Maternal & Child Health Partner Programs: FFY 2022 Needs Assessments

 

For ongoing needs assessment work in the interim years between Title V MCHBG 5-Year Statewide Needs Assessments, Montana’s program benefits from partnerships with other maternal and child health programs housed in the Family and Community Health Bureau (FCHB).  This narrative begins with brief summaries of several needs assessments completed in FFY 2022.

 

Children’s Special Health Services Section (CSHS): Cleft Clinic Needs Assessment 2022

 

The current system of state-funded Cleft Clinics (Clinics) was established many decades ago, and the landscape of healthcare and available providers has changed significantly since then. In recent years, several trends have emerged that prompted the need for this assessment. These concerns include a lack of consistent state-based funding, a burdensome administrative system, decreasing ability for providers to volunteer their services at the Clinics, and a decreasing number of participants attending the Clinics.

 

Today, the Clinics still provide a convenient way for 150 patients each year to see approximately 8-10 providers in a single day, receive basic evaluations from each, and then receive a plan of care for Cleft Lip and Palate (CL/P) or other craniofacial conditions, based on the team of providers seen. Within MT there are approximately 800-850 people aged 0-17 years old with CL/P who would benefit from annual team-based care planning. While ACPA still recommends team-based care as best practice, there are alternative and improved ways to achieve an interdisciplinary approach to CL/P that would better fit the existing healthcare landscape.

 

Montana now has: greater access to pediatric specialists across the state; improved access to specialists outside of Clinics; increasing telehealth capacity; and larger, more complex medical systems forming networks across the state for coordinating and maintaining care. Together, all these factors improve patient CL/P care and access. When considering a redesign of the Clinics statewide, however, numerous differences across communities and healthcare systems make it unlikely that one model would be the best option across all communities in MT.

 

The Cleft Clinic Needs Assessment identified the following general opportunities for improvements:

 

Increase Access

• Consider telehealth options for access to Clinics in rural areas.
• Investigate low-cost ways to establish Clinics in population centers that currently lack Clinics (Helena, Kalispell, Bozeman).
• Provide additional support to American Indian / Alaska Native communities to narrow racial disparities in CL/P access and specialized care.

 

Establish Strategic Partners

• Study establishing a connection or partnership with MT State University College of Nursing to support a Bozeman-based Clinic or statewide care coordination center.
• Determine whether MT School for the Deaf and Blind (Great Falls) could provide the necessary screenings and evaluations at the Clinics at little or no charge.
• Intermountain Healthcare, based in Salt Lake City, has recently merged with St. Vincent’s Healthcare in Billings, MT. They provide ACPA-standard CL/P care and may be able to make this CL/P care available to patients in the Billings area.
• Shriners Hospital for Children provides CL/P nationally and internationally. It may be possible to establish MT-based access through a combination of telemedicine and financial support.
• Work with Office of Public Instruction and local school districts to ensure that they understand how to support patients in using the Clinics, and that individualized education plans and legal implications of Section 504 of the Rehabilitation Act of 1973 are applied equitably to people with CL/P.

 

Ensure Stable Funding for SFY 2027 and Beyond

• Work with MT Medicaid to increase reimbursement rates billed for HCPCS T1025 and T1024.
• Increase the number of private insurers that cover the HCPCS T1025 and T1024.
• Understand all of the possible procedures that could be conducted at the Clinics by each participating provider type and provide education to providers.
• Improve and ensure adequacy of MT Medicaid reimbursement rates for those specific procedures that could be conducted and billed at Clinics (if billing by individual provider and procedure).
• Consider applying for grants that could contribute to “baseline” funding for Clinics starting in SFY 2027.
• Engage in continuous research and conversation with healthcare partners to identify long-term or consistently sustainable financial structures for Clinics.

 

Improve Quality in Clinics

• Use an Electronic Health Record system.
• Research and replace the CHRIS system with one that better suited to the needs of the Clinics. Consider a system that will allow each provider to electronically chart in real time and access the charts between Clinics. Review providers note templates and work with providers to improve and modernize these.
• Further investigate the lack of participation from orthodontic specialists and support changes to incentivize their involvement.
• Advocate for the presence of mental health professionals on the Clinic team.
• Encourage the inclusion of pediatricians on the Clinic team.
• Promote CL/P continuing education opportunities for all providers who participate in Clinics.
• Consider creating a Community of Learning (COL) or other quality improvement collaborative to bring Clinic site Coordinators and teams together to collaborate on QI projects across sites.
• Develop and use a robust patient registry that can follow patients from infancy to adulthood.

