III.C. Needs Assessment Update

III.C.1. Ongoing Needs Assessment activities

 

OHA 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. For a description of the 2020 Five Year Title V Needs Assessment, please see link provided.

 

• 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, assessment and evaluation strategies, activities, and measures were developed 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.

 

• 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.

 

• Dissemination of the report on the Title V Five Year Needs Assessment among partners, providers, and grantees.

 

• 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 adverse childhood events and cognitive disability using data from a four-year race/ethnicity oversample from the Behavioral Risk Factor Surveillance System (BRFSS). A manuscript on this analysis has been composed and is currently undergoing approval processes with the Maternal and Child Health Section and CDC, for submission to a peer-reviewed journal.

 

• Title V Research Analyst served as consultant for Babies First/CaCoon during transition to the use of new data collection forms, and a new data collection system, THEO. Part of the process of developing the new forms was soliciting feedback and information from service providers, community partners, and expert consultants. A data equity workgroup was formed with these multidisciplinary partners, including community members, in order to improve Title V funded home visiting data collection; by increasing the cultural and linguistic responsiveness of the questions and collection methods, and by framing the data collection using a trauma informed lens.

 

• 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 has begun work on and evaluation of the partially Title V funded Babies First home visiting program. The first stage of the evaluation is 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 is individual qualitative interviews with staff at Babies First sites, including Nurse Supervisors, Nurse Home Visitors, and Community Health Workers. The interviews have been completed and are currently being analyzed using qualitative data analysis software. Next stages of the evaluation will be conducted in following grant period years.

 

OCCYSHN ongoing NA activities

OCCYSHN’s ongoing needs assessment activities included (a) review of the most recent NSCH data (2019-2020), (b) planning a third participatory needs assessment study, (c) review of end of year programmatic reports required of LPHAs who contract with OCCYSHN, (d) one-on-one or group conversations with LPHA grantees when providing technical assistance, and (e) monitoring of reports from partner agencies

 

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 increased from 70.8% in 2018, to 72.0% in 2019, to 73.0% in 2020. 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 increased slightly from 93.2% in 2017 to 93.7% in 2018 and remains higher than the national level. Exclusive breastfeeding at six months increased in Oregon from 35.6% in 2017 to 36.3% in 2018. 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, increased from 122.1 in 2018, to 125 in 2019, though this increase is not statistically significant. In 2019, rates were highest among non-Hispanic White children (136), followed by non-Hispanic Black children (129.7), and non-Hispanic Asian/Pacific Islander children (82.7). Rates were lowest among Hispanic children (77.3). There was insufficient sample size to reliably report the rate among non-Hispanic American Indian/Alaska Native children.

 

• Bullying prevention: The rates of parent reported bullying perpetration and bullying victimization both decreased from 2018/2019, to 2019/2020, from 16.1% to 15.4%, and 44.1% to 38.3%, respectively. In 2019/2020, rates of perpetration were highest among non-Hispanic White adolescents (19.1%), followed by Hispanic adolescents (9.2%), non-Hispanic multiple race adolescents (8.4%), with the lowest rates of perpetration among non-Hispanic Asian adolescents. Rates of victimization were also highest among non-Hispanic White adolescents (44%), followed by non-Hispanic multiple race adolescents (37.9%), then Hispanic adolescents (26.6%), with non-Hispanic Asians having the lowest rate of victimization (23.3%). Sample size of the National Survey of Children’s Health in Oregon was not sufficient to examine rates for either of these performance measures among non-Hispanic Black, non-Hispanic American Indian/Alaska Native, or non-Hispanic Native Hawaiian/Other Pacific Islander adolescents.

 

• Toxic stress, trauma, ACEs, and resilience: From 2019 to 2020, the percent of new mothers who experienced at least 2 types of prenatal stress increased from 42.8% to 46.6%. This increase may have been partially due to the stress brought on by the covid-19 pandemic. The highest rates of new mothers who experienced at least 2 types of prenatal stress were among non-Hispanic American Indian/Alaska Native mothers (67.6%), followed by non-Hispanic multiple race mothers (61.6%), then non-Hispanic Pacific Islander mothers (58.1%), then Hispanic mothers (47%), then non-Hispanic White mothers (46.9%), then non-Hispanic Black mothers (44.9%), with the lowest rates among non-Hispanic Asian mothers (26.6%).

