Needs assessments for Alabama’s Title V program are collaboratively conducted by ADPH and ADRS, through FHS and CRS, respectively. An analysis of quantitative and qualitative data gathered through paper and web-based surveys, focus groups, key informant interviews, and from select databases and national surveys yielded a variety of issues for the population health domains. After convening advisory committee meetings, national priority areas and state needs were identified. See the MCH Title V Block Grant to States FY 2021 Application/FY 2019 Annual Report for more details regarding the process, goals, framework, methodology, level, and extent of stakeholder involvement, quantitative and qualitative methods, data sources used, data collection, finalization of priority needs, and development of the State Action Plan for the 5-year comprehensive needs assessment, as originally submitted.

 

Ongoing Needs Assessment Activities

 

To address the ongoing needs of the state's maternal and child population, the Alabama Title V MCH Program continually engages stakeholders and assesses changes in population health and emerging issues. Staff and stakeholders continue to develop and implement ESMs and SPMs, along with the activities outlined in the five-year State Action Plan during the FY 2021- 2025 reporting cycle.

 

ADPH

 

In FY2022, FHS began engaging in ongoing needs assessment activities to assess changing MCH population demographics, emerging health trends, and shifting program capacities.

 

The UAB AEAC conducted interviews with district MCH coordinators between May and July 2022. These interviews were intended to learn about staff members’ level of understanding of the Title V Program and to gather information about district focus areas and activities; strengths and challenges; perceived MCH needs; and involvement with local partners and the general community. The coordinators identified strengths related to community partnerships, support, and resources, and noted transportation issues, barriers to healthcare access, and health and socioeconomic disparities experienced by rural and low-income populations as challenges. Perceived needs continued to align with priority needs identified for the 2020-2025 cycle. An additional need was identified to develop additional staff training related to Title V and MCH systems approaches. Staff training was developed for FY 2023.

 

In 2023, the Title V MCH leadership and the UAB AEAC developed and launched an MCH provider survey to gather feedback on progress related to addressing current priority needs and to identify any emerging needs. Survey analysis is in process. A similar family survey is anticipated to be launched in July 2023 and will be distributed through CHDs, social media, and in partnership with a community-based organization that assisted UAB with the 2020 Needs Assessment.   

 

Changes in Title V Measurements

 

The MCH Epi Branch met with program staff from the Perinatal Health Division, the Child and Adolescent Health Division, OHO, and the Office of Women's Health to discuss the comments received during the Title V Block Grant Review. After these discussions, Alabama inactivated and modified measures due to data-related issues. The changes in measures could be the result of the following:

 

• Unavailable Data Sources
• Stronger Data Sources Available
• Similar Measures Being Reported

 

The measures below were inactivated and/or modified:

 

1. SPM 1-Percent of children who receive a blood lead screening test at age 12 and 24 months of age.

Reason: After an internal review, SPM 1 and ESM 6.3 were the same. Alabama will continue to report the Medicaid numbers for ESM 6.3. For SPM 1, Alabama has decided to change the Medicaid data source to the Healthy Homes and Lead Positioning Surveillance System (HHLPSS) to better measure provider practice and laboratory reporting in regard to blood testing in children less than 3 years old. With this data source, Alabama can look at the total number of 2-year-old children who received a lead screening at both their 12 and 24-month follow-up visits. With this new data source, children with private health insurance or self-pay would also be included in this analysis. A new measure SPM 9 was added to replace this measure.

 

2. SPM 6-Percent of staff trained at daycare providers/centers on CPR/First Aid.

Reason: The denominator was the total number of staff trained at daycare facilities. Alabama had to inactivate this measure due to the denominator no longer being captured.

 

3. ESM 1.1: Proportion of women aged 15-55 who report receiving a preventive medical visit in the past 12 months by increasing total enrollment percentage in the Well Woman Program by 2 points annually.

Reason: The data source for this measure was originally looking at the BRFSS statewide number of completed preventive medical visits. The problem with this data source is that the Well Woman Program is only active within 9 counties. After meeting with the program staff, it was decided to change this measure to look at ways to increase Well Woman enrollment among FP participants. Well Woman has partnered with 211KNOW so participants can receive text messages on the importance of heart health.

