Priority: Economic Mobility

Update on PM annual objectives:

SPM 2: Percent of households that spend more than 30% of household income on housing costs

The SPM 2 annual objective for reporting year 2021 is 31.0%. The annual objective for reporting year 2022 is 31.0%.

For the upcoming reporting period, MCH Block Grant dollars will support 1.0 FTE on the Maternal and Infant Wellness team at CDPHE; implementation of the strategies outlined in the state action plan; and contracts with local public health agencies to implement economic mobility local action plans. To advance and expand impact, MCH is exploring opportunities to align with and leverage other funding sources. The funded strategies and associated outcomes for this priority are summarized below. For a more detailed description, refer to the full state action plan.

According to the Federal Register, the connection between economic status and health is well-established, and poverty can have serious effects on children’s long-term health. Among U.S. children younger than 18 years of age, one-third (33.2%) live in families with incomes below 200 percent of the federal poverty level ($50,200 for a family of four), the level at which Colorado families can be economically self-sufficient (The Self-Sufficiency Standard for Colorado 2018, Colorado Center on Law and Policy). Economic insecurity and food insecurity have increased due to COVID-19 . As of July 2021, 14% of Colorado adults living in households with children reported that children in the household weren’t eating enough because the household couldn’t afford enough food, and 21% of Colorado renters with children in the household were not caught up on rent (Center on Budget and Policy Priorities).

Based on the most recent statewide MCH needs assessment, Colorado MCH identified economic mobility as one of the program’s 2021-25 priorities addressing the social and structural determinants of health. For the corresponding state performance measure, Colorado MCH selected the percent of households that spend more than 30% of household income on housing costs as an indicator of economic well being. According to the U.S. Census Bureau, households that must devote more than 30% of income to housing costs are “burdened” by housing costs, meaning that after paying housing expenses, households at the bottom rungs of the income ladder would likely struggle to meet other essential needs such as food, clothing, and medical care.

As a new priority, the first year of the economic mobility state action plan focused on assessment and asset mapping, partner outreach and relationship building, community engagement and inclusion, and internal collaboration across programs. A full-time Economic Mobility Specialist was hired in January 2021 to develop the strategic direction of economic mobility work within the MCH program. The position collaborates with other MCH priority coordinators, local public health agencies, cross-departmental partners, and community organizations to improve the economic mobility of Colorado families.

The economic mobility state action plan includes four strategies. The first focuses on increasing access to income supports including tax credits, the second on promoting and strengthening equitable family-friendly policy, and the third on strengthening and expanding common eligibility and enrollment in services that support economic mobility. The final strategy is on gathering and sharing data and research related to economic mobility and health outcomes for MCH populations.

Increased access to tax credits has been shown to reduce child abuse and neglect, infant mortality, child poverty and their associated lifelong negative health impacts (National Academies of Sciences, Engineering, and Medicine, A Roadmap to Reducing Child Poverty, National Academies Press, 2019). Activities related to increasing access to tax credits are focused primarily on the Earned Income Tax Credit and the expanded Child Tax Credit under the American Rescue Plan Act of 2021. The MCH program is working to better understand barriers to filing taxes, as many low-income Americans who do not owe income tax do not file taxes and therefore do not access the tax benefits they are owed. In Colorado, one in four who are eligible do not claim the Earned Income Tax Credit.

The recently passed American Rescue Plan Act represents a significant opportunity to connect eligible Colorado families to an expanded Child Tax Credit that could lift up to 40 percent of children out of poverty. Depending on implementation, this new tax benefit could mean a benefit of up to $3,600 per child per year. The Rescue Plan also expands the Earned Income Tax Credit. Colorado MCH is exploring partnership opportunities to increase awareness about the benefit of filing taxes and how to do so. Conversations with existing and potential partners include the MCH-funded care coordination program for CYSHCN, Medicaid, home visitation, the Colorado Department of Revenue, the Center for Community Wealth Building and WIC. CYSHCN Care Coordination Consultants will share information about expanded eligibility for these programs through their statewide network of care coordinators. They will also explore barriers to tax credits for families of CYSHCN through facilitated discussions at statewide meetings and the potential addition of a prompt about these benefits on their care coordination intake form, which is completed by close to 1,000 families who are enrolled in the program each year.

