Process Description

For this, and the next years (2022-2024), the Health Needs Assessment Update (HNA), of the Maternal, Child and Adolescent Health Program (MCAHP) and the Children with Special Health Care Needs Program (CSHCNP) will assess the State Action Plan (SAP) for 2020-25. The pandemic had a direct effect on MCAHP/CSHCNP services and programs, thus significant changes were made to provide services during the emergency (see 2021 Health Needs Assessment Update). To document and evaluate actions implemented throughout a year, an assessment of the SAP was developed to inform decision-making regarding the strategies included in the plan. The Plan-Do-Study-Act Cycle (PDSA) facilitates constantly monitoring and identifying recommendations to enhance strategies included in the SAP.

PDSA cycles provide a framework for developing, testing, and implementing changes leading to improvement. It allows staff to highlight barriers and challenges faced in the process of implementing actions and considering ways these may be overcome. Title V evaluators designed an online tool to facilitate data entry for staff in charge of implementing the SAP. A model of the PDSA instrument (Table 1) is attached as part of the supporting documents (PR 2022 Health Needs Assessment Supporting Document).

Given that the SAP will be fully implemented by 2025, this year, the information was reported until April 2022; however, it will continue to be gathered throughout the next years.

To analyze the information gathered in the PDSA cycles, the Title V evaluators performed text analysis and presented their recommendations to the HNA Steering Committee for final revision of the plan. In addition, the evaluators met with the team in charge of implementing the SAP to discuss recommendations for continuity or inactivation of activities/strategies.

A chi-square for trend analysis of the last three years to assess the progress of the indicators by domain was performed to complement the PDSA. Average Annual Percent Change (AAPC) was also calculated to determine whether there was an increase or decrease in the indicators under monitoring.

Completing the first phase of the PDSA had a limitation. The MCAHP currently does not have a Pediatric Consultant, therefore some of the scheduled strategies or activities for Infant/Perinatal and Child domains could not be carried out. For this reason, the PDSA only assessed those strategies whose activities were either completed before the Pediatric Consultant ceased providing services or implemented by the Home Visiting Program (HVP).

Data availability for the 3-year chi-square for trend analysis also had a limitation. Data was not available for the three years under study for some indicators. In some cases, the data source was a survey that is carried out every two years or it was interrupted due to the impact of hurricane María and then by COVID-19. For this reason, some indicators could not be included in the trend analysis. When possible, other available data sources that measured the same indicator were used for the purpose of this analysis. The supporting document includes a table of the indicators not included in the analysis and other data sources (Table 2).

The committee reviewed and updated the SAP considering the findings of this HNA, and feedback provided in the Public Input (for details refer to section III.F. Public Input).

The priority needs remained as proposed in 2020 HNA. Some strategies of the SAP were reviewed and updated or eliminated according to the findings of this HNA.

Health Status by Domain: 3-year Chi-Square for Trends Analysis

Following are the significant findings of the trend analysis. For the detailed analysis tables by domain refer to the supporting document.

Women/Maternal Health

According to 2020 International Database (IDB) the number of WRA was 806,330 (10 to 14 y/o: 10.8%; 15 to 19 y/o: 11.7%; 20 to 24 y/o: 13.1%, 25 to 34 y/o: 25.9%, and 35 to 49 y/o: 38.5%). According to the American Community Survey (ACS), about 91% of the WRA were insured during 2019.

2021 Vital Statistics (VS) reports 19,336 live births (LB), a 1.5% increase since 2020 (19,053 LB). It should be noted that this is the first time, in more than 10 years, that a slight increase is observed in births. Most births occur in women between 20 and 34 y/o (80.5%), followed by women 35 y/o or older (12.9%) and teens 10 to 19 y/o (6.6%). About 66% of live births are from mothers covered by the government health plan (GHP).

Preventive medical visits in the past year in women 18 to 44 y/o (NPM 1) significantly decreased by 4.2% between 2018 to 2020 (Table 3). During the period of observation, improvement was observed in most NOMs related to NPM 1, although not all were significant. Those indicators that significantly improved were the percent of early term births (AAPC: -2%), the percent of women who drink alcohol in the last 3 months of pregnancy (AAPC: -30%), and teen birth rate of 15 to 19 y/o (AAPC: -7.7%). On the other hand, a significant increase of 77.3% was observed in severe maternal morbidity rates.

Preventive dental visit during pregnancy (NPM 13.1) also decreased (AAPC: -9%) but it was not significant. However, the related NOM, children 1 to 17 y/o, who have decayed teeth or cavities in the past year reported a significant improvement (AAPC: -2%).

Perinatal/Infant Health

According to 2020 IDB, the number of infants was 25,095, representing less than 1% of the total population. Infant mortality (IM) increased in average 3% from 2018 to 2020 (6.6/1,000 vs. 7/1,000). According to the 2019 ACS, about 93.1% of infants were insured.

All three NPMs related to a safe sleep environment (NPM 5A, 5B, 5C) improved between 2018 to 2020 (Table 4), however, only the percent of infants placed to sleep on their backs increased significantly by 7%. None of the NOMs related to these NPMs showed significant changes. Although post neonatal mortality and SUIDs rates showed a decrease of 12%.

Child Health

According to the 2020 IDB there were 250,214 children 1 to 9 y/o that represent 8% of the total population. According to the ACS, about 97% of the child population were insured during 2019.

Form CMS-416 for the Annual EPSDT Participation Report showed a significant decrease (Table 5) in oral preventive visits on children 1 to 17 y/o (AAPC: -1.6%).  However, the NOM related to this NPM, children 1 to 17 y/o who have decayed teeth or cavities in the past year, showed a significant improvement (AAPC: -2%).  

Adolescent Health

According to 2020 IDB, the number of adolescents 10 to 21 y/o was 456,984 that represents 14.3% of the total population (10-14 y/o: 38.9%; 15-17 y/o: 24.8%; 18-19 y/o: 17.7%; and 20-21 y/o: 18.6%). During 2019, 94.5% of adolescents 10 to 21 y/o were insured (ACS).

YRBSS 2019 reported a 44% decrease of adolescents, ages 12 to 17 y/o, who are bullied or who bully others (NPM 9). However, since data is not available for the three years under study, AAPC and significance could not be calculated.  Despite this decrease, adolescents’ mortality and suicides increased during the study period, although it was not significant (AAPC: 0.1% and AAPC: 4.9%, respectively).

Form CMS-416 for the Annual EPSDT Participation Report showed a significant increase (Table 6) in preventive medical visits during the past year on adolescents 12 to 17 y/o (AAPC: 1.3%). Related NOMs also showed an improvement, but only the teen birth rate was significant (AAPC: -7.7%).

Children with Special Health Care Needs

According to the 2019 MCH-JS screener, approximately 162,101 (27.3%) children ages 0 to 17 years in PR had a special health care need. The most frequent conditions in this group of children are asthma (38.4%), speech disorder (35.9%), anxiety (28.6%), learning disabilities (26.6%), and ADD/ADHD (26.2% each). Ninety nine percent (99.1%) are covered by a health insurance, 72.6% of them under the GHP. The previous prevalence based on a PR-adapted National Survey of CSHCN was 16.6% in 2010, and 18.6% in 2015.

Based on the 2019 MCH-JS, the prevalence of ASD in children 3 to 17 years of age is 3.1% (1 in 32), an increase when compared to previous PR-CSHCN surveys (1 in 100, 2010; and 1 in 40, 2015). The PR-SET-NET has also identified a high prevalence of ASD among a cohort of children born to mothers with laboratory evidence of Zika virus infection during pregnancy. The CHSHCN Program, PR-SET-NET and CDC are working collaboratively in the data analysis.

A pilot project, “Identification and Monitoring of CSHCN Families’ Needs”, was conducted at the Bayamón RPC during the months of June to August 2021 to help families identify and prioritize their needs. The Family Needs Survey (Donald B. Bailey, Jr. & Rune J. Simeonsson, FPG Child Development Institute, University of North Carolina at Chapel Hill) was used for data collection. The survey has been validated and used to identify families’ needs. It contains seven topics: Information (7 items), Family & Social Support (8 items), Financial (6 items), Explaining to Others (5 items), Child Care (3 items), Professional Support (3 items), and Community Services (3 items) for a total of 35 items. Items have three (3) response alternatives: “No”, “Not Sure” and “Yes”. The two open-ended questions of the survey were modified. The first question asked families to identify their three top priorities, and the second one to document any need not included in the questionnaire. Seventy-five (75) families attending the RPC for the first time participated in the project. Reliability and internal consistency results based on the Cronbach Alpha coefficients was .939 for the entire scale, which represents a very good internal questionnaire consistency.

“Information” was the top need reported by families (72.4%), followed by “Explaining to Others” (45%) and Community Services (42.3%). Indicators for “Explaining to Others” includes how to explain to parents/in-laws, siblings, friends/neighbors, and other children. The three indicators for community services are: 1- a doctor who understands me and understands the child's needs, 2- talking to other parents who have a child like mine, and 3- a dentist. The graph below shows the percentage distribution of needs per topic.

