Ongoing Assessment Activities – Data Collection and Analysis:

 

The Title V MCHBG is housed in the Maternal and Child Health Coordination (MCHC) Section which also includes the HRSA funded Maternal Health Innovation Grant, known as the Montana Obstetrics and Maternal Support (MOMS) Program. The MCHC, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and Children’s Special Health Services (CSHS) are sections in the Family & Community Health Bureau (FCHB). MOMS, WIC, and CSHS engaged in needs assessment activities during this reporting period.

 

WIC Needs Assessment Highlights

 

Introduction

 

WIC released the results of their 2021 Needs Assessment in January 2022, which was conducted from summer 2020 to summer 2021 by the WIC program in conjunction with Yarrow, LLC,  a contracted public health consulting organization. Data for this assessment were sourced from both primary and secondary data sets at the national, state, and local levels. The direction and scope of the Needs Assessment were shaped by: the WIC Nutrition Services Standards; the Montana WIC Program Director/Section Supervisor; and key Montana WIC staff.   The WIC Needs Assessment was conducted to better understand the needs and resources of the WIC program; its participants and services; and to be used as a guide to WIC’s comprehensive statewide nutrition services plan.  A copy of the full report is available at: https://dphhs.mt.gov/assets/ecfsd/WIC/WICNeedsAssessment.pdf

 

As of 2021, Montana had 29 local agencies and 84 clinics, noted on the following map. Satellite clinics are operated by WIC staff who travel out to a location to provide services in a smaller community at regular intervals, depending on size and need.

Needs Assessment Findings

Findings from the WIC Needs Assessment Survey 2021 suggest that the major barriers to care for the WIC population, as perceived by WIC staff, are the time required of participants to take off work or school or other commitments in order to attend appointments, transportation barriers, and that WIC participants may not find enough value or interest in the nutrition education services provided. Additional findings include:  

 

Program Participation

When looking at participation trends in the Montana WIC Program from 2016 to 2021, overall participation in the Montana WIC program decreased by 22%. The largest drop in participation was seen among women (pregnant, breastfeeding, and postpartum), with a 32.9% decrease from 2016 to 2021. Total children participants exhibited the smallest participation decrease: 13% from 2016 to 2021 (figure 1).

Participant Depression Screening

In 2017, the Montana WIC Program began training staff and implementing the Patient Health Questionnaire (PHQ)-2, which asks two questions to screen for whether a person has experienced a depressed mood over the past two weeks, which may warrant further assessment and follow-up care. By 2018, all women being certified in any category were asked the PHQ-2 questions at the time of certification, including at mid-certification for breastfeeding women. Over the three-year period from 2018 to 2020, more than a quarter of women screened positive for potential depression at least once.

 

Breastfeeding Peer Counselor Programs

Peer counseling programs have found great success in many areas, including breastfeeding. 78.2% of WIC participants have access to Breastfeeding Peer Counselor Programs (BPCP).  BPCP significantly increases the rate of breastfeeding among MT WIC participants. Additionally, MT WIC staff clearly indicated in the MT WIC Needs Assessment Survey 2021 that Breastfeeding Peer Counseling was an area of WIC programming that needed improvement.

With the known benefits of breastfeeding for mother and baby, expansion of BCPC across Montana was identified as a priority area.  The WIC NA identified a need for BCPC targeted expansion to agencies identified as small, located in Northeast Montana, and Tribal or agencies serving Tribal communities.  Currently, very few small agencies, no agencies in Northeastern Montana, and just two Tribal communities have access to BPCPs. WIC Staff are focusing on efforts to expand BPCP to more local agencies. Additionally, heightened emphasis will be placed on ensuring all necessary staff are appropriately trained as certified lactation counselors (CLCs). The following map shows the location of the Montana WIC Program’s Breastfeeding Peer Counselors and Service Areas.

Food Security

Underutilization of services like WIC is a contributing factor to food insecurity alongside larger, more systemic issues in Montana such as food deserts, insufficient living wages, and high medical and childcare costs. Close to one in five participants self-identify as “food insecure” or “sometimes food insecure” when first entering the Montana WIC Program.

 

WIC staff used the USDA’s Economic Research Service’s (ERS) interactive mapping tool, to identify food deserts across Montana. The areas of green in the following map show places in the state where people meet the ERS definition of low-income Census tracts and live more than 1 mile from a grocery store in urban areas or more than 10 miles from a grocery store in areas considered to be rural. Six of the eight Montana counties without Montana Food Bank Network services or partners lie in areas that were determined to be food deserts.

 

Referrals

Referrals are an important aspect of WIC Program recruitment and services. The Montana WIC Program both receives and sends referrals from and to a variety of organizations to better meet the wide range of participants’ needs. As part of the wider network of social services available to residents in Montana, the Montana WIC Program must maintain relationships with a variety of organization across the state. 

 

The State of Montana has recognized the importance of interagency referrals and the need to increase efficient referrals across the State. To this end, the State supported the development of an electronic referral system named CONNECT in 2009, with a significant refurbishment and roll out in 2019. WIC began utilizing CONNECT in 2020 and is in the process of increasing the utilization of the system across all local agencies.

 

WIC Participant Survey 2021

Every year during the summer, from July to September, the Montana WIC State Office conducts a survey of Montana WIC Participants. This is to ensure that the State Office is adequately meeting the needs of families and addressing any issues or concerns. The information from the survey is used to inform quality improvement efforts and strategic planning.  It is also shared with other programs in the FCHB which could benefit from the insights it provides, including the Title V MCHBG.

This survey was provided to participants in 2021 via text with a link to a Qualtrics survey to be collected electronically. It was also available through a link on the Montana WIC Shopper Application, and in paper form available from local WIC agencies.  The following highlights help provide useful insights into a population which is also served by many Title V MCHBG programs, and undermines many negative stereotypes:

• Only 9% of participants do not have at least a High School diploma or GED;
• Only 11% have more than two children;
• Only 1% are younger than 18;
• 61% find the breastfeeding information WIC provides to be somewhat or very important;
• 89% find learning about or connection to community resources (referrals) to be somewhat or very important

Children’s Special Health Services: New & Upcoming Needs Assessments

The Children’s Special Health Services Section (CSHS) is preparing to launch three separate needs assessments, beginning in June 2022.

 

Cleft Clinic & Specialty Care Needs Assessment

 

This needs assessment is designed to obtain parent, patient, and provider input on the condition of specialty care in Montana and includes three steps.   The assessment phase will lead into the development of a comprehensive plan with goals, strategies, and action steps for implementation of identified improvements.

 

The first step will entail a historical review of CSHS’s provision and coordination of specialty pediatric care.  This will provide historical context and background information.  This, in turn, will provide a deeper understanding of the current situation. 

 

The second step will be to gather information on the current state of pediatric specialty clinic services and outreach.  Current providers will be surveyed to determine: 1) current services and alignment with CYSHCN; 2) Strengths, Weaknesses, Opportunities, and Threats (SWOT) of cleft, metabolic, and Cystic Fibrosis clinics; and 3) coordination of care for patients between clinics.

 

Additional activities in step 2 include:

• As necessary based on survey, conduct interviews with current providers and others as directed by CSHS to understand current specialty clinic services and outreach;
• Develop focus group/key informant questions for current families and consumers of specialty care clinics to determine 1) experience; 2) access and, 3) coordination of care for patients in between clinic visit; 4) other needs or concerns;
• Conduct focus groups/interviews with current families and consumers to determine 1) experience; 2) access and, 3) coordination of care for patients in between clinic visit; 4) other needs or concerns;
• Gather statewide clinic locations, services, outreach efforts and contact info: Examples include: endocrinology, gastroenterology, nephrology, neurology, neurosurgery, orthopedic, orthopedic spine, pulmonary, rheumatology, urology, developmental behavioral health, cystic fibrosis, hemophilia, muscular dystrophy;
• Gather clinic data points, i.e.: number of attendees; discharge services; return rate; types of providers; costs; and patient outcomes;
• Gap analysis between best practices and current state of specialty care against CYSHCN Standards of Care.

 

A third step in the assessment process focuses on finances; with a review of the financing and operational structure of clinics.  This includes: a comparison to two to four similar states; and review of Medicaid financing options.  Additionally, analysis will cover: optimal clinic structure for the best and more comprehensive care; sustainable funding options; care coordination between visits; and recommendations for sustaining specialty care from a MCHBG perspective.

 

Behavioral Health Access Line Assessment

 

Prior to receiving the Montana Access to Pediatric Psychiatry Network (MAPP-Net) funding, a MAPP-Net Utilization Needs Assessment was conducted, and it indicated that providers would support and utilize a consultation line.  However, the actual utilization data indicates an underutilization of the MAPP-Net Consolation Access Line.  To determine why and how to improve usage, CSHS has contracted with the University of Montana Rural Institute for Inclusive Communities (UMRI) Research Services Team to oversee a Behavioral Health Access Line Assessment.