An important partner from the inception of the priority has been GetAhead Colorado, which is the Earned Income Tax Credit outreach program developed by Gary Community Investments/The Piton Foundation. GetAhead has been promoting the Earned Income Tax Credit in Colorado for 30 years, with hundreds of partners around the state. GetAhead houses data and expertise on Earned Income Tax Credit participation in Colorado, as well as tested materials and social media messaging for outreach. Since 2019, GetAhead and the Economic Mobility Specialist have been collaborating to support the development of tax strategies. The Piton Foundation and its programs are currently undergoing significant organizational change, and as of May 2021, Piton transitioned out of the role of lead organization for Earned Income Tax Credit outreach in Colorado. As part of the sunset of their programs in June 2021, Piton transferred its partner database, data tools and promotional materials to Colorado MCH, and its free VITA tax site operations to Mile High United Way, an established partner in tax outreach via the 2-1-1 resource and referral system.

In July 2021, the MCH program was selected by the Governor’s Office to apply for a Fostering Access Rights in Equity grant through the Department of Labor. Colorado’s application is focused on assistance for low-wage women workers, especially those of color and including immigrants and refugees, to take full advantage of the opportunities that the federal and state Earned Income Tax Credit and Child Tax Credit provide. If awarded, Colorado’s outreach and dissemination activities will occur statewide, while direct assistance for benefits will focus on three communities in Colorado with higher populations of people of color, immigrants and refugees: the cities of Aurora and Denver, and Mesa County, located on the rural Western slope.

This focus was selected based on compelling data that illuminates economic inequities for this population. Data indicate that many Colorado families have trouble meeting expenses because they are working in low-wage jobs (National Center for Children in Poverty. 50-State Demographics Data Generator). In Colorado, Hispanic white birthing parents of children ages 0-3 years (compared to non-Hispanic white birthing parents) were significantly more likely to be worse off financially compared to before the pandemic started Hispanic white and Black birthing parents were significantly more likely to report experiencing food insecurity after the start of the pandemic (CDPHE, Health eMoms, COVID-19 Survey, 2018-2020 Birth Cohorts). In Colorado, immigrants make up one out of every ten residents and in 2018, 262,992 were women. Nearly one in eight Coloradan workers is an immigrant. Colorado welcomes on average 1,650 individuals per year through the federal refugee resettlement program, the vast majority of whom arrive in metro Denver and Aurora (80% in 2017) (American Immigration Council. Immigrants in Colorado (2020)).

In addition, Colorado is tied for the third-lowest EITC participation rate in the U.S. (73.3%), and has at least 37,000 children in the state who may be eligible for the CTC but who haven’t been claimed on a recent tax return. EITC non-participants are more likely to live in rural areas, be self-employed, have children with disabilities, and not be proficient in English (IRS. Earned Income Tax Credits and Other Refundable Credits).

Since the pandemic began, more than 1 in 3 female caregivers were forced to stop working or reduce their work hours or responsibilities and could not afford to do so; Black and Latina women were significantly more likely to say that they could not afford these changes (University of Oregon. Mothers of Young Children Speak on Work During the Pandemic (May 2021)). Mile High United Way 2-1-1, which refers Colorado families to free tax assistance, noted there were only 21 free tax assistance sites in 2021, compared to ~140 in 2018/2019, due to the disruption created by COVID-19. As a result, appointments filled up quickly, with fewer families having access to this support during a higher time of need.

Notification of the grant awards are anticipated to occur in September 2021. While that application is pending, the Economic Mobility Specialist is continuing to explore additional funding opportunities, in partnership with the Governor’s Office, to support outreach and connection to tax credit resources for the MCