Needs Assessment Update

Vermont continually reviews MCH data and gaps in services. Vermont’s COVID-19 has impacted MCH efforts over the two and a half years, as the majority of MCH staff were deployed for a large percentage of the response to the Department’s Health Operations Center (HOC). MCH is proud of this work including contact tracing and index patient interviews, quality improvement and data review to support contact tracing efforts, standing up the School and Childcare branch of the COVID-19 response, leading the effort to create a case manager program for Vermonters in need, and taking on leadership roles in the state response. Our needs assessment update includes the following:

• VT MCH’s Strategic Plan, aligns with our Title V framework, and we plan to update our Strategic Plan and process for Title V reporting in 2023.
• Annual review of MCH outcomes at the district, county & state level for key MCH topics: infant mortality, LBW, preterm delivery, pre-pregnancy BMI & weight gain during pregnancy, prenatal care entry, adequacy of prenatal care utilization, smoking around pregnancy, teen birth/pregnancy rates & new families at risk. A Vital Statistics bulletin is posted annually.
• Our Division of Health Surveillance publishes regular data briefs on key MCH topics & special populations including PRAMS, BRFSS, YRBS, & School Health Profiles. While some of this work has been delayed as staff worked on the COVID-19 response, with additional COVID-19-specific capacity being added at the Health Department, we anticipate we will soon be able to dedicate additional time to this work.
• VT finalized the State Health Assessment and State Health Improvement Plan in 2018, which continues to guide our work. The SHA and SHIP help the state prioritize goals & objectives for health, monitor trends, identify gaps & track progress. The SHA/SHIP use a health equity framework, evaluating data by key populations that have experienced historical injustice. The SHIP priorities include outcomes that specifically relate to MCH topics: optimal child development, substance abuse & mental health.
• Many of our programs solicit ongoing consumer feedback through satisfaction surveys. We convene regular advisory councils that include representation from professionals & direct consumers.
• Needs assessments are regularly conducted by programs at MCH (including, home visiting and family planning) and partners such as: The Office of Head Start, Department for Children and Families and Substance Use Programs. This information is shared and incorporated into our program planning.

Overall direction for VT’s Title V needs assessment & ongoing planning is provided by the MCH Leadership Team with representation from all programmatic areas. Our 2020 needs assessment findings are helping to develop & refine materials & methods to best meet the needs of these communities.

MCH Population Needs

Women/Maternal Health

The landscape in women’s health services continues to improve. Through the VT Blueprint for Health, women’s health providers provide enhanced health & psychosocial screening along with comprehensive family planning counseling & timely access to LARC. These screening efforts align with perinatal mood and anxiety disorder screening through the Screening, Treatment, and Access for Mothers & Perinatal Partners (STAMPP) cooperative agreement with HRSA. The Blueprint for Health provides staff capacity, training, & payments to support effective follow-up to provider screenings. New laws codify the ACA’s contraceptive coverage rules into state law. Currently, there is a constitutional amendment on the ballot to codify the right to abortion services.

Nurse home visitors, parent educators, & WIC staff regularly screen pregnant women for tobacco use & refer to the Quit Line resources & medical follow up. MCH and it’s partner division: Substance Use Programs is gearing up to lead a strategic planning process around substance use in pregnancy and early parenting to identify gaps and improve systems and coordination, as well as inform programmatic efforts for Opioid Abatement funds. Vermont’s Perinatal Quality Collaborative is gaining more momentum and deeply engaged in multiple quality improvement efforts in both hospital and community settings. We have applied for the CDC PQC opportunity, which will help us to improve birth certificate quality, as well as improve clinical-community linkages to provide care and supports across fields.

Perinatal/Infant Health

VT continues to be a leader in US perinatal & infant health outcomes, including low rates of elective caesarians; perinatal regionalization; services, supports, & treatment for infants exposed to opioids; & breastfeeding initiation & duration. In recent years, Vermont passed legislation to require paid sick leave for employees, which is of major significance in supporting perinatal, infant & family health. Legislators have (unsuccessfully) attempted to pass paid family leave, which may be brought before the legislature again in the coming session. Vermont is moving forward with the expansion of postpartum Medicaid until 1 year postpartum, which is expected to launch in early 2023. Additionally, MCH is working to expand nurse and family support home visiting through Medicaid and we have a legislative proposal pending to expand the DULCE model (described elsewhere). VT is stepping up efforts around safe sleep & SUID prevention, including working with birth hospitals to implement safe sleep policies & a comprehensive messaging campaign for parents & providers. VT launched a breastfeeding strategic planning process informed by stakeholder input just before the pandemic, which we have recently begun to revisit.