 

The Behavioral Health Access Line Assessment is composed of three key informant interview cohorts: 1) the 52 providers who indicated in the initial Utilization Needs Assessment their support and use of an Access Line but have underutilized or never used it; 2) providers, not among the 52, who have utilized the Access Line; and 3) providers enrolled in the MAPP-Net Program but have not utilized Access Line. 

 

UM RII will conduct Zoom or telephone interviews with all key informant cohorts, which have been identified by the MAPP-Net Program Specialist and CSHS Title V/Section Supervisor.  UM Rural III will analyze the key informant interview results.  CSHS intends to use the results to identify both the reasons for the lack of calls to the consultation line and what changes could be considered to increase the MAPP-Net Consultation Line utilization; and to understand the gap between the support and actual utilization for program improvement next steps.

 

Diversity, Equity, and Inclusion Evaluation for MAPP-Net

 

In a separate evaluation of the MAPP-Net Program, CSHS is working to gather and report data about the mental and behavioral health needs of three groups of youth in Montana: LGBTQ, Native American, and Homeless. This analysis, with a timeline of June – December 2022, will identify existing resources in Montana for mental and behavioral health services specific to the three populations.

 Activities:

1. Review of literature related to the specific groups of interest;
2. Key informant interviews;
3. Resource mapping.

 Deliverables:

1. Needs assessment supplemental report. This will be appended to the October 2019 Montana Access to Pediatric Psychiatry Network: Statewide Needs Assessment Final Report along with other subsequent needs data gathered since October 2019;
2. List of Montana-based and other relevant resources to improve behavioral health services for the three groups;
3. Care guides that address issues specific to each group.

 

MOMS Program Needs Assessment Contributions

 

The MOMS Program began working with the University of Montana Rural Institute for Inclusive Communities (UMRII) on a maternal health system needs assessment in March 2021. This needs assessment gathers information on Montana's maternal health system and services to identify areas of strength and need. The assessment focuses on the health system capacity, delivery of services, and the experiences of the patient population. The needs assessment utilizes the World Health Organization (WHO) Strengthening Health Systems to Improve Health Outcomes framework, which outlines the essential elements and activities that make up a strong health system.

 

To date the UM/MOMS maternal health system needs assessment activities have focused primarily on the healthcare delivery system, emphasizing obstetric care.  As appropriate, the results have been used by the MCHBG Program Coordinator and CPHDs.    The next phases of the UM/MOMS needs assessment tasks will help inform 2025 to 2030 MCH Needs Assessment and selection of priority areas and national/state performance measure to address the population domains. Discussions have begun to operationalize a partnership with UM and the Title V program’s specific priority areas for Title V. In FFY 2023, UM will be focused on data collection for: service delivery (primary care and patient experiences), healthcare workforce (clinical and non-clinical settings), and health information systems (data systems, health system performance, and health status).

 

A copy of the MOMS Severe Maternal Morbidity in Montana Report, released in September 2021, is available at: https://www.mtmoms.org/wp-content/uploads/2021/10/SevereMaternalMorbidityMontanaReport_final-1.pdf

 

The MOMS Maternal Health in Montana Full Report, released in May 2022, is available at:  https://www.mtmoms.org/wp-content/uploads/2022/07/MOMS_MaternalHealthMT_Final-5.25.2022-1.pdf

 

County Public Health Department’s Pre-Contract Survey Highlights

 

Each June, CPHDs complete a Pre-Contract Survey (PCS) and submit data on: contact information and staff responsibilities; administrative details; services provided; FICMMR and MCHBG information and processes; and feedback on FCHB support. The survey results provide a picture of CPHD resources across the state.  The PCS also captures the choice of performance measure for the upcoming federal fiscal year, along with the CPHD’s evidence-based or informed activities and evaluation plans.

 

The following graph shows the hours open per week.  Eleven CPHDs, or 22%, are open less than 40 hours per week, and two are open less than 20 hours per week.  This speaks to the capacity of frontier-level population counties to provide access to public health services.

 

 

 

This following graph shows the number of full-time equivalent staff, illustrating the capacity challenge in terms of available personnel.