The table below shows the numbers and percentages of families identifying the information topic item as a need. The top information needs reported were for present and future services, and about the child’s condition.

Information Needs Topic

 

Of the top three priority needs identified by families in the 1st open-ended question, 58.5% were related to items in the information topic. Other needs identified by 50% or more of the families in the scale were: 1- Financial: Obtaining special equipment for my child’s needs (61.6%), 2- Explaining to Others: Finding reading material about other families who have a child like mine (51.4%) and 3- Financial: Paying for therapy, day care, or other services my child needs (50.6%).

The findings confirm the importance of identifying and addressing CSHCN families’ information needs.

PDSA Analysis:

A summary of the key findings of the PDSA is presented below. For a detailed PDSA description refer to the supporting document.

Women/Maternal Health

The Women/Maternal Health domain has two priority needs: promoting the health and wellbeing of WRA (associated to NPM 1) and improving birth outcomes (associated with NPM 13.1).

To address this area, the team established 8 strategies, all which have been initiated and are being addressed through 40 activities. A range of 1 to 20 activities per strategy were registered. The status analysis reflects that 27.7% of the activities have not started, 32.5% are in progress, and 40% were completed. Of the 40 activities that were originally planned, more than half (60%) remained active, while 40% were inactivated, either because they were completed (87.5%) or were eliminated after being initiated (12.5%).

To address improving birth outcomes, the team established 9 strategies. Of these, 55.6% have been initiated and are being addressed with 10 activities. A range of 1 to 3 activities per strategy were registered. The status analysis reflects that 30% have not started, 70% are in progress, while none were completed. Of the 10 activities that were originally planned, all remained active.

Limitations such as pandemic-related restrictions to home visits, preventive/prenatal visits, and oral health visits were identified when implementing the SAP. Other barriers (beyond the team’s control) also impacted the progress of certain activities. The WRA Care Pocket Guide would have been disseminated by 2021, however the purchase process and the approval of educational material and videos took more time than expected. In terms of updating the Preventive Care Guidelines for WRA, the participation in the committee required volunteer time which at times became a barrier as well. Another identified barrier is that underserved areas may lack prenatal care (PNC) providers, thus affecting the outreach and referral of pregnant women to initiate PNC.

The PDSA allowed the team to identify a strategy that should be eliminated from the SAP: Apply a mental health intervention model among participants of the HVP. After analyzing the suitability of a variety of mental health models it has not been possible to find a program that fits with the current service model of the HVP. Also, barriers such as the cost of the program, availability of materials and training in Spanish and staff requirements, were identified. Given that an appropriate intervention model could not be identified, it is recommended to inactivate this strategy. Recommendations include that the Home Visiting Nurses (HVNs) receive regular training to hone their knowledge and skills in mental health to allow them to make appropriate identification of such needs within participants, supportive interventions, and referrals.

The team also identified areas in need of improvement for which they could implement a change. For example, to update and disseminate the Preventive Care Guidelines for WRA, the need of bi-annual meetings for update recommendations was identified. This can be improved by establishing one-on-one interactions using virtual platforms for meetings. Also, the dissemination to the general community was not possible due to lack of personnel. To achieve this, it is recommended to explore the development and coordination of a dissemination plan that may include training of HVNs, develop a Fact Sheet for community distribution and consider the use of social media. To disseminate among health care providers, the identified need is to do so through the College of Physicians and Surgeons of PR and the development of a virtual online CME session for physicians. In terms of the development and dissemination of the WRA Care Pocket Guide, the inclusion of people with lived experiences in the entire process of design of the pocket guide and educational modules was identified.

Perinatal/Infant Health

The Perinatal and Infant Health domain has one priority need: decrease infant mortality (associated with NPM 5).  To address this area, the team established 12 strategies. Of these, 42% have been initiated and are being addressed with 17 activities. A range of 1 to 11 activities per strategy were registered. The status analysis reflects that 47.1% activities have not started, 35.3% are in progress and 17.6% were completed. Of the 17 activities that were originally planned, 82.4% remained active, while 17.6% were inactivated because they were completed.

Most of the activities address safe sleep practices. The HVP families were reached by the HVNs and were offered education on safe sleep practices. The promotion of healthy lifestyles during pregnancy was implemented by social media, short videos, and the use of the prenatal care webpage, “Encuentro de mi vida” (Encounter of My Life), because activities in the community at the time were not possible.

For this domain, the main challenge (what the team can work with) identified was the lack of a Pediatric Consultant that could implement and follow-up all the strategies proposed in the SAP. Another challenge was that the changes in service delivery of the HVP during the pandemic made it harder for the HVNs to verify the safe sleep practices of families.