Children’s Health

VT continues to expand its services & supports for early childhood. VT’s Help Me Grow system is about to celebrate its sixth birthday, demonstrating considerable successes. We have rolled out the statewide developmental screening registry with health care providers, early care & learning providers & other partners. Help Me Grow now offers online developmental screening removing barriers for families and providers. Vermont is also the lead on the HRSA ECCS opportunity and is actively engaged in statewide discussions around early childhood systems and potential restructuring.

While VT is ranked among the healthiest states for many public health indicators, we are concerned about the growing number of children who do not engage in the recommended amount of physical activity. In partnership with WIC & our chronic disease division, we are promoting physical activity recommendations in ECE environments, schools & communities.

VT is committed to strengths-based approaches to supporting children, families, & communities. In partnership with VCHIP, VT has recently reinvigorated the state’s commitment to implementing the Touchpoints approach.

Adolescent Health

VT has relatively high rates of adolescent well-visits on the National Survey but claims data & survey data with providers suggest that these are not comprehensive or quality well-visits. VT has high rates of adolescent substance use & other risk behaviors. To this end, VT was one of the first five states chosen to participate in the initial AYAH CoIIN, & we have continued our commitment to quality improvement focused on behavioral health. VT has formalized a VT Youth Advisory Council, with the goal to actively engage adolescents & young adults in strategies to create youth friendly services. In addition to improving AWVs, VT aims to promote healthy behaviors among youth through an empowerment model and coordinated linkages to after school programs.

VT has worked closely & in partnership with pediatric and family medicine providers to provide up-to-date information on COVID-19, including vaccination for adolescents as well as provide anticipatory guidance to families of babies, children, & adolescents regarding COVID-19.

CSHN

VT MCH continues to leverage substantial federal grants for systems & programs to complement the significant existing CSHN work accomplished by Title V funds for the past many years. CSHN programs have been able to move towards systems-building, population-based & enabling services to support families, a model that more thoroughly supports children & families by supporting comprehensive, coordinated, clinical service delivery, while utilizing traditional payment models. VT continues to work to improve coordination among family service entities and improve overall systems health, which we plan to do through further refinement of the role of CSHN Care Coordinators. Ongoing efforts to refine data analysis help identify gaps in & barriers to the system, to achieve a comprehensive, coordinated system of state & community services & supports.

VT Title V is in the very final phases of transitioning a large part of our Child Development Clinic to the UVM Medical Center. With Title V funding, UVMMC hired a Developmental Behavioral Pediatrician, and we’ve established an integrated clinic with child psychiatry & CDC to diagnose & treat children with concerns of developmental delay & autism. This has been years in the making & is a major success for children & families. VT continues to work closely with our partners at the Department of Mental Health, Department of Aging and Independent Living, Department for Children and Families/Child Development Division, and Department of Vermont Health Access (Medicaid). We established a working group to address barriers in accessing timely developmental assessment and evaluation, and support families in accessing resources and services even during times of long waits.

Title V Program Capacity

There have been no changes in the Title V organizational structure; although, VT also seeks to expand capacity through existing staff, new staff, & partnerships. In 2020, Breena Holmes, MD, MCH’s previous Division Director, transitioned out of her position. Dr. Holmes is now faculty at the University of Vermont Medical Center and Vermont Child Health Improvement Program and continues to work closely in collaboration with MCH. Ilisa Stalberg, MSS, MLSP, the Deputy Director of MCH, was promoted into the role of Division Director providing strong leadership, continuity of vision & mission implementation, & support for staff and partners during this challenging time in public health.

Title V/MCH sits within the Department of Health (VDH), the state’s health agency & is overseen by Commissioner of Health, Dr. Mark Levine. VDH is one of 6 departments within the Agency of Human Services, therefore enjoying joint leadership & close partnerships with: Departments of Mental Health, Health Access (Medicaid & health reform), Disabilities, Aging, & Independent Living, Children & Families, & Corrections. The AHS Secretary reports directly to the Governor. The Governor has identified increasing early childhood & higher education funding, as a continuum, as one of the top priorities of his administration.

The AHS Secretary & Governor have a strong interest in prevention & are focusing efforts on home visiting as a key strategy to ensure the healthy future of Vermonters. In fact, he allocated funds in the SFY20 budget for sustained home visiting which unfortunately was put on hold due to COVID, but work has restarted with a launch date of Jan 1, 2023. 

The MCH Division, led by Ilisa Stalberg, has primary oversight for all Title V programming. Several other federal initiatives are housed within the MCH Division: WIC administration, MIECHV, Help Me Grow, Title X, PREP, EPSDT/school health. VT’s CSHN program is under the MCH Division.