 

 

 

While motor vehicle traffic deaths in Montana have been trending downward over the last 20 years, they still remain significantly higher than the in the U.S. overall. The following graph shows a comparison by child age groups from 2011 to 2020.

 

 

 

 

The next graph is from the Title V Information System.  It shows National Outcome Measure 16.2, for the adolescent motor vehicle mortality rate: for ages 15 – 19; per 100K; from 2007 to 2019.  Montana’s trend line is on top in the yellow, compared to the U.S. rate in blue.

 

 

In FFY 2021, 15 CPHDs had motor vehicle-related injury-prevention activities: 11 for car-seat safety; and 4 for distracted driving and seatbelt usage. The following chart shows the number of certified car-seat technicians at CPHDs across the state, which is another indicator of limited capacity.  Twenty-five of the responding counties had no certified car-seat technicians affiliated with their CPHD.

 

 

Changes in Health Status and Needs Statistic Update

 

Pregnant Women, Mothers and Infants

 

A snapshot of the health status of MT’s pregnant women, mothers, and infants may be seen from the following common health indicators.

 

The health status data of 1) pregnant women, 2) mothers and infants, and 3) women of child-bearing age serves as an indicator of how well programs are addressing respective needs of each group. The Montana Office of Vital Statistics (OVS) supplied the following data: In 2020 there were 10,870 resident births, of which 1,072 (9.9%) were to American Indian (AI) mothers; 831 (7.6%)  births were infants weighing less than 2,500 grams; 1,059 (9.7%) were infants less than 37 weeks gestation;  8,169 (75.2%) infant’s mothers received prenatal care beginning in the first trimester; 1,278 (11.7%) of infant’s mothers smoked during pregnancy; and 2,975 (27.4%) of infants were born via cesarean section . Of those infants born in 2020, 92.2% were ever breastfed (PRAMS).

 

As noted above, births to American Indian mothers comprise 9.9% of Montana’s resident births; however, race is correlated for the following MCH outcomes:   

• The number of infants born to women who received prenatal care beginning in the first trimester was 569 AI (47.3%) and 7,399 White (79.5%).
• The number of mothers who smoked during pregnancy was 321 AI (26.7%) and 931 White (10%);
• The infant mortality rate for 2016 through 2020 was 11.9 per 1,000 live births for AI and 4.3 per 1,000 for White.

 

A preliminary review of the 2016-2020 CDR data, indicates that sleep-related circumstances

strongly correlate to infant deaths (<18 months age).  Of the 87 sleep-related deaths of infants, 56 were White, 26 were American Indian or Alaskan Native, 5 Hispanic/Latino (any race), and 5 were Multi-Racial.  AI citizens make up 6.7% of the total population, but constitute 30% of all sleep-related infant deaths.

 

Children and Adolescents

 

In 2020, there were 218,318 children ages 1-17 years in MT, and of this total, 26,576 (12.2%) are AI (OVS).  MT’s childhood mortality rate for this age group was greater than the U.S. rate: 32.5 deaths per 100,000 children compared to 21, respectively.

 

Young people involved in fatal crashes continue to be a serious problem in MT. From 2016-2020, MT’s motor vehicle traffic (MVT) crude mortality rate for children aged 0-17 years was greater than the U.S. rate with 6.2 deaths per 100,000 children in MT compared to 3.0 deaths per 100,000 children nationwide (Source: WISQARS, unintentional MV-T deaths, Age 0-17, crude rates MT vs US.) 

 

The 2019-2020 National Survey of Children’s Health (NSCH) reported the following statistics for MT:

• 18.0% of children aged 0-17 years lived in households where someone smoked; 
• 53.7% of children aged 0-17 years without special health care needs had a medical home;
• 79.0% of children aged 12-17 years had one or more preventive medical care visits;
• 65.9% of children aged 0-17 years were adequately insured;
• 9.1% of children aged 1-17 years had oral health problems in the past 12 months;
• 80.4% of children aged 1-17 years had one or more preventive dental visits. 

 

MT’s rate of birth to adolescents, aged 15-17 years, was 4.8 per 1,000 in 2020, and MT’s 2018-2020 suicide rate per 100,000 teens, aged 15-17, was 22.6 (OVS).  The suicide rate is almost three times that of the U.S. rate of 8.6 per 100,000 teens.