Being able to ensure a high standard in the content of the HVP interventions for safe sleep practices was an identified challenge as well. However, this need of improvement can be addressed by offering regular training and updates on this topic to the HVNs. 

As discussed with the team, all strategies proposed for Perinatal/Infant Health domain will continue for the following years.

Child Health

The Child Health domain has one priority need: improve preventive health in children (associated with NPM 13.2). To address this area, the team established 6 strategies. Of these, 66.7% have been initiated and are being addressed with 7 activities. A range of 1 to 2 activities per strategy were registered. The status analysis reflects that all activities are in progress, while none were completed. Of the 7 activities that were originally planned, all remained active.

As in the previous domain, the main challenge identified was the lack of a Pediatric Consultant that could implement and follow-up all the strategies proposed in the SAP. Another challenge was the pandemic-related restrictions that limited the number of activities that could be provided in the community by the Community Health Workers (CHWs), Health Educators (HEs) and HVNs. Even though the pandemic limited the amount of activities that could be conducted, CHWs and HEs were able to offer some education to participants of the parenting courses. Also, HVNs provided education virtually, but this made it harder for the HVN to ascertain the healthy lifestyles adopted by the family.  Being able to ensure a high standard in the content of the HVP interventions for healthy lifestyles practices was another challenge, but this need of improvement can be addressed by offering regular training and updates on this topic to the HVNs. 

As discussed with the team, all strategies proposed for the Child Health domain will continue for the following years.

Adolescent Health

The Adolescent Health domain has one priority need: improve health and wellbeing of adolescents (associated with NPMs 9 and 10). To address this area, the team established 10 strategies that are being addressed with 30 activities. A range between 2 and 5 activities per strategy were registered. The status analysis reflects that 56% of the activities are in progress, 40% have not started and 3% were completed. Of the 30 activities originally planned, 13% were inactivated (25% completed and 75% eliminated).

The successful collaborative efforts with the right partners allowed the completion of one activity related to the development of the Youth Intervention Guides to promote resilience and reduce youth trauma after stressful events.  On the other hand, challenges to start other 2 activities related to this priority were identified, thus they were eliminated.  These activities were already included as part of the plan of the guide itself and it would have been redundant to keep it as part of the SAP.

An activity related to the development and dissemination of an Emergency Preparedness and Response guide that considers the needs of this population, was eliminated because the MCH Emergency Preparedness Toolkit workgroup was dissolved after the Youth Intervention Guide was completed.

In terms of activities that are active and in progress, some challenges and needs were identified by the team.  Not having a graphic artist to support them during the review and development of the Youth Health Promoters Project (YHPP) pre and post questionnaire made the design difficult. Also, the pandemic measures kept schools in virtual mode during FY 2020-2021 thus implementing the YHPP during this period was not possible. Regarding the media campaign and webpage aimed at adolescent health, communication with the agency was not effective, since they did not develop a concept that would be attractive to the young population as requested and according to the input provided by the youth themselves. On the other hand, this provided an opportunity for change; a new agency was hired, having a better communication and youth were on board since the beginning of the development of the new re-designed campaign.

As discussed with the team, all strategies proposed for the Adolescent Health domain will continue for the following years.

Children with Special Health Care Needs

The PR priorities for the CSHCN domain are medical home (NPM11), transition to adult health care (NPM12), early identification and diagnosis of ASD (SPM1) and reducing the prevalence at birth of folic acid preventable NTD (SPM2). Below is the progress report for the NPM11 and NPM 12 strategies and activities.

The original 5 years SAP included eight (8) strategies and 21 activities to address the medical home priority. As of June 2022, 18 activities (85.7%) were completed, one (1) was in progress (4.7%), the EHR implementation, and two (2) were not initiated (9.5%). Two (2) of the completed activities remain active because they are associated to data quality. The other sixteen (16) completed activities were inactivated. The two (2) activities not initiated: 1) implementation of a communication model with PCPs and 2) implementation of strategies to enhance family/professional partnerships will be implemented in FY 2022-2023. 

The original 5 years SAP also included three (3) strategies and five (5) activities to address the transition to adult health care priority. As of June 2022, 3 activities (60%) were completed, one (1) activity (20%) was in progress, training to program’s service providers on the Transition Guide; and one (1) activity (20%) was not initiated. The activity not initiated, education to physicians on Got transition, will be implemented in FY 2022-2023. The completed activities were inactivated.

The NA update finding on the importance of identifying and addressing CSHCN families’ information needs is included in the 5 years SPA strategies and activities.

