III.C. Needs Assessment Update
III.C.1. Ongoing NA activities
MCAH Ongoing NA Activities
Ongoing needs assessment for the MCAH population in Oregon was conducted throughout the year through various assessment and surveillance projects. Some of the ongoing activities have been described in previous needs assessment updates.
- Review of disparities and data trends in National Performance Measures, National Outcome Measures, and State Performance Measures.
- As a part of the increased focus on addressing social determinants of health, previously developed assessment and evaluation strategies, activities, and measures were reviewed and updated for use at both the state and local level, to monitor and improve efforts to address upstream risk and protective factors for maternal and child health, with a specific focus on equity. These strategies and activities can be seen in the Cross Cutting Plan: Foundations: Assessment & Evaluation, Section III.E.2.c. and in supporting document 5.
- In partnership with SSDI, ongoing quality assurance of the reporting functionality for local grantees was conducted, to ensure reliable data for evaluation and reporting purposes.
- Annual assessment of local grantee measurement and evaluation, with the provision of technical assistance as necessary.
- Ongoing collaboration with Oregon Office of Health Analytics to ensure the representation of maternal and child health outcomes, including Title V priorities, in Coordinated Care Organization metrics.
- Ongoing partnership with the Oregon Early Learning Division to develop performance measurement metrics which are inclusive of maternal and child health indicators, including those relevant to Title V priority areas. This partnership included the provision of reliable performance measurement data to the ELD, for use in their data dashboard.
- Analyzed racial and ethnic disparities in preterm birth, infant mortality, and SIDS/SUIDs related infant mortality, in partnership with the MCH Policy Team, for use in the production of a Safe Sleep Fact Sheet.
- In partnership with CSTE/CDC Applied Epidemiology Fellow and MCH Epidemiologist (CDC Assignee), conducted analysis on the association between racial and ethnic discrimination in health care settings, and the utilization of preconception, prenatal, and postpartum care. A manuscript on this analysis is being composed and will undergo the necessary approval processes with the Oregon Health Authority and CDC, for submission to a peer-reviewed journal.
- Title V Research Analyst continues to work in partnership with the Nurse and Babies First/CaCoon teams during the transition to the use of new data collection forms, and a new data collection system, Tracking Home Visiting Effectiveness in Oregon (THEO). All home visiting sites have begun using the THEO system. Babies First and CaCoon sites have provided feedback on the new data collection forms, and this feedback will be used to update language of the forms, in an effort to improve data equity for all communities served. The development of a reporting process and database to accompany the data collected is underway
- Babies First evaluation: In partnership with the MCH Nurse Team, the CDC/CSTE Applied Epidemiology Fellow, and the CDC Assignee MCH Epidemiologist, the Title V Research Analyst continued working on the evaluation of the partially Title V funded Babies First home visiting program. The first stage of the evaluation was a qualitative analysis of program processes across the state. The program was developed in Oregon based on best practices, as a safety net to serve families who are not eligible for home visiting programs with strict eligibility requirements such as Nurse Family Partnership. Since the program was designed to be flexible, each county administers the program slightly differently, so an evaluation of the processes at each site is crucial to examine the effectiveness of different components of the program. The first stage of data collection was individual qualitative interviews with staff at Babies First sites, including Nurse Supervisors, Nurse Home Visitors, and Community Health Workers. The interviews were analyzed using qualitative data analysis software, and lessons learned have been shared in a report. Next stages of the evaluation are being developed, which will include soliciting feedback from communities and clients served by the program, in an effort to improve equity of services provided.
- The Title V Research Analyst is working in partnership with the Nurse Team to evaluate the effectiveness of a pilot program to provide Babies First and CaCoon home visiting service providers with group reflective supervision.
- The Assessment, Evaluation, and Informatics (AE&I) team developed two equity goals for the coming year, as a part of a section wide effort to improve health equity. The first goal is to compare programmatic demographic data to data of communities served, to examine the equity of our service provision. The second goal is for the AE&I team to attend training as a unit on the use of strengths-based data reporting, to minimize harm and build trust with historically marginalized communities.
- Two new Key Performance Measures were developed for the Maternal and Child Health Section, examining infant mortality and maternal morbidity, specifically focusing on racial/ethnic inequities. The performance measures are being used at the level of the Public Health Division and will help to leverage resources and capacity for prevention efforts, including upstream and social determinants of health activities.