 

• Culturally and linguistically appropriate services: From 2018/2019 to 2019/2020, the percent of children with a healthcare provider who is sensitive to their family’s values and customs increased slightly from 94% to 94.3%. 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 decreased slightly from 42.8% in 2018/2019 to 41.4% in 2019/2020. 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

Less than a quarter of CYSHCN (22%) in Oregon received care in a well-functioning system in 2019-2020. Numerous disparities were observed for CYSHCN with more complex health needs as compared to CYSHCN with less complex health needs. For example, fewer CYSHCN with more complex health needs had adequate and continuous insurance (61% vs 74%), received care that met the standards of a medical home (33% vs 55%), received family-centered care (78% vs 97%), effective care coordination (45% vs 71%) and transition services (21% vs 47%) and both preventive medical and dental care (70% vs 84%). These CYSHCN also had greater difficulty getting needed referrals (40% vs 11%) and a majority of them had difficulty accessing needed mental health treatment or counseling.

 

A greater proportion of transition-aged CYSHCN (12-17 years) had a plan of care to meet their health goals and needs as compared to non-CYSHCN in the same age group (41% vs 24%). However, only about a quarter of CYSHCN (24%) had plans of care that addressed transition. Furthermore, only 14% of transition-aged CYSHCN saw adult healthcare providers as compared to 20% of non-CYSHCN. About half of CYSHCN (49%) did not know how to obtain or keep insurance as they became an adult and did not have anyone discuss this with them. The results suggest that there are opportunities for improvement in transition preparation for CYSHCN.

 

 

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

Over the past year, Oregon’s Title V program has continued to be impacted by the COVID-19 pandemic, although to a lesser extent than the previous year. As OHA stood up its COVID Response and Recovery Unit (CRRU) during 2021, some Title V staff accepted 18-24 month positions in the new Unit, while others who had served on the Emergency Response Team returned to their regular positions. Limited duration positions were created to backfill staff serving on the CRUU and ongoing staff stepped up to fill gaps as they were able, allowing most MCH capacity to be retained. Additional staff deployments during the Omicron surge created more temporary vacancies, with some work consequently delayed or deferred.  HR capacity to post and fill positions has been severely strained this year resulting in delays in filling positions, including one key MCH OPA 3 position which was vacant for more than 6 months.  Title V staff have continued to work primarily remotely for the year, with the opening of the Portland State Office Building taking place on May 1, 2022. Increases in state level capacity are anticipated in the coming year as 3 new MCH management positions have been approved by the legislature and will be filled in the coming months. 

 

At the local level, MCAH Title V capacity continues to be strained to varying degrees throughout the state. All local public health authorities continue to be engaged in responding to the COVID-19 pandemic, and its multiple impacts on the MCH population. In some LPHAs MCH staff are playing key roles in their local COVID-19 response and have had to shift local staffing to support COVID-related activities for the MCH population – including health education, support for quarantine and isolation, contact tracing, assistance with access to vaccination, etc.  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). As the pandemic stretches on the strain on local public health is growing, with staff suffering directly from the public’s lack of support for their COVID-related work. MCH services which are not pandemic-related are also impacted as bad feelings about the Public Health Department’s role in pandemic response often spills over into negative feelings and treatment of staff and program offerings in MCH.  These shifts, as well as increased needs of the MCH population resulting from the pandemic have resulted in some grantees needing to modify their Title V plans and change the Title V priorities on which they are focused.

 

OCCYSHN changes in Title V program capacity and impact on service delivery

At the state level, our program capacity has remained relatively stable. During FY21, we hired a Bilingual Outreach and Training Specialist into our Family Involvement Program, which expanded our capacity to conduct Table Talks and training sessions completely in Spanish. In spring 2022, one of our longest serving ORF2FHIC Parent Partners left her position to focus on her career. During FY21, we filled an Implementation Specialist vacancy in our Systems and Workforce Development Unit. We recently hired a Systems Innovation Project Manager to join the S&W team. The additional capacity will help us expand our cross-systems care coordination efforts.  As described in Section BG2023_III.E.2.b.iii, we hired a part-time Senior Program Evaluation Research Analyst in October 2021, which strengthened the capacity of our Assessment and Evaluation Unit.

 

At the local level, public health authorities and their partners, including clinical providers, have been generally negatively impacted by COVID-19 response as described by OHA MCAH. Their diminished capacity has further limited their ability to provide services to CYSHCN and their families. LPHA capacity to conduct home visits has diminished, and referrals to the CaCoon nurse visiting program have dropped sharply. LPHAs are gradually rebuilding and recovering 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 activity implementation. For example, key findings showing that CYSHCN who are members of Black and Latinx communities experience institutional 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 plan. Additionally, OHA MCAH and OCCYSHN will collectively explore ways to advance LPHA capacity to provide culturally responsive, antiracist care. Given the continued need for CYSHCN, particularly those with more complex needs, to receive support preparing for transition to adulthood, we also continue our Children with Medical Complexity CoIIN work (Block Grant plan Section 12.2).