 

4. ESM 5.1: Number of sleep-related deaths

SPM 8: Decrease the number of infants dying from sudden infant death syndrome  (SIDS).

Reason: The Perinatal Division staff has decided to inactivate both measures due to being similar to the National Outcome Measure 9.5. Moving forward, the Perinatal Division will focus its efforts on strengthening hospital partnerships so the LOCATe and Perinatal Regionalization will be effective in reducing infant mortality within Alabama.

 

5. ESM 6.1: Proportion of children birth to age 19 that received a well child appointment in the past year.

Reason: In past reports, the numerator for this measure only looks at the total number of EPSDTs provided within seven counties. The denominator looks at the statewide number of EPSDT screenings completed. Due to this limitation, the denominator needed to be changed to look at only children within this age group who visited any of the seven CHDs. ESM 6.4 was created to replace this measure.

 

6. ESM 6.2: Proportion of children birth to age 19 that received a developmental screening in conjunction with a well-child appointment in the past year

Reason: After internal discussion, Help Me Grow only provides developmental screenings for only children up to 5 years old. In the past, the denominator included all children from birth to age 19. This may not be an accurate method to showcase the reach of services provided to this population.  

 

7. ESM 10.1: Proportion of adolescents, aged 12 to 19, that received an adolescent well visit in the past year.

Reason: Alabama originally used the National Survey of Child Health to determine the total number of adolescents aged 12 to 19 who completed an adolescent well visit that occurred with the CHDs. One limitation of this data source is that the survey data does not include those between the ages of 18 and 19. After an internal review, Medicaid data will be used as the new data source to determine who received a well visit among adolescents within the 12 to 19 years age group. Utilization of this data source will help better link the efforts made by Well Woman, FP, and the Adolescent Pregnancy Prevention Programs to encourage this population to complete a well visit.  

 

CRS

 

CRS engages in ongoing needs assessment activities to assess emerging needs, changing conditions, and system capacity. As part of the 2021-2025 Five-Year State Action Plan, CRS is soliciting feedback and seeking input regarding our transition and care coordination services. The UAB AEAC administers the annual surveys and analyzes the survey data. CRS values public input from individuals with lived experience and seeks input from families and youth on an ongoing basis through the State Parent Advisory Committee (SPAC), Local Parent Advisory Committees (LPAC), and Youth Advisory Committee (YAC). CRS also holds an annual Hemophilia Advisory Committee meeting to seek input into programmatic and policy issues related to the Alabama Hemophilia Program administered by CRS. Information collected during the various advisory committee meetings allows CRS leadership to continually assess the health needs of CYSHCN and the system capacity to address these needs. Additional efforts to solicit ongoing feedback include a series of staff and community partner surveys around access to services. These surveys are being administered and analyzed by UAB. Customer satisfaction cards are also being administered in some CRS offices to obtain feedback related to clinic operations.

 

Health Status and Needs of the MCH Population

 

Children with Special Health Care Needs

Per the 2020-2021 National Survey of Children’s Health (NSCH) data, Alabama is trending better in the transition indicator than nationwide. The 2020-2021 NSCH data indicated 22.5 percent of YSHCN in Alabama receive the services necessary for transition to adult health care compared to 20.5 percent nationwide. The state and nationwide indicators are down from the 2019-2020 NSCH data which indicated 27.9 percent of YSHCN in Alabama received the services necessary for transition to adult health care compared to 22.5 percent nationwide.

 

Per 2020-2021 NSCH data, Alabama is trending better in the medical home indicator than nationwide. The 2020-2021 NSCH data indicated 47.3 percent of CSHCN have a medical home compared to 42.0 percent nationwide. The same indicator for 2019-2020 NSCH data indicated 42.9 percent of Alabama CSHCN had a medical home compared to 42.2 percent nationwide. Despite NPM 11 not being selected for the 2021-2025 five-year State Action Plan, CRS continues educating CYSHCN and their families on the benefits of a medical home through activities outlined in our SPMs.

 

Per 2020-2021 NSCH data, Alabama is trending better than the nationwide percentage in CSHCN receiving care in a well-functioning system at 17.6 percent compared to 13.7 percent nationwide.