OCCYSHN ongoing NA activities
OCCYSHN conducted ongoing needs assessment activities throughout through surveillance and evaluation activities, which included:
- Review of the most recent NSCH data (2020-2021). We are particularly excited that these results included our statewide oversample for race and ethnicity.
- Review of end-of-year programmatic reports required of local public health authorities (LPHA) that contract with OCCYSHN.
- Review of data provided by LPHAs to evaluate shared care planning activities.
- Review of National Core Indicator (NCI) Child and Family Survey (CFS) statewide results (2018-2021) for Oregon. Currently, we are working with OHSU’s University Center for Excellence in Development & Disability (UCEDD) to disaggregate select results by race and ethnicity.
- Review of Oregon Consumer Assessment of Healthcare Providers and Systems (CAHPS) Children with Chronic Conditions (CCC) survey results.
- Review of Oregon Health Authority Coordinated Care Organization (CCO) annual incentive metric performance reports.
- Discussions with families during Oregon Family-to-Family Health Information Center “Table Talks.”
- One-on-one conversations with LPHAs when providing technical assistance.
- Conversations with Community Health Workers as part of program development.
III.C.2. Changes in health status and MCAH needs
OHA MCAH changes in health status and MCAH needs
Changes in health status in Title V areas of identified need are noted below.
- Well woman care: The percent of women age 18 to 44 with a past year preventive visit in Oregon decreased from 73.0% in 2020 to 65.6% in 2021. Sample size obtained by the BRFSS survey is not sufficient to disaggregate single years of data by race/ethnicity in order to examine racial/ethnic disparities.
- Breastfeeding: The rate of breastfeeding initiation in Oregon decreased slightly from 93.7% in 2018 to 87.2% in 2019 but remains higher than the national level. Exclusive breastfeeding at six months also decreased in Oregon from 36.3% in 2018 to 34.2% in 2019, but also remains higher than the national level. Disaggregation by race/ethnicity is not available from the National Immunization Survey for either of these performance measures.
- Child injury prevention: The rate of hospitalization for non-fatal injury per 100,000 children, ages 0 through 9, decreased from 125 in 2019, to 108.2 in 2020. In 2020, rates were highest among non-Hispanic Black children (192.8), followed by non-Hispanic White children (105.8), and Hispanic children (89.1). Rates were lowest among non-Hispanic Asian/Pacific Islander children (71.5). There was insufficient sample size to reliably report the rate among non-Hispanic American Indian/Alaska Native children.
- Toxic stress, trauma, ACEs, and resilience: From 2020 to 2021, the percent of new mothers who experienced at least 2 types of prenatal stress decreased from 46.6% to 41.3%. The highest rates of new mothers who experienced at least 2 types of prenatal stress were among non-Hispanic Black mothers (52.7%), followed by non-Hispanic American Indian/Alaska Native mothers (52.1%), then non-Hispanic multiple race mothers (52.0%), then non-Hispanic Pacific Islander mothers (51.8%), then Hispanic mothers (42.3%), then non-Hispanic White mothers (40.9%), with the lowest rates among non-Hispanic Asian mothers (30.5%).
- Culturally and linguistically appropriate services: From 2019/2020 to 2020/2021, the percent of children with a healthcare provider who is sensitive to their family’s values and customs increased slightly from 94.3% to 94.5%. Sample size of the National Survey of Children’s Health in Oregon was not sufficient to disaggregate data by race/ethnicity.
- Social determinants of health and equity: The percentage of children living in a household that received food or cash assistance increased slightly from 41.4% in 2019/2020 to 41.7% in 2020/2021. Sample size of the National Survey of Children’s Health in Oregon was not sufficient to disaggregate data by race/ethnicity.
OCCYSHN changes in health status and MCAH needs
- Overall, the percentage of CYSHCN who receive care in a medical home (NPM 11) has increased overtime. However, a greater portion of CYSHCN who identify as White report receiving care within a medical home than do CYSHCN who identify as a racially or ethnically minoritized. The same pattern in findings exists for receipt of services to prepare for transition to adult health care (NPM 12).
- Fewer CYSHCN with more complex health needs (41.5%) receive care in a medical home compared to CYSHCN with less complex needs (62.8%).
- Thirty-one percent of CYSHCN reported that they did not need care coordination, compared to 62% of children and youth without SHCN. Of those CYSHCN who needed care coordination, 31% did not receive effective coordination, compared to 11% of non-CYSHCN. Thirty-three-point two percent of CYSHCN with more complex health needs reported that they did not receive effective care coordination, compared with 21.8% of CYSHCN with less complex health needs.