 

III.C.5. Changes in organizational structure and leadership

 

OHA MCAH changes in organizational structure and leadership

Changes in OHA, PHD, and MCAH Title V leadership and staffing over the past year have been minimal:

• Jordan Kennedy moved to a new position in OHA in August 2021. Recruitment for his replacement is currently underway.
• Two new management positions will be added to MCH this year. Catalina Aragon will be the new MCH Program and Policy Manager; the other position is in recruitment. Both managers will support and coordinate with Title V work across the MCH section.
• Several State level Title V staff either took limited duration positions or moved to other OHA positions this year. Both Title V lead positions – the bullying prevention and the MCH Title V programs position - have been filled.

 

Changes in local level public health leadership have been extensive over the past two years – both among administrators and staff leading MCH programs. The stress of the ongoing COVID-19 response is resulting in continuing resignations and strains on local public health capacity.

• Half of local public health administrator positions (16 of 32) have turned over between March 2020 and April 2022.
• 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.
• 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 COVID-19 response.

 

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.

 

Changes in OHA organizational structure have continued over the past year in response to the ongoing COVID-19 pandemic. The pandemic response was initially managed through an emergency management/incident management team structure. During the summer of 2020, Oregon established the COVID-19 Response and Recovery Unit (CRRU), to coordinate statewide efforts to prevent and mitigate the spread and effects of the pandemic. The CRUU is a shared unit of the Oregon Health Authority (OHA) and the Department of Human Services (DHS), which is now being integrated into the Public Health Division. One of the key changes associated with the CRUU that impacts the MCAH population is the development of community engagement specialists and contracts with multiple community agencies across Oregon to provide outreach and COVID-related support to their populations. Although this is not a change in MCAH Title V capacity, the impact of this structural and capacity change on MHAC population in marginalized communities around the state cannot be over-stated. There are currently 179 community agencies receiving funding to support the COVID-related needs of individuals and families in their communities. The work is being actively 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.

 

An additional OHA structural change this year has been the development 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 and builds upon CBO funding and engagement initiated during the COVID-19 pandemic. 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 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 MCAH changes in organizational structure and leadership

Fortunately, OCCYSHN has not experienced organizational structure or leadership changes within our center, the Institute on Development and Disability, or within the OHSU Department of Pediatrics.

 

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 direct as well as indirect impacts of COVID-19 on the MCAH population, as well as the related issues of racial justice and equity, and mental and behavioral health.

• COVID-19 continues to be a significant public health issue impacting the MCAH population in Oregon.  The impacts of the pandemic include both the direct impact of the disease – particularly the disproportionate impact on communities of color, as well as the economic and social impacts related to the ongoing closures, job losses (particularly for low-income families and women of color), women being forced to leave the workforce to care for children who are without childcare or school, etc., and inequitable access to vaccines. increased significantly. Targeted Federal funding, as well as flexibility in use of Title V funding to address these issues are helpful. However, limitations in available qualified staff in many areas of the state (especially rural areas), as well as staff turn-over with the ongoing high stress nature of the response present ongoing capacity challenges.

 

• The need to focus on racial justice and equity as core public health work has also been an emerging focus this past year. This is on ongoing issue, but the disparities and injustice of the past two years – both due to the pandemic and 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.

 

• Mental and behavioral health needs of children, youth and families have also escalated during the past year – in relation to both the above issues. Children, youth, and families are experiencing unprecedented isolation and have been cut off from many of their usual forms of social and community support. The need for culturally responsive 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. 

 

• A shortage in infant formula due to supply chain issues and the recall of several products has impacted the safety and wellbeing of infants across Oregon, particularly among low income and marginalized communities. Programs such as home visiting and WIC, in partnership with community-based agencies, have been key in connecting families to resources during this shortage.

 

OCCYSHN emerging public health issues and capacity to address them

As our staff becomes aware of reports or news stories that describe issues affecting CYSHCN, and populations of CYSHCN (e.g., those with disabilities) and their families, we share them with applicable partners, particularly when we lack capacity to act. For example, the State Interagency Coordinating Council’s (SICC) 2021-2022 Governor’s Report showed shortfalls in the percent of Oregon 3-5 year olds receiving adequate levels of Early Childhood Special Education services; the shortfalls are particularly pronounced for children with moderate and high needs. OHSU’s University Center for Excellence in Development and Disability (UCEDD) has a number of connections within the Oregon Department of Education, and faculty and staff with particular interest in the early childhood population. The Family Involvement Program Manager, Care Coordination Specialist, and an ORF2FHIC Parent Partner (latter two staff are SICC members) presented these findings during a UCEDD staff meeting, which facilitated a connection between their personnel and the SICC.