The goal of KY’s Title V Block Grant Needs Assessment is to improve the maternal and child health outcomes by better understanding strengths and weaknesses of current operational structures, gaps in service, and the needs of target populations. Continuous review enables the state to strengthen partnerships for more effective implementation of plans to identify and develop strategies to improve outcomes for the MCH population throughout KY.

 

Many stakeholders were involved throughout the process including local health department staff and patients, OCSHCN staff and patients, and a diverse group of MCH stakeholders. To measure progress on current priorities and build evidence to identify new priorities, quantitative and qualitative analysis techniques were utilized.

 

KY identified the state priority needs during the 2020-2025 Needs Assessment to be:

 

1. Infant mortality with specific concerns related to prematurity, substance use exposure (NAS), SUID, abuse and neglect, nutrition, and growth and development
2. Improving women’s health with specific concerns around access to care, resources and referrals, substance use disorder, maternal mortality, maternal morbidity, and obesity
3. Child injury prevention and mortality with focus on preventable causes of death and improved well child assessment/immunizations
4. Child growth and development with specific focus on behavioral health and ACEs and parental engagement/support, improved physical activity, reduced obesity rates, and substance use exposure
5. Adolescent mental health and suicide prevention
6. Adolescent behavior risk with focus on healthy lifestyle to reduce obesity, prevent substance use including tobacco products, reduce teen pregnancy, and build social and emotional resilience
7. Children with special health care needs’ ability to transition to adult care and education services, ongoing community access to care, addressing health literacy, and parental supports

 

Needs Assessment Plan

 

Despite the state of emergency that existed for much of 2020, which continued in large measure throughout 2021 during both the Delta and Omicron variant surges of COVID-19, KY MCH Title V continued to participate in program reviews, data analysis, and evaluations as part of an ongoing annual needs assessment. These analyses included data review, surveys such as the Behavioral Risk Factor Surveillance System (BRFSS) and PRAMS, advisory board reviews, and regional virtual meetings throughout 2021. At program level, ongoing review of logic models, program plans and processes are evaluated as per program standards. Program information is used to inform ongoing modifications to annual strategic planning. Analysis of quantitative data is reviewed monthly for many MCH programs.

 

Ongoing Needs Assessment Activities

 

The Title V Needs Assessment is an ongoing, data-driven, collaborative process that includes state officials, families, service providers, community organizations, LHD staff, policymakers, and supplemental funding agencies, as well as support personnel and other stakeholders. The key guiding principles with which KY develops all MCH programs, while prioritizing MCH populations, are health equity and implicit bias, community input and engagement, data driven decisions, evidence-informed best practices, collaborative efforts with agencies, and stakeholders and systems as well as transparency and accountability.

 

MCH seeks ongoing input from consumers and families through a variety of surveys, meetings, and outreach activities at the program level of work. Annually, MCH data are derived and analyzed from multiple data sources and evaluated annually and quarterly over a 5-year period.

 

MCH has included the parent and consumer voice in survey assessment and educational material review primarily within the home visitation and early intervention programs. Additionally, consumer input from providers of services is sought during advisory meetings and ongoing program consultation or technical support. The Division of Epidemiology continues the evaluation and dissemination of data as a function of providing timely and up-to-date reporting for programmatic compliance and effectiveness.

 

Quantitative and qualitative data reports are provided to a variety of stakeholders, legislators, and public health leaders across the state. This information is often utilized in data presentations to improve awareness of the state of health outcomes impacting mothers and babies. Historically, this data was presented at a variety of venues such as the annual MCH Conference. The past two years, MCH was not able to host a live MCH conference but was able to make available several webinars on the KY TRAIN system related to maternal and child health topics. Ongoing pediatric and perinatal webinars are added periodically for stakeholders and providers. MCH is also currently working on an MCH learning series, a format tailored to specific audiences. The format would be designed for both remote and in-person, when possible, and would consist of webinars, lectures, trainings for MCH staff, LHD employees, providers, teachers, clients, and other stakeholders.