- Eighteen percent of CYSHCN report not receiving family-centered care, which represents a higher percentage than non-CYSHCN. Similarly, a higher percentage of CYSHCN reported not getting, or experiencing great difficulty getting a referral (2.8%), compared to non-CYSHCN (<1%).
- CYSHCN are less likely to report having continuous and adequate health care insurance (NPM 15) compared to children and youth without SHCN.
- Twenty-one percent of 2020-2021 National Core Indicators Child Family Survey (NCI CFS) respondents reported that their Developmental Disability (DD) services “sometimes” or “seldom/never” changed when their families’ needs changed (similar to the rates in the prior two years). Four in ten of respondents whose child does not communicate verbally (e.g., uses gestures, sign language, or a communication aid) reported that there was “sometimes” or “seldom/never” a support worker who could communicate with the child. This represents a 33% increase from 2019-2020, and a 60% increase from 2018-2019.
- Of the 2020-2021 NCI CFS respondents, 14% reported that their child’s primary care provider, 17% of their child’s dentists, and 15% of their child’s mental health service providers “sometimes” or “seldom/never” understood their child’s disability-related needs.
- Respite care remains an unmet need for families of children who receive DD services.
- Sixty-seven percent of respondents to Oregon’s Consumer Assessment of Healthcare Providers and Systems Children with Chronic Conditions (CAHPS CCC) survey (who are insured through Oregon’s Medicaid program) reported that they were “always” or “usually” able to access specialized services for their child. This represents an increase from the two prior years.
- Three-quarters (75%) of respondents reported receiving coordination of care for their child, which is a similar result to the prior two years.
- Higher percentages of respondents’ report “always” or “usually” having access to prescription medications (86%), having a personal doctor who knows their child (88%), and getting needed information (89%). Access to prescriptions and needed information decreased from the prior two years. Having a personal doctor who knows their child has stayed roughly the same.
- The health care workforce, including the public health workforce, continues to experience capacity challenges.
III.C.3. Changes in Title V program capacity and impact of those changes on service delivery
OHA MCAH changes in Title V program capacity and impact on service delivery
Oregon’s state level Title V MCAH program has continued to stabilize after the COVID-19 pandemic, with some staff previously deployed on the COVID response returning to MCH work, and some positions which had remained vacant for long periods being filled. MCAH staff have settled into a hybrid combination of remote and in-person work. OHA’s Human Resources capacity to post and fill positions continues to be a problem however, resulting in long delays in posting and filling positions. Nonetheless, our vacant MCH OPA3 position was filled in July 2022, and three additional management positions in MCH have now been created and filled. The MCH Assessment and Evaluation Unit manager has been on intermittent military leave this year, but coverage for that position was provided by other managers and AEI staff as needed. As we move forward to prepare for the 2025 Title V Needs Assessment, the program hopes to increase capacity for family and community engagement through a combination of contracted positions during the upcoming NA cycle, and eventually full-time family/community engagement position.
At the local level, MCAH Title V capacity continues to be strained to varying degrees throughout the state. Most local public health authorities continue to experience workforce capacity issues in the wake of the COVID-19 pandemic. In some LPHAs MCH staff are being asked to fill multiple roles which takes a toll over time. For many grantees, staffing is limited, staff have resigned, and there are challenges to filling positions (especially in rural areas and where there are culturally/linguistically specific needs). The end of Pandemic emergency measures have impacted local public health and communities in a variety of ways which are just beginning to be felt and will continue to reveal themselves over the coming year (i.e. with families losing benefits due to Medicaid recertification and the end to pandemic food stamp supplements). Staff in the LPHAs suffer the ongoing impact of the public’s lack of support for their COVID-related work. MCH services which are not pandemic-related have also been impacted as bad feelings about the Public Health Department’s role in pandemic response spills over into negative feelings and treatment of staff and program offerings in MCH. Many local grantees have shifted a portion of their Title V work to conduct activities which will be positively viewed and help to re-build the Health Department’s image in the community (i.e., car seat or bike helmet events).
OCCYSHN changes in Title V program capacity and impact on service delivery
OCCYSHN’s program capacity is stable. Our Assessment and Evaluation unit lost a Program Evaluation Research Associate in February 2023. The Systems and Workforce Development, Family Involvement, and Administrative units are fully staffed, and have had no recent turnover.
