access grant.  Through that avenue, family leader participation is supported in the form of a cross-sector advisory committee and a Technical Workgroup charged with developing a family survey. 

Innovations in staff structures and workforce financing

Staff Structures

Nebraska Title V has been working to refill and expand its internal capacity to provide epidemiological support for some time, and two exciting new developments in 2020 mark the achievement of this goal.  The Office of MCH Epidemiology enthusiastically welcomed the addition of an Epidemiology Surveillance Coordinator as well as a CDC Public Health Assignee to their team, and looks forward to the additional capacity which will allow Title V to not only improve existing surveillance, monitoring, and reporting functions but to add new projects as well.

NDHHS has a relatively long history with the CHW workforce, having offered training through the Office of Women’s and Men’s health to assist in outreach and navigation particularly for chronic health conditions.  At this time, a variety of organizations and systems are offering CHW training, yet there is no mechanism for statewide consensus and coordination of developments in the workforce nor of preparing employers, health professionals, and teams for integration of the CHW.  Title V is a partner with other leadership partners including the Public Health Association of Nebraska, the Nebraska Association of Local Health Directors, the Nebraska Action Coalition-Future of Nursing, and Community Health Workers, to continue development of the workforce in meaningful, consensus-driven ways.  In 2020, Title V contributed three noteworthy work products to support continued CHW workforce development:

• A scholarly report describing in new detail the emerging CHW workforce in Nebraska, drawing on focus groups of CHW and surveys to describe the work, interests, and perspectives of CHW working in Nebraska communities;
• A review of training opportunities for CHW in Nebraska, accompanied by recommendations for standards and methods in CHW training to address core competencies and increase validation and acceptance of CHW contributions to population health outcomes; and
• A report from a large statewide cross-sector group, which considered financing and sustainability opportunities for the CHW workforce in Nebraska, and provides an updated and timely basis for continuing consensus work to adopt standards and practices conducive to payer structures.

All of the above reports, along with “highlights” documents are available:

Also in 2020, Title V is working with a key partner at the University of Nebraska – Lincoln, Center for Children, Families, and the Law, to host an on-line discussion group and listserve for CHW; open a virtual training platform to deliver a library of MCH-related training topics for CHW; and create a mobile application of the Nebraska Resource and Referral System, which is populated with statewide resources including those to help families meet social as well as physical and mental health needs, to support the role of CHW as bridging people to resources.

Workforce Financing

In a context of changing health payment systems, it is particularly challenging to introduce new workforce models, such as including CHWs on integrated teams.  In a fee-for-service environment, providers want to see a reimbursement stream open for the work of the CHWs. However as more systems including Medicaid in Nebraska transition to more value-based pay models, the financing mechanism shifts to CHWs as an asset to achieve better health outcomes (and lower costs).  In Nebraska, Community Health Workers are working in both community level roles in local public health departments, and in clinical service systems, such as hospital networks and Managed Care Organizations.  An individual, fee for service based financing mechanism may not translate well for local health department employers of CHWs. 

The findings of the study on financing and sustainability options for CHW focused primarily on Medicaid as a means to provide for CHW through the funding of contracts with Nebraska’s Managed Care Organizations.  However the report also points to additional steps toward establishing CHW as recognized members of integrated health care teams, including improving CHW training, establishing a certification process for qualified CHW, and establishing metrics and documentation methods that demonstrate the unique contributions of CHW to care outcomes.