 

Increase Public Knowledge

• Update the Department of Public Health & Human Services (DPHHS) website with additional information, including: how the Clinics are administered; what is covered by insurance; and the providers that families will have access to through the Clinics.
• Consider regular press releases or other media stories that promote CL/P general knowledge and Clinic awareness specifically.
• Provide suggested information and wording to participating Clinic sites for their websites and patient materials.

 

MT Access to Pediatric Psychiatry Network Access Line: 2022 Needs Assessment

 

The purpose of the MT Access to Pediatric Psychiatry Network (MAPP-Net) 2022 Needs Assessment was to update the 2019 MAPP-Net Needs Assessment, with a specific focus on the MAPP-Net Access Line. Since its implementation in 2019, the MAPP-Net Access Line has been under-utilized in MT, despite the broad support and enthusiasm indicated by participants in the 2019 Needs Assessment. The information in the 2022 Needs Assessment was intended to identify the reasons for underutilization and to inform programmatic changes. 

 

To gather and report data on the under-utilization of the MAPP-Net Access Line, the University of MT Rural Institute for Inclusive Communities (UMRIIC) Evaluation Team developed and implemented evaluation activities, including a statewide survey of MAPP-Net enrollees and MAPP-Net Project ECHO participants. They also conducted 12 key informant interviews with stakeholders identified in collaboration with MT DPHHS and the coordinating organization. 

 

The UMRIIC Evaluation Team sent the Access Line Survey to 107 MAPP-Net enrollees and 256 Project ECHO participants between October 3, 2022 and October 21, 2022. In total, there were 65 responses. Of those, 24 (37%) were MAPP-Net enrollees and 41 (63%) were Project ECHO participants.

 

Drawing on the data collected in this evaluation of the MAPP-Net Access Line, the UMRIIC Evaluation Team made the following recommendations for the MAPP-Net Program with the objective of improving utilization of the Access Line.

1. Increase awareness of the MAPP-Net Access Line and work to build trust within the community of mental/behavior healthcare providers.  Strategies for improving awareness of the program may include expanding outreach to wider-audiences, developing audience-specific messaging, and collecting and sharing success stories from providers who utilize the Access Line.
2. Designate a program champion. This person should be a Child and Adolescent Psychiatrist or a Primary Care Physician who serves as the face of the program, helps staff the Access Line, and assists with outreach efforts across the state.
3. Improve the efficiency of the enrollment process for utilizing the Access Line. Improvements to the call service process should take into consideration the following:

• All requests submitted online are directed to the Child and Adolescent Psychiatrist staffing the line.
• When providers submit an online request, provide an opportunity for the provider to schedule a time to speak with the Child and Adolescent Psychiatrist directly.
• For providers phoning into the Access Line, prioritize the shortest call back time possible.

 

4. Maintain an Advisory Board consisting of diverse group of key stakeholders (mental/behavioral health care providers, physicians, pediatricians, parents, and youth) to guide MAPP-Net decision-making and inform program strategies.

 

Montana Obstetrics & Maternal Support (MOMS) Program

 

The MOMS Program supported the MCHBG with several studies aimed at informing challenges and nuances related to NPM1: Well-Woman Visit, with the ultimate aim to elevate maternal health as a priority health issue in Montana.

 

The MOMS Program contracted with the University of Montana Rural Institute for Inclusive Communities (UMRIIC) for data collection and analysis, evaluation, and research services. Their staff launched several research projects to gather more information on maternal health, focusing on the experiences of pregnant people and providers within the health system:

 

• A provider survey: Understanding and Improving Barriers to Treatment and Care of Postpartum Depression aimed to identify provider bias related to the treatment and care of pregnant women with substance use disorder.

 

• A study: Facilitators and Barriers to Seeking Postpartum Care aimed to identify risk and protective factors associated with seeking care for postpartum depression symptoms among Montana women who use substances.

 

• A patient survey: Maternal Health Care Experiences gathered information on patient experiences interacting with the healthcare system before, during, and after pregnancy to identify unmet needs.  The information from these surveys was used for Year-4 MOMS Strategic Planning in June 2022, which included staff representing Billings Clinic, UMRIIC, the MOMS Program Coordinator, and the Title V Director/MCHC Supervisor.  Additionally, the results are being considered as a part of ongoing Title V MCHBG needs assessment data collection.