At the local level, public health authorities and their partners, including clinical providers, are still negatively impacted by the pandemic. Diminished capacity affects their ability to provide services to CYSHCN and their families. Local public health authority (LPHA) capacity to conduct home visits has not returned to pre-pandemic levels, but it is slowly on the rise. Referrals to the CaCoon nurse visiting program, which dropped sharply during the pandemic, are gradually increasing. LPHAs continue to rebuild and recover relationships with area providers and families, after losing significant momentum during the pandemic.
III.C.4. Efforts to operationalize NA findings
OHA MCAH efforts to operationalize NA findings
MCAH Title V has continued this year to implement the re-structured program framework which aligns our MCAH Title V work with our 2020 Needs Assessment findings. The new framework, shown below, demonstrates our commitment to align Title V policies and programmatic work to respond to the upstream needs of social determinants of health and equity, trauma/toxic stress/ACEs and resilience; and culturally/linguistically responsive services. These 3 state priority areas are being approached in an integrated manner as “Foundations of Maternal, Child, and Adolescent health. Work across the Foundations areas is focused on policy & systems; workforce capacity and effectiveness; community, individual and family capacity; and assessment and evaluation. Domain-specific work on national priorities (well woman care, breastfeeding, child injury, and bullying prevention) is also being conducted in sync with and using the lens of our Foundations work. All plans for the coming year in the state action plan reflect these efforts to operationalize our state’s needs assessment findings.
OCCYSHN efforts to operationalize NA findings
OCCYSHN continues to use 2020 needs assessment findings to inform our annual block grant planning and implementation. For example, key findings showing that CYSHCN who are members of Black and Latinx communities experience intuitional and personally mediated racism serve as an impetus for us to incorporate health equity and antiracism into our work as described in our state action plans. Additionally, OCCYSHN continues to focus workforce development and infrastructure building strategies on promoting family-centered, integrated cross-systems care coordination for CYSHCN.
III.C.5. Changes in organizational structure and leadership
OHA MCAH changes in organizational structure and leadership
Changes in state MCAH Title V leadership and staffing over the past year have been as follows:
- Catalina Aragon joined the MCH Section in August2022 as the new MCH Policy and Programs Manager
- Allison Potter joined the MCH Section in July 2022 as an OPA3 Title V program analyst and the new coordinator for the Oregon Mothers Care Program.
- Two additional management positions have also been added in MCH. Although these do not directly work on the MCAH Title V program, the increased management capacity reduces burden on the Title V Director and frees up additional capacity for cross-system policy work.
- Rosalyn Liu has taken a position as interim manager of the Adolescent Health, ScreenWise & Reproductive Health Section, and Wes Rivers has stepped into her role as Adolescent and School Health Unit Manager and Title V Adolescent Health Coordinator.
Changes in local level public health leadership have been extensive over the past several years – both among administrators and staff leading MCH programs. The stress of the COVID-19 response and its aftermath is resulting in continuing resignations and strains on local public health capacity.
- More than half of local public health administrator positions have turned over in the past three years.
- One LHPA has ceased operating entirely and ceded their local public health authority to the state, which is conducting only state mandated public health functions in that county. Two other LPHAs have stopped providing MCH Title V funded services.
- There has also been extensive turn-over in local public health MCH staffing due in part to retirements and resignations brought on by the stress of the last several years on local MCH programs.
The State Title V program has adjusted program and reporting structures to accommodate strained local public health capacity and help to ensure maximal support for the MCH population during the pandemic. The state and local Title V are also engaging jointly in a year-long Learning Journey with the National MCH Workforce Development Center to identify additional supports for the MCH workforce – especially in rural communities.
Multiple changes in organizational structure at the higher levels of the OHA and its’ Divisions have occurred over the past year. The end of the Pandemic Emergency response resulted in the dismantling of OHA’s COVID Response and Recovery Unit, with many resulting leadership changes across the agency. In addition, the election of Governor Kotek to office in November 2022 resulted in the replacement of multiple state agency heads including the OHA Director and the Director of Behavioral Health. An interim OHA director, David Baden, is currently filling the position while a search for a permanent Director is underway.