 

Changes in Health Status and Emerging Needs

 

Throughout 2021, COVID-19 has continued to impact the state’s priority needs in many ways. The pandemic has created a shift in priorities and in the response to those needs. This shift included structural and operational services as well as evaluation of those services. Other shifts included:

 

1. Increased focus on emotional and mental health to all populations.Increased utilization of telehealth or other means of telecommunication by MCH staff as remote work continues
2. Workforce development moved from conference or classroom settings to remote learning
3. Improved capacity for enrollment and linkage to other services utilizing electronic platforms
4. Local schools' response post-COVID and mental health
5. Establishment of School Health Branch within MCH and bringing on additional staff to serve those needs
6. Reestablishing contacts and connections for some MCH and OCSHCN programs where in-person services are essential
7. Continued emphasis on health equity, diversity and inclusion at the program level
8. Establishment of a Health Equity Branch within KY DPH

 

Continued COVID-19 Pandemic Response and Beyond

 

Beginning in early 2020 and throughout 2021, due to the Delta and Omicron surges, KY MCH responded to State-of-Emergency orders and mandates issued by federal and state officials through our well-established emergency operations plans, policies, and procedures. Beginning in March 2020, staff from across the department were advised to work remotely to stem the tide of rising COVID-19 cases among the general population. Some staff members were temporarily reassigned to other tasks and roles to assist in the response efforts. While most, if not all staff have now resumed their regularly assigned duties, many state employees continue to work remotely with leadership and some managers and returning to in-office work 2-3 days per week. With the peaks and valleys of the pandemic, the impact on our workforce has continued throughout this past year. There have been some signs of return to normal work. HANDS, First Steps, and many of our nutritional programs have returned to in-person services. Many of KY’s schools returned to full in-person instruction in 2021. However, disagreements over masking at the local level have dominated much of the conversation, which has had an effect on teachers and educational staff as well as state employees. Given the anticipated effect of the pandemic on both state and local budgets, MCH anticipates budget reductions may occur. The impact of the pandemic will likely be felt for years to come, affecting the well-being of our workforce and local communities, especially LHDs. As the pandemic has continued, several issues have emerged that will clearly influence MCH’s work as we move into the future:

 

• Health outcomes for those with COVID-19 have been poorest for those communities most impacted by housing instability, food insecurity, and poor access to health care in areas such as rural Eastern KY and other rural areas throughout KY as well as less affluent areas in larger cities.

 

• Debates over masking and COVID-19 immunizations have spilled over into other areas of public health such as childhood immunizations and the need for more (or less) government oversight of programs and policies.

 

Health Equity

 

MCH partners with the Office of Health Equity (OHE) to promote activities raising awareness of health inequities. The OHE provides training on aspects of cultural competence for communities and programs. The OHE is a strong partner of MCH in providing training focused on:

 

• Public health equity approaches
• How to incorporate equity approaches into state plans for smoke-free environments in public housing
• Ways to address infant mortality disparities seen in communities of color, African American communities in particular

 

OHE prepares the biennial Minority Health Status Report to inform key decision makers about health disparities and inequities affecting Kentuckians. With the guidance of OHE, KDPH has adopted a department-wide health equity policy to guide equity efforts. In 2021, the OHE was reorganized out of direct oversight by the Commissioner’s Office and was established as a stand-alone division within KDPH. 

 

MCH continues to review program plans and initiatives with a lens to reduce health disparities/inequities and to guide LHDs to include these efforts in annual planning for work within the MCH best practice packages.

 

Workforce Capacity and Emergency Response

 

Throughout 2021, MCH saw continued utilization of virtual platforms and stakeholder meetings for information sharing and communication. As a response to pandemic restrictions, which continues, MCH has become a regular convener, attender, or leader of multiple stakeholder meetings. This has led to an Increase of cross-collaboration for population outreach, service provision and virtual educational opportunities, improved communications, linkage of many stakeholders with shared purpose or mission, and an increased workforce regardless of the employing agency to meet capacity of state needs.