 

Maternal & Child Health Partner Programs: Current Needs Assessment Activities

 

This portion of the narrative details several needs assessment activities by partner programs which are currently underway.

 

Adolescent Health Needs Assessment

 

Work on the Adolescent Health Needs Assessment began in earnest in January 2023, with partial funding support from the MCHBG. To begin, Adolescent Health Program staff created, modified, and edited a list of health indicators to guide the assessment. The list has been organized based on a social-ecological model to ensure a holistic approach. Substantial secondary data has been collected from several sources, including Youth Risk Behavior Surveillance System; Behavioral Risk Factor Surveillance System; and Prevention Needs Assessment Youth Survey.  To help shape and inform the focus group questions, seven key informant interviews were conducted.

 

Institutional Review Board (IRB) approval for statewide adolescent focus groups was obtained from the University of Montana IRB. Only one focus group has been conducted, although significant efforts continue to be made to recruit adolescents from across the state for these groups. Individual IRB applications were also written and submitted to seven tribal college IRBs. Conversations with tribal leaders (with additional approvals needed at the tribal level) are being conducted on behalf of the team by the DPHHS American Indian Health Director.

 

Finally, two surveys were created and sent out to collect additional primary data. The first survey, Sex Education in Montana Schools, was sent out to all public and private middle and high school principals or superintendents listed in the OPI Directory of Montana Schools.  To-date, 44 responses have been received. The second survey titled Montana Adolescent Health Survey for Educators, Healthcare Professionals, and Community Members, was also initially sent to all public and private high school and middle school principals. The email asked those recipients to please forward the email/survey on to anyone in their school district, healthcare system, or clubs/groups/organizations in their community that routinely interact with adolescents. To date, 86 responses from this second survey have been received.

 

By late September 2023, it is expected that primary data collection will be complete, and a preliminary report provided for review.  A final report will be completed in November 2023, and dissemination to stakeholders will occur in December.  All Tribal data collected on tribal lands will be given to those individual tribal nations.

Oral Health Program (OHP)

 

The OHP began work on the 2024 Oral Health Workforce Assessment with WIM, LLC in March 2023, during an OH Partner’s Stakeholder meeting attended by 40+ individuals and organizations all with a vested interest in improving access to oral health services.  These stakeholders included: advocates and families for adults and children with disabilities and special healthcare needs; dentists; dental hygienists; university systems; and tribal public health. 

 

The 2024 Oral Health Workforce Assessment aims to provide additional insight to trends in the oral health workforce in Montana, and the impact of COVID-19 on the field. The OHP will use the 2024 Assessment as a guide for future workforce development projects, which includes targeting the areas and populations most in need of oral health providers.

 

Title V MCHBG: Current Needs Assessment Activities

 

Statewide 5-Year 2025 Needs Assessment: Phase 1 and 2 Activities and Purpose

 

In January 2023, Montana’s Title V MCHBG Program began discussion with UMRIIC on Phase 1 of work for the Statewide 5-Year 2025 Needs Assessment.  The purpose of Phase 1 is to help prepare and lay the groundwork for Phase 2, which has an overall purpose to collect primary data from key groups (parents/caregivers, maternal health stakeholders, and tribal communities) on maternal and child health in Montana through a statewide survey and qualitative interviews. It is also to improve the representation and inclusion of service recipients in the MCHBG needs assessment process.

 

As part of Phase 2 activities, UMRIIC will conduct a statewide survey with parents/caregivers to collect information on the health needs of families across Montana. UMRIIC created a draft survey based on the Minnesota Department of Health and Human Services Discovery Survey.  Phase 1 covers continued survey development, with UMRIIC hosting listening sessions to engage parents/caregivers in further designing the survey questions and recruitment plan. UMRIIC will integrate their feedback into a revised version. They will be sharing the updated materials with the Title V Needs Assessment Team for discussion at a meeting on August 8th.  This team includes the American Indian Health Director for Montana’s Department of Public Health & Human Services.  The feedback from the parents/caregivers and needs assessment team will shape the final survey for the beginning of Phase 2 implementation in the fall of 2023.

 

Health Status and Needs of Montana’s Title V MCHBG Population

 

Results from the ongoing Needs Assessments previously detailed in this narrative offer insights regarding the priorities identified in the Statewide 5-Year 2020 Needs Assessment.  These priorities continue to remain pertinent: Access to Public Health Services; Bullying Prevention; Family Support & Health Education; Infant Safe Sleep; Medical Home; Children’s Oral Health; and Women’s Preventive Healthcare. 