An additional OHA structural change this year has been the implementation of shared equity and public health modernization funding for Community Based Organizations (CBOs) across Oregon. This is a key component of OHA’s commitment to community engagement and equity. The CBO funding opportunity braided funding from multiple state and federal sources and programs, with the goal of simplifying the process for CBOs to engage with OHA by blending funding for 8 program areas into one shared application, with a commitment to shared workplan, reporting, and budget tracking requirements. A total of $31 million was awarded to 147 CBOs for work spanning Adolescent and School Health; Commercial Tobacco Prevention; Communicable Disease Prevention; Emergency Preparedness; Environmental Public Health and Climate Change; HIV/STI Prevention and Treatment; ScreenWise: Breast and Cervical Cancer Prevention; and Overdose Prevention. Although this is not a direct change in MCAH Title V capacity, our program partners in the work and the impact of this structural and capacity change on MHAC population in marginalized communities throughout the state cannot be over-stated. Community based organizations across the state are implementing upstream equity and public health projects. They are supported by a diverse team of community engagement specialists, whose focus is on reducing barriers and ensuring that local communities and agencies have the support they need from the state. Although MCH Title V funding is not included in the grants, the Title V Program is working in partnership with the newly funded grantees and programs to support the equity work as it impacts MCAH populations.
OCCYSHN changes in organizational structure and leadership
OCCYSHN has not experienced organizational structure or leadership changes within our center, the Institute on Development and Disability, or the OHSU Department of Pediatrics.
In September 2022, OCCYSHN’s Director, Benjamin Hoffman M.D., was elected president of the American Academy of Pediatrics. He serves as president-elect for calendar year 2023, and he will take over as president for 2024. While this national position comes with considerable responsibility, Dr. Hoffman has time and remains committed to leading OCCYSHN. His growing knowledge of the people and policies affecting CYSHCN nationally is valuable to OCCYSHN. He also brings a deep understanding of the issues facing Oregon CYSHCN to his national advocacy for children’s health.
III.C.6. Emerging public health issues and capacity to address them
OHA MCAH Emerging public health issues and capacity to address them
Key emerging MCAH public health issues in Oregon this year include the “long tail” of the COVID-19 pandemic and its many impacts on the MCAH population, as well as ongoing issues of racial justice and equity, and mental and behavioral health.
- Women, children, youth, and families in Oregon continue to experience the impacts of the COVID-19 pandemic. These impacts span the social, educational, financial, developmental, and mental/emotional health realms.
- The need to focus on racial justice and equity as core public health work continues to emerge and evolve. This is an ongoing issue, but the disparities and injustice of the past several years – due to the pandemic, to police and other racial violence - have elevated the issues and our need to focus public health capacity and resources directly on anti-racism work. The new proposed NPM examining racial and ethnic discrimination during healthcare is a timely addition to Title V work being conducted in Oregon. We have recently completed an analysis examining the association between racism in healthcare and the utilization of preconception, prenatal, and postpartum care among communities of color, and have found a need for additional resources to be allocated to this issue.
- Increasing problems related to housing/homelessness and their impact on health are very significant for the MCAH population in Oregon. The Title V MCH program is partnering with Oregon’s Medicaid program and other state partners to find opportunities to address housing/homelessness as and MCH issue. Both the Legislature and Oregon’s new Medicaid 1115 Waiver will provide some additional resources to address this issue but needs continue to far outstretch resources.
- With the Supreme Court overturn of Roe v Wade and other court battles over access to gender affirming care, issues related to reproductive health and sexual or gender identity (SOGI) have arisen as more prominent concerns for the MCAH population.
- Mental and behavioral health needs of women, children, youth, and families have also escalated during the past several years. The need for culturally responsive mental health and addiction services for children, youth and families has never been greater. The state is working to respond in a variety of capacities, but at this juncture needs far outweigh capacity.
OCCYSHN emerging public health issues and capacity to address them
As OCCSYHN becomes aware of findings, reports, or current events that describe issues affecting CYSHCN, and populations of CYSHCN, and their families, we share them with applicable partners, particularly when we lack capacity to act. During FY22, we successfully advocated for including YSHCN and transition in Oregon’s 1115 Medicaid waiver and the reinstatement of EPSDT outside of the Waiver. Currently, and into FY24, we will work with OHA’s Medicaid program to solidify YSHCN eligibility criteria for CMS-approved expanded benefits. We will continue to promote our CYSHCN-focused training for community health workers and seek to adapt it for the Latinx population. This effort addresses lack of effective care coordination and workforce shortages, as well as promoting culturally sensitive care for a minoritized population of CYSHCN and their families.
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