 

Changes in Title V Program Capacity or MCH Systems of Care

 

Title X Family Planning Grant Awardee Change

 

On March 30, 2022, DPHHS was notified that the FCHB’s Title X/Family Planning Program was not awarded the Title X Grant beginning on April 1, 2022.  DPHHS had been the sole awardee for the past 50 years. The grant was instead awarded to Bridgercare, a non-profit reproductive and sexual healthcare clinic, founded in 1972, located in Bozeman, Montana.

 

DPHHS received a no-cost extension of current grant funding until September 30, 2022 and is working closely with Bridgercare to transition Title X Family Planning Clinics from their existing contracts with DPHHS, to being subrecipients of Bridgercare. The phased transition plan ensures there will be no break in services.  As of October 1, 2022, all Title X Family Planning Clinics will be subrecipients of Bridgercare, and DPHHS will begin final closeout and reporting activities.

 

Montana Maternal Mortality Review and Prevention Program

 

Montana recently received a CDC grant award for Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM), which is housed in the Maternal and Child Health Coordination Section (MCHC).  The Nurse Abstractor/Grant Manager is supervised by the Title V Director/MCHC Supervisor, who also supervises staff administering federal grants focused on maternal health:  Montana Obstetrics and Maternal Support (MOMS); Fetal, Infant, Child, and Maternal Mortality Review/Prevention (FICMMR); and the Title V/Maternal and Child Health Block Grant programs.

 

This funding directly supports the work of the Montana Maternal Mortality Review & Prevention (MMRP) committee; to identify, review, and characterize maternal deaths; and identify prevention opportunities. Goals include: 1) facilitate an understanding of the drivers of maternal mortality and complications of pregnancy and better understand the associated disparities; 2) determine what interventions at patient, provider, facility, system, and community levels will have the most effect; and, 3) inform the implementation of initiatives in the right places for families and communities who need them most.

 

The MMRP Program hired a Nurse Abstractor/Grant Manager, whose duties include but are not limited to: data abstraction from the local FICMMR teams serving the 56 local health departments and seven reservations; supporting the Montana Maternal Mortality Review Committee (MMRC); data entry into the CDC MMRIA; fulfill CDC reporting requirements; and providing technical assistance and reports to the state FICMMR Coordinator, FICMMR teams, MOMS Maternal Health Leadership Council (MHLC) and Montana Perinatal Quality Collaborative (MPQC) related to implementing prevention recommendations.   Due to a family move, the Nurse Abstractor/Grant Manager’s last day was July 1, 2022, and the position is being advertised.  

 

Changes in Organizational Structure and Leadership

 

Montana’s Title V Program is housed within the Early Childhood & Family Support Division (ECFSD) of the Department of Public Health & Human Services (DPHHS).  Jamie Palagi has been the Division Administrator since its inception in January 2020. Ms. Palagi resigned effective June 17, 2022.  A new Division Administrator, Tracy Moseman, is set to begin work on August 13, 2022.  Ms. Moseman has been the Faith and Community Based Services Coordinator, in the DPHHS Director’s office.  In this role, she has brought community partners together to offer innovative solutions for accessing services. Ms. Moseman holds a bachelor’s degree in Sociology-Criminal Justice, and a master’s degree in Public Administration. Her previous roles over the course of 21 years of public service include: leading health and safety initiatives in public schools through various positions at the Office of Public Instruction; improving community and school-based prevention services; and supporting public safety and offender success during her tenure at the Montana Department of Corrections.

 

Following the loss of the Title X federal award, two Title X Family Planning program staff and the Family Planning & Adolescent Health Section Supervisor have left their positions for new opportunities.  The two remaining Adolescent Health program staff will temporarily report to the FCH Bureau Chief.  Due to the recent change in funding to the Family Planning & Adolescent Health Section, the FCHB will undergo strategic visioning and planning to determine the future organizational structure of the bureau. This will begin in August 2022.

 

Emerging Public Health Issues

 

DPHHS and the Montana Department of Justice, in conjunction with local law enforcement, have identified an alarming number of fatal opioid overdoses across the state. Seizures of fentanyl by law enforcement have increased dramatically in Montana; more fentanyl was seized in the first 3 months of 2022 than in the previous four years combined.

 

Further, there was a 112% increase in fentanyl-related cases from 2020 to 2021. In 2020, there were 41-fentanyl related deaths, and in 2021 that number rose to 87. The number of opioid overdose-related 911 responses increased by approximately 35% in 2021 compared to 2020.

In 2021, there were 836 opioid overdose-related 911 responses by ground transporting EMS agencies.