 

Emergency response plans were updated to include lessons learned throughout the pandemic response which continues to be the case. The Delta and Omicron surges in 2021 have demonstrated the need to have readily available and up-to-date plans and procedures in order for staff to pivot on a moment’s notice. The demand for state government and its agencies to shift and readjust quickly has been great and KDPH and MCH has responded accordingly, professionally and to a high standard.

 

Local hospitals were deeply impacted with staffing shortages related to the pandemic. This led to different emergency regulation changes for nurses and other providers. The nursing shortage in KY persisted throughout 2021. 

 

Additionally, the lack of social workers in the state reached crisis levels in late 2021, resulting in the administration taking drastic measures to attract graduates to the profession and significantly increase social worker pay throughout the state.

 

The ability to recruit and hire qualified candidates for MCH continued throughout 2021. MCH and state government continues to have challenges regarding workforce recruitment and retention in recent years. Financial uncertainty with the KY Retirement Systems have prompted many senior staff to retire or otherwise leave state government. Those who do remain are oftentimes burdened by extra duties and responsibilities. In addition, the disparity in pay of the public sector versus the private sector has resulted in the inability to attract qualified personnel to fill those ranks in state (and local) government. MCH and other departments continue to face these personnel barriers in an ever-changing workforce.

 

Priority Updates

 

In 2021, mental health has emerged as a greater need now more than ever of our clients, mothers and families, as well as children in our schools. In addition, mental health of our providers and caregivers also is of utmost concern. The politics around KY’s and local level response to COVID-19 has been bitterly debated among policy makers and the public, which has taken a toll on healthcare workers and the profession of public health in general. This, along with other factors such as compensation and physical demand, has driven many away from the profession. In the coming year and beyond, the mental health of the populations in which we serve and of our employees needs to be one of our critical priorities.

 

MCH continues to meet the ever-changing needs of women and children throughout the state through innovative practices, use of technology, and up-to-date reporting. The pandemic has also demonstrated the need to keep policy makers informed with greater frequency and with accurate information in order for them to make the best decisions possible that effect women and children throughout KY. The dispensing of misinformation has been very challenging. As a result, the collecting, analyzing, and reporting of accurate information, which has always been a highest priority, has become even more important and needed almost daily, particularly when it involves public health.

 

Women/Maternal Health

 

The focus remains to improve the percent of women receiving annual preventive health visits, focusing on improving women’s health across the life course. By doing so, KY hopes to improve pregnancy outcomes and reduce maternal mortality rates. MCH was successful in development of a well-woman best practice package which was launched for FY23. This event corresponded with KY’s health department media outreach efforts to promote COVID-19 vaccination for pregnant women, which was rapidly developed and released in February 2021. The focus of the prenatal program is to continue and to improve collaborations with local providers, FQHCs, and birthing hospitals to provide culturally competent, evidence-based care and referral for individual needs.

 

Perinatal/Infant Health

 

The NPMs focused on breastfeeding remained a constant. Throughout 2020 and into 2021, outreach and technical assistance were limited in scope and volume. As a result of the pandemic, nutrition services saw an increase in WIC enrollment because of the economic decline. Job loss and the additional stress placed on families heightened the need for mothers and families to seek government services. Critical health assessments that had historically been performed during in-person WIC appointments were limited, thereby decreasing the ability to identify risk factors and provide nutrition information for clients. These assessments, which are now being held virtually or over the phone are more critical than ever to determine positive outcomes for clients.

 

MCH continues to address safe sleep to reduce infant mortalities. In March of 2020, KY saw a rapid increase in SUID deaths. MCH CFR quickly responded by waiving the crib match, increasing social media messaging locally, and providing guidance to local birthing hospitals. In 2021, the rate fell to 66 SUID deaths from the 2020 rate of 81.

 

Child Health

 

As previously mentioned, 2021 saw a return to in-person instruction to most, if not all, of KY schools. There continued to be a great deal of work performed around the obesity and nutrition NPM to promote physical activity and healthy nutrition since much of this instruction was limited for nearly a year. The Healthy Schools Team which was very innovative during those periods of virtual learning had to readjust and be innovative again after students were back to school in person.

 

Work continued regarding the child injury SPM, with collaborative work performed by many agencies around safe kids with concentration in healthy and safe homes. Social media platforms became the most efficient source for distribution of short safety videos and materials.

 

Adolescent Health

 

Mental health and risk behavior concerns persisted this past year with limited peer-to-peer engagement. Unfortunately, the usual adolescent activities were limited due to pandemic restrictions. Prior to the pandemic, KY rejoined the Child Safety Learning Collaborative to develop a targeted approach to reduce child/adolescent injury. This led to a three-prong approach:

 

1. Data review
2. Program review
3. “Zero suicide” curriculum - implemented 4-part approach

 

Much work continued around the “Zero Suicide” curriculum in 2021.

 

OCSHCN

 

The 2020-2025 Needs Assessment identified the needs for children with special health care needs as: ability to transition to adult care, access to education services, ongoing community access to care, addressing health literacy, and parental support. OCSHCN has continued to work on these ongoing needs during the pandemic, which remained relatively unchanged, but have been exacerbated over the past year due to the continuing pandemic and most especially the delta variant within the timeframe. Families often must forgo care due to long waiting lists, problems scheduling appointments, issues with eligibility criteria, complex systems to navigate, childcare coordination, language and cultural barriers, transportation issues particularly in eastern KY, and economic constraints. Significant gaps still exist in accessing the needed supports to transition from pediatric to adult health care, especially for youth with complex medical needs. As COVID-19 continued to spread, children and youth with special health care needs continued to be at an increased risk for more severe illness and complications. OCSHCN continues to work with parents, teachers, caregivers, and other stakeholders in order to address the needs of children and youth across the state. Telehealth has played a positive role in addressing needs before and during the pandemic, and it will long afterwards.

 

Operationalization of the Five-Year Needs Assessment

 

MCH did not lose sight of the long-term visions and goals. Review of strategic plan, data sets, and program policies and procedures were adapted to meet current pandemic requirements. Individual programs were expected to weekly provide updates to MCH director and monthly reporting was completed to all levels of KDPH leadership.

 

Organizational Structure

 

The KY Executive Branch has 11 cabinets, with the CHFS being the largest. The state health agency, KDPH, and OCSHCN are organizationally located within CHFS. Administration of the Title V program occurs through the Division of Maternal and Child Health within the KDPH.

 

The foundational statute KRS 211.180, gives CHFS the responsibility and authority to formulate, promote, establish, and execute policies, plans, and programs relating to all matters of public health. This allows MCH to collaborate with LHDs to fund Title V evidence informed strategies based upon the priority needs. MCH administers many programs, regulatory services, and health promotion initiatives, which include:

 

• Nutrition Services
  • Federal funded Special Supplemental Nutrition Program for Women, Infants and Children (WIC) including vendor enrollment
  • Nutrition education
  • Breastfeeding education, surveillance, and breast pump rentals
  • Medical nutrition therapy
  • Engagement with local farmer’s markets
• Early Childhood Development
  • Health Access Nurturing Development Services (HANDS), a voluntary home visitation program that supports families from pregnancy (primigravida/multigravida) through age 2 of the child
  • Child Care Health Consultation Program provides trainings and technical assistance to out of home childcare settings on health and safety
  • IDEA Part C, Early Intervention Services – First Steps provides comprehensive services for children with developmental disabilities from birth to age 3
  • Early Childhood Mental Health (ECMH) addresses social, emotional and behavioral issues for children through age 5 and various pilot programs for Help Me Grow
  • Partnership with Governor’s Office of Early Childhood and BHDID to contract with the 14 regional community mental health centers for program implementation
  • Birth Surveillance Registry (KBSR) provides surveillance for possible causes of birth defects through age 5 and linkage of children with birth defects to university genetic clinics and First Steps
  • Kentucky Strengthening Families (KYSF) focuses on enhancing the protective factors of the family
  • Healing, Empowering, Actively Recovering Together (HEART)
• Child and Family Health Improvement
  • Perinatal program provides technical assistance on reduction of early elective deliveries, presumptive eligibility, and linkage to resources
  • Maternal mortality reviews all maternal deaths, within one year of the end of the pregnancy
  • Pediatric programs include
    • Child Fatality Review and Injury Prevention
    • Coordinated School Health
    • School Health Nursing
    • Childhood Lead and Poisoning Prevention
• MCH Supportive Services provide epidemiologic support for
  • NAS Surveillance Registry
  • SUID case registry
  • Pregnancy Risk Assessment Monitoring Survey
  • Kentucky Birth Surveillance Registry with linkage to genetic clinics and IDEA Part C services
  • MCH Budget and Expenditure Monitoring
  • MMR data collection for MMR Report
• School Health Branch
  • School Health K-12 testing program
  • School Health Nurses and Infectious Disease Investigation
  • School Health Training and Coordination
  • Coordination with KDE and Healthy Schools Team