 

In Montana, County Public Health Departments (CPHDs) are the primary providers of Title V MCHBG services to their residents. Information gathered from the CPHDs also indicate that Access to Public Health Services and Family Support & Health Education remain priorities.  On the FFY 2024 CPHD Pre-Contract Survey, 31 counties choose SPM 1: Access to Public Health Services for their performance measure, and 12 choose SPM 2: Family Support & Health Education, which addresses social determinants of health.

 

The FCHB and its MCH programs were key contributors to the 2019-2023 Montana State Health Improvement Plan. FCHB staff continue to be key partners for addressing the objectives found in the Priority Area 4: Healthy Mothers, Babies, and Youth section, and the Priority Area 5: Adverse Childhood Experiences section.  The 2020 Montana State Health Improvement Plan report offered a snapshot of the MCH population’s health status on these key objectives: infant mortality rate for all Montanans; sleep-related infant deaths; births from unintended pregnancy; prenatal care for pregnant women; breastfeeding for WIC-participating infants; and postpartum depression screening. Even though improvement is being met, ongoing needs continue in the areas of: infant safe sleep; women’s preventive healthcare; access to public health services; family social services support; and health education for families. 

 

Capacity Changes in Title V MCHBG Programs and Systems of Care, Especially for CSHCN, and Impact on Service Delivery

 

Staff turnover has been a challenge for both the Children’s Special Health Service (CSHS) Section, and the Maternal & Child Health Coordination (MCHC) Section.  CSHS is currently conducting a third round of interviews to try and fill the Nurse Consultant position.  Previously, CSHS had a Program Assistant position; however, the position will not be refilled.

 

Both the MCHBG and FICMMR programs rely on contracts with the CPHDs for implementation of population-level services.  These local departments are still experiencing staffing shortages related to fallout from COVID-19 stresses, and difficulty with recruitment for relatively low-paying positions for nurses. From 2020-2022 there was a thirty percent turnover rate in CPHD staff tasked with implementing the programs at the local level, which impacts the CPHDs’ ability to provide services in a consistent manner.

 

Montana’s Title V MCHBG Partnerships and Collaborations with other Federal, State, Local, and Tribal Entities

 

As detailed in the narratives for: the National/State Performance Measures; Health Care Delivery Public & Private Partnerships; Family Partnership; and Public Input; collaborations are extensive and extend beyond the state borders.  Many of these are long standing partnerships which have evolved with the changing composition of Montana’s population, such as: the University of Washington School of Dentistry; Montana School for the Deaf and Blind; Comprehensive Statewide Cancer-Control Coalition; Montana Chapter of the American College of Obstetricians and Gynecologists; the Montana Breastfeeding Coalition; and Healthy Mothers Healthy Babies,  These partnerships and collaborations are pivotal to address the health care needs of the MCH population.

 

The value of working within the realm of state government is significant for all FCHB programs’ ability to connect with the eight American Indian Nations, each recognized as their own sovereign government.   As noted in the AH Needs Assessment summary, the American Indian Health Director is key to involving Tribal input.  Also, the Tribal Relations Manager’s expertise is valued when establishing tribal government contracts, such as the home visiting contracts with the Blackfeet, Fort Peck, and Northern Cheyenne tribes. 

 

In the last several months, the Title V MCHBG Director, FCHB Bureau Chief, MOMS Program Specialist, and the Maternal Mortality Review/Prevention Program Specialists have contributed to a workgroup aimed at addressing how to address the increase in the syphilis rate, especially congenital syphilis.  Co-led by the State Medical Officer and the STD/HIV/Hep C Supervisor, over 350 healthcare professionals and local and tribal health department staff were made aware of the emerging health care crisis and CDC recommended protocols to decrease the rate. 

 

Changes in Organizational & Structure and Leadership

 

The ECFSD has witnessed several changes in the past year.  In August 2022, Tracy Moseman transitioned from her role as the Director’s Office of Faith and Community Based Services Coordinator to the ECFSD Division Administrator. The ECFSD recently underwent an organizational structure analysis, and with the recent addition of the Preschool Development Birth through Five Grant, is undergoing reorganization.

 

Within the DPHHS Director’s Office, David Gerard began as Director Charlie Brereton’s Deputy Director in April 2023.