Conclusions

The results of this HNA must be seen within the context of the COVID-19 pandemic that adversely affected access to health services as these were interrupted and/or limited.  The PR Title V experienced disruptions and modifications in its services, initiatives, and programs during the first 2 years of the SAP (2020 and 2021), and this is reflected in the current HNA.

The first years of the SAP were necessary to adapt programs and services to the current situation.  The HVP developed a protocol to guide services during the pandemic, thus making a quick adaptation from home visits to virtual services. Several digital educational tools were created to push further health promotion. This included a virtual prenatal course, webinars and videos that address MCAH in various areas and the enhancement of media campaigns and webpages addressing prenatal, postpartum, and infant care, as well as adolescent health. Social media was also a tool that Title V used as a strategy to reach the community as much as possible.

When implementing activities, long-term relationships with the right partners was the most outstanding success in the PDSA. Other identified successes are the inclusion of persons with lived experience in the development of educational projects and the commitment/involvement of Title V staff in different activities.

The PDSA also allowed the team to identify challenges and needs to improve or overcome in the SAP. Some of these needs are staff training to enhance services, use of social media and other partners for dissemination, and strengthen communication and collaboration with stakeholders, among others.  

Other limitations or barriers were identified as well, such as long-term commitment of members to participate in different committees and PRDOH internal processes like communication between offices, documentations, and purchases.

2022-25 Annual objectives for each indicator were reviewed based on the chi-square for trend analysis. It is expected that the SAP will be fully implemented by the end of the cycle, thus the 5-year trend analysis will show improvement in the observed indicators.

Changes in organization structure and leadership:

Currently there are no changes regarding the organization structure and leadership of the PRDOH and PR Title V Programs.  For details see in Section VI. Organizational Chart.

Title V Partnerships, Collaboration, and Coordination:

MCAHP/ CSHCNP enhance health promotion and leadership through formal agreements - committees, task forces, and alliances, coalitions, cross coordination, resource, and data sharing – with other federal, state and local agencies.

A major focus of MCAHP/ CSHCNP is to strengthen family partnerships. For details see Section III.E.2.b.ii.

Following an updated list of MCAH/CSHCN Programs partners:

Other MCH Investments:

1. MIECHV
2. SSDI

Other federal investments:

1. CDC (PRAMS, HIV/STDs Prevention Division, PR-SET-NET, EHDI-IS)
2. Centers for Medicare and Medical Services
3. Early Intervention Program
4. FEMA
5. Immunization Program
6. Personal Responsibility Education Program
7. Sexual Risk Avoidance Education Program
8. WIC Program

Other HRSA programs:

1. HRSA Funded Health Centers
2. Ryan White HIV/STD Program
3. Early Hearing Detection and Intervention Program

State and local MCH programs:

1. Autism centers
2. MCAHP regional offices
3. Regional pediatric centers

Other programs within the State Department of Health:

1. Administration of Mental Health and Anti-Addiction Services
2. Chronic Disease and Health Prevention Programs
3. Demographic Registry Office
4. Emergency Medical Services for Children
5. Medicaid Program
6. Office of Informatics and Advanced Technology
7. Office of Public Health Preparedness and Response
8. Office of Regulation and Certification of Health Professionals

Other governmental agencies:

1. Education Department
2. Family Department
3. Head Start and Early Head Start Programs
4. Insurance Commissioner Office
5. PR Health Insurance Administration
6. PR Institute of Statistics

Tribes, Tribal Organizations, and/or Urban Indian Organizations:

PR has no tribes, Tribal Organizations, and/or Urban Indian Organizations

Public health and health professional educational programs and universities:

1. Health and Justice Center, San Juan Bautista School of Medicine
2. Institute on Developmental Disabilities, UPR Medical Science Campus
3. Medical Science Campus, University of PR
4. PR Family to Family Health Information Center
5. PR-Neonatal Screening Laboratory
6. UPR University – Agricultural Extension

Other state and local public and private organizations that serve the state’s MCH population:

1. AAP Puerto Rico Chapter
2. APNI
3. ASI
4. Association of Primary Health Care of PR
5. Highway Safety Commission
6. Hospital Association
7. Institute for Youth Development
8. La Leche League PR
9. March of Dimes
10. Maternal Fetal Medicine Specialist
11. MAVI
12. Oral Health Alliance
13. PR Boys and Girls Club
14. PR Breastfeeding Coalition
15. PR Pediatric Society
16. PR Society of Pediatric Dentistry
17. PR-ACOG
18. Pro Familia (Planned Parenthood)
19. Promani
20. Proyecto Lacta
21. Proyecto Nacer
22. Quality Office of La Fortaleza
23. SER de PR
24. United Way
25. Women and Patient Procurator