 

As per the mandates and authorizations in state statute, services provided by OCSHCN include:

 

• Direct care gap-filling clinics for those children with a diagnosis on the agency’s eligibility list
• Audiology services, including hearing conservation, testing, hearing aid fittings, and programming for cochlear implants. OCSHCN administers KY’s Early Hearing Detection and Intervention (EHDI) newborn hearing screen surveillance program
• Foster care support programs, which support children with special needs in the child protective service system in collaboration with DCBS
• Family to Family (F2F) Health Information Centers, aid families and professionals in navigating health care systems; information, education, training, support and referral services; outreach to underserved/underrepresented populations; health programs and policy guidance; and collaboration with other F2Fs, family groups, and professionals in efforts to improve services for CYSHCN
• Operation of the First Steps (Early Intervention) point of entry in the state’s largest region
• Care for CYSHCN through its regional centers, ongoing partnerships and collaborations

 

Leadership

 

Dr. Steven Stack became the Commissioner of Public Health just weeks prior to the enactment of COVID-19 emergency policies. Throughout his tenure the past two years, his leadership has been pivotal in monitoring and responding to the emergent needs from the pandemic.

 

Throughout the pandemic, having Medicaid, KDPH, and many other programs, under the steady leadership of the veteran Cabinet Secretary Eric Friedlander, was pivotal in the efficient response to a myriad of needs. Many MCH initiatives or staff were diverted to the pandemic response, with greatest impact on staffing being among both state level and LHD staff. This resulted in reduction of population health activities by LHDs, the infrastructure of which did not have capacity beyond pandemic response and core public health services. With the increasing need of MCH leadership staff directed to the pandemic response and program management, an additional Title V Block Grant Coordinator position was established.

 

MCH Leadership Staff

 

• Connie White, MD, MS, FACOG is the Senior Deputy Commissioner for Clinical Affairs, and is Board Certified in OB/GYN with emphasis on patient education and preventive medical care
• Henrietta Bada, MD, MPH, is the MCH Division and Title V Director and is Board Certified in pediatrics and neonatal-perinatal medicine and directs all MCH programming
• Andrew Waters, MPH, is the Assistant MCH Division Director and manages day-to-day MCH operations, budget planning and administration, and functions as the MCH legislative liaison
• Matt Belcher, MPA, Title V Block Grant Coordinator, has 15 years of experience in grant writing and administration, and local community development
• Jan Bright, RN, BSN, Manager of the Child and Family Health Improvement Branch and Title V Block Grant Administrator, has 31 years of pediatric nursing experience
• Tracey Jewell, MPH, Manager of the Program Support Branch, is a MCH Epidemiologist with over 22 years of experience in DPH and Title V
• Nicole Nicholas, MS, RD, LD; Manager of the Nutrition Services Branch has over 23 years of experience as a registered dietician, KY WIC programs
• Paula Goff, MS; Manager of the Early Childhood Development (ECD) Branch has over 33 years of experience in ECD programs and IDEA Part C
• Michelle Malicote, RN, Program Administrator and Branch Manager of the MCH School Health Branch
• Julie McKee, DMD; State Dental Director: KY Oral Health Program
• Karen McCracken, MCH Family Consultant: Early Childhood Mental Health, KY Strengthening Families, and family informed workgroups
• Vivian Lasley-Bibbs, MPH, directs the Office of Health Equity and is a Health Disparities Epidemiologist and Healthy People 2020 State Coordinator