Partnerships, collaboration, & coordination – public, private, family  

VT is a small rural state with proportionally small state government agencies. Committed staff across children & family-serving state agencies work closely with each other & family organizations to address the needs of children & families. VT has many strengths & is at the leading edge of significant innovation & advancement in health care delivery & financing. Title V is actively engaged in ensuring a statewide system of services, which reflect principles of comprehensive, community-based, coordinated, family-centered care. Examples of key partnerships:

Vermont Department for Children and Families. MCH works in close partnership with the Division of Family Services to ensure public health is at the core of child welfare programming, including ensuring that all children newly entering state’s custody have up-to-date medical and dental health services. We also work very close with the Child Development Division (CDD) to align our early childhood efforts, including Children’s Integrated Services (CIS). These efforts provide a continuum of prevention & early intervention services for eligible prenatal/postpartum women, infants & children 0-6 & their families. During the pandemic, MCH worked very closely with the child care team and CIS at CDD to ensure for guidance for child care providers and timely response to emerging topics.

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

American Academy of Pediatrics VT Chapter (AAPVT). VDH collaborates with AAPVT to assist VDH in the development of more efficient & effective health care services for children & families through consultation with the health care professional community & to identify & improve systems of care for children at risk. A monthly Primary Care & Public Health Integration meeting convenes the leadership of MCH, VCHIP, AAP, AAFP, Planned Parenthood, ObGyns, & internal medicine providers, to coordinate various projects.

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

Agency of Education. MCH collaborates with the health education consultant at Agency of Education to align skills and content in our state’s approach to health education in public schools. We also work closely with AOE around essential school health services through our state school nurse consultant. AOE and MCH worked in tight partnership during the pandemic to develop policy and implement guidance for schools throughout the pandemic, including the 2022-2023 upcoming school year.

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

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

Emerging Issues

Maternal and Child Health works to align our approaches to our Governor’s platform which is:

• Growing the Economy through Expanding and Strengthening VT's Workforce
• Making VT More Affordable:
• Protecting the Vulnerable and Natural Resources
• Addressing the Opioid Epidemic
• Preserving the Environment
• Supporting Safe and Healthy Communities

Vermont’s MCH program is a leader in the state’s COVID-19 response including a focus on health equity, health & vaccine education for families and providers, and standing up the state’s School and Childcare Branch. VT is committed to continued engagement and learning around the social determinants of health & heath equity. While VT is consistently ranked as one of the healthiest states in the nation, data shows not everyone has an equal opportunity to be healthy. To further promote the understanding & recognition of SDOH, VT has engaged in several strategies, including: Bright Futures Guidelines Roadshow, and implementation of the Developmental Understanding and Legal Considerations for Everyone (DULCE) model (both described elsewhere). Additionally, through participation in the CHHS Aligning Early Childhood and Medicaid (AECM) initiative and in partnership with the ACO, VT is advancing strategies to modify how we stratify risk for children in health care payment reform.

As in all states, VT continues to work to address the opioid crisis. VT is the recipient of the HRSA funded initiative: Screening and Treatment for Maternal Depression and Related Behavioral Disorders Program. VT recently participated in ASTHO’s Opioid Use, Maternal Outcomes, and Neonatal Abstinence Syndrome Initiative Learning Community and is developing an action plan to address postnatal support for families with SUD. VT is also advancing a coordinated message around the prevention for & treatment of all substance use, including alcohol, tobacco, cannabis, opioids & other drugs: One More Conversation.

VT works closely with colleagues in the Family Services (FS) Division (child welfare) at DCF. Efforts are underway to ensure the medical and dental needs of children in custody are known to FS Caseworkers and foster parents, as well as the clear identification of children with special health needs, as these cases are often overlooked with serious consequences. Additionally, Vermont (including MCH) is participating in a CMS Affinity Group to improve coordination and care for children in foster care.

VT continues to work to align its suicide prevention & response efforts but is challenged by siloed strategies & competing priorities. We are engaging state level leadership to help coordinate suicide prevention efforts across our agency including Department of Mental Health & Medicaid.

On August 15, 2019, Vermont relinquished our Title X funding and has only just rejoined the program (April 2022). The Vermont Department of Health has partnered for over 40 years with U.S. Department of Health and Human Services (HHS) and our family planning network, Planned Parenthood of Northern New England (PPNNE), to provide critical family planning services to thousands of Vermonters through the Title X program. During the hiatus from Title X, the Health Department moved forward to use state funds to preserve the access to services provided by PPNNE. This means that from a patient perspective, the type and range of care received should have been the same as it was funded under Title X. Funding for the administration of this new state-funded program (staff time) was supported directly through Title V.