 

Title V Program Capacity Organizational Structure

 

ADPH

Please see the MCH Title V Block Grant to States FY 2021 Application/FY 2019 Annual Report for more details regarding "ADPH's Organizational Structure" and "ADRS' Organizational Structure" for the 5-year assessment of needs, as originally submitted. Current organizational charts for ADPH, FHS, ADRS, and CRS are attached to this document.

 

Agency Capacity

Please see the MCH Title V Block Grant to States FY 2021 Application/FY 2019 Annual Report for more details regarding "ADPH Program Capacity" and "CRS Program Capacity" for the 5-year assessment of needs, as originally submitted. Following are updates reflecting changes that have occurred since the original submission.

 

ADPH Program Capacity

 

As part of the MCH Title V transformation, ADPH has moved to a more collaborative model for delivering Title V services. Title V staff have developed structures and processes to facilitate collaboration between state and county offices. These processes necessitate that state and CHD staff work together to design strategies and plans to improve community health. Resources have always been allocated to the CHDs where we know services were delivered to those in great need; however, the newer processes ensure the appropriate partners are involved as we assess the communities’ needs and develop programs to improve the health of the local populations. Within the Title V MCH leadership team, there are four divisions and offices that develop and deliver programs and services to the MCH population, 1) the State Perinatal Division 2) the Office of Women's Health 3) the Child & Adolescent Health Division, and 4) OHO. The division and office directors along with the MCH coordinator lead the implementation and evaluation of the Title V strategies across the state, including the management of county MCH projects led by the district MCH coordinators located in six ADPH public health districts.

 

CRS Program Capacity

 

The Alabama Title V CSHCN Program ensures the capacity to promote and protect the health of CSHCN in our state. CRS’ mission embodies the principles of comprehensive, community-based, and family-centered care. The mission of CRS is to enable children and youth with special health care needs and adults with hemophilia to achieve their maximum potential within a community-based, culturally competent, family-centered, comprehensive, coordinated system of services. Coordinated health services are delivered via 14 community-based offices across 7 districts. CRS staff are not restricted by district boundaries in the delivery of services and families are similarly unrestricted and may access services in any CRS office. Any state resident, from birth to 21 years of age, who has a special health care need is eligible for CRS services. CRS offices are co-located with EI and VRS in most locations, which facilitates service coordination and smoother transitions for CYSHCN.

 

CRS continues to operate seven programs to serve CYSHCN and their families. Services provided in each of these programs are funded in full or in part by Title V funds. The seven programs are Clinical Medical, Clinical Evaluation, Hemophilia, Care Coordination, Information and Referral, Parent Connection, and Youth Connection.

 

MCH Workforce Capacity

 

Please see the MCH Title V Block Grant to States FY 2022 Application/FY 2020 Annual Report for more details regarding “ADPH’s MCH Workforce Development and Capacity” and “CRS Workforce Development and Capacity” for the 5-year assessment of needs, as originally submitted. The following are updates reflecting changes that have occurred since the original submission.

 

FHS

There have been major changes in FHS’ program capacity with several positions vacant or experiencing high turnover. There have been four Title V directors in 4 years and three MCH Epi Branch directors in 3 years, with one only in position for 6 months. Since May 2022, Tommy Johnson, DMD, State Dental Director has served as the acting MCH Title V director. Dr. Johnson previously served as FHS’ acting deputy director from June 2021 through December 2021 and Acting bureau director from Dec 2021 through March 2022.

 

OHO was without a fluoridation coordinator starting in FY 2021 and continuing into FY 2022. This vacancy impacted the fluoridation grant process as well as water plant site visits. Mallory Rigsby joined OHO as the fluoridation coordinator on April 1, 2022. She has been an ADPH employee since December 2010. Ms. Rigsby has prior state experience in childhood lead poisoning prevention, tobacco cessation, and Food and Drug Administration (FDA) tobacco inspections. Academic credentials include an undergraduate degree in healthcare management.

 

Carolyn Miller was appointed as the director of the State Perinatal Division on October 16, 2021, and the director of the Office of Women's Health on May 1, 2022. Before that, she was the FHS social work director. Katrina Cuffey joined ADPH as the infant mortality prevention coordinator on September 1, 2022. She has worked for ADPH since 2019, starting as a staff nurse in rural CHDs. Ms. Cuffey's background includes 7 years of nursing experience in various practice settings as well as 8 years of teaching experience. Academic credentials include two bachelor's degrees and a graduate degree in education.

 

ADPH cost center data provided by ADPH's Bureau of Financial Services was used to estimate the number of ADPH FTEs devoted to serving Title V populations. FTEs reported here are not limited to those paid for by Title V, because funds from other sources also assist in paying for services to Title V populations. Excluding WIC cost centers, 354.38 FTEs served Title V populations in FY 2022. The positions accounting for 5 percent or more of the total non-WIC FTEs serving Title V populations were aides (5.3 percent), social workers (6.2 percent), nurses (32.1 percent), and nurse practitioners/midwives (9.16 percent), and mobile employees (9.41 percent). In FY 2022, 183.61 FTEs were devoted to WIC, increasing by 15.1 percent (or 27.68 FTEs) since FY 2021. In FY 2022, 1.25 FTEs were devoted to SSDI.

 

CRS

 

CRS has experienced several staff changes at the State Office. The clinic operations specialist position has been vacant since the beginning of FY 2023. CRS has faced many challenges in filling this position due to the changing nature of the workforce. As a result of COVID-19, many federal and private sector employers began offering more remote work options and other flexibilities currently not available in Alabama state government. An additional barrier is the location of the position. Several current CRS employees inquired about the position but ultimately did not want to uproot their families to relocate. The duties of this position have been temporarily reassigned to other state office specialists to ensure the continuation of services.

 

The Care Coordination Program specialist that started in April 2022 returned to her previously held position in August 2022 leaving the position vacant. Effective November 1, 2022, Kristin Moore accepted the Care Coordination Program specialist position. Ms. Moore has 12 years of social work experience. She began working for CRS in 2016 and most recently served as a social work specialist in the Montgomery CRS office. Her academic credentials include an undergraduate degree in psychology and a graduate degree in social work.

 

In addition, Ms. Susan Colburn who served as the state parent consultant (SPC) for over 26 years retired effective July 1, 2022. Ms. Colburn tirelessly advocated for policy change to improve the system of care, promoted a culture of family-centered care, and instilled the value of family engagement in all staff. CRS is currently recruiting a new SPC.

 

Data provided by the ADRS Personnel and Human Resources Division was used to provide the number of CRS FTEs devoted to serving CYSHCN. FTEs reported here are not limited to those paid for by Title V, because funds from other sources also assist in paying for services to CYSHCN.

 

As of April 2023, 194 FTEs are in the field: 7 district supervisors, 1 custodian, 46 administrative support assistants (ASAs), 48 social workers, 33 nurses, 16 rehabilitation assistants, 5 nutritionists, 11 audiologists, 10 physical therapists (PT), 9 SLPs, 5 occupational therapists (OT), and 3 rehabilitation counselors.

 

As of April 2023, 13 FTEs are at the State Office: 9 administrative and 4 clerical staff. Administrative staff includes 1 assistant commissioner, 1 assistant director, 1 health services administrator, 1 SLP, 1 audiologist, 1 nurse, 1 social worker, and 2 patient account managers.

 

CRS currently has 28 budgeted vacancies: 10 ASAs, 8 social workers, 3 nutritionists, 2 nurses, 1 epidemiologist, 1 rehabilitation specialist, 1 OT, 1 SLP, and 1 rehabilitation assistant.

 

Through a contract with Easter Seals of Central Alabama, CRS has on staff 10 parents of CYSHCN. As of April 2023, there is one part-time regional parent consultant (RPC), and nine part-time local parent consultants (LPCs). The SPC is based in CRS’ State Office. The RPC and LPCs are based in their local CRS office. Currently, there is 1 SPC and two vacant LPC positions. See section III.E.2.b.ii. Family Partnership for additional information on these positions.

 

CRS also employs 2 part-time youth consultants (YCs) at the State Office under the Easter Seals contract. One of the YC positions is currently vacant.