 

OCSHCN Leadership Staff

 

• Ivanora Alexander, BS BME, OCSHCN Executive Director, has a 14-year history with KY’s CYSHCN program and has prior service as a rehabilitation engineer/manager designing technology for children and adults with special health care needs. 
• Edith Halbleib, JD, OCSHCN Deputy Executive Director, 25 years of experience as an attorney, with 9 years of experience as the managing director, deputy executive director, or executive director of organizations within the Commonwealth.
• Bethanie Morgan, MD, OCSHCN Medical Director, joined OCSHCN as the medical director in March of 2022, after working as a pediatric neurologist and as a contracted provider for OCSHCN. She first worked with OCSCHN as a medical student at the University of Kentucky in 2005. Dr. Morgan has over 15 years of experience as a pediatric neurologist.
• Michelle Marra, RN, BSN, Director of Clinical & Augmentative Services, 29 years of experience as a Pediatric Nurse with over 15 years focusing on school-age children and youth with special health care needs.
• Freida Winkfield Shaw, CPA, Director of the Division of Administrative & Financial Services, has over 20 years of accounting, budgeting, and finance experience and 15 years in grants management.
• Jonathan Borden, MBA, EDD, Assistant Director of the Division of Administrative & Financial Services, has over 15 years of experience dealing with policy analysis and reporting in both the public and private sectors.
• Sondra Gilbert, Director, F2F, works with the American Academy of Pediatrics’ Section on Home Care, Midwest Genetic Network, CMC CollN, Family Voices, and Parent to Parent of KY.

 

Agency Capacity

 

MCH capacity continued to be stretched in multiple ways in 2021. There continues to be ongoing turnover of staff from many programs with staff promotions, retirements, and those in pursuit of higher paying positions within state government. This continues to impact program operations secondary to the loss of institutional and program knowledge and skills, thereby needing to train and onboard new staff. The constant shifting of policies/procedures to meet the pandemic emergency further hindered the ability of MCH to operationalize program strategic plans. In many areas MCH adapted to emergencies and rapid changes in regulations by quickly diverting staff to telecommute schedules, moving meetings and trainings to virtual platforms, and utilizing accessible technology to improve efficiency.

 

The greatest barrier to MCH work was the overtaxed LHD system and hospital system which shifted their primary focus to COVID-19 response in 2020 and continued throughout 2021 during the Delta and Omicron surges. Adherence to social distancing protocols within our programs and services, working remotely into a second year on an already taxed workforce, and the encouragement of continued vaccinations and boosters among the general public continued to dominate personnel workload this past year. Funding, hiring, and onboarding new staff locally to address the public health emergency and core public health programming supersedes the MCH package work and other collaborative work within their communities. Continued limitations for face-to-face meetings and contacts demand additional planning and organization in a system in which every minute is a precious commodity to protect the public.

 

Continued Partnerships, Collaboration, and Coordination

 

Partnerships with state agencies and community partners extend the reach and influence of MCH. MCH and OCSHCN strive to collaborate with federal partners and private organizations to help meet aligned agency goals and to address the priority needs of the women, children, and children with special health care needs. With a 90-plus year history of service provision, OCSHCN has developed formal and working relationships with a variety of programs providing services to children.

 

Partnerships exist with WIC, family planning, FQHCs, BRFSS, Department for Child Welfare, KDE, DBHDID, DMS, and FRYSC. In addition, KY partners with KY Injury Prevention and Research Center at UK, the predominate agency for injury prevention and the statewide injury prevention plan for children. KDPH and OCSHCN have cross collaboration to provide home visitation to medically complex children in foster care, training, workforce development, expertise, and specialty providers for gap filling services for children with special needs. These collaborations exist with KY Early Intervention Services (formerly First Steps), Early Hearing Detection and Intervention, and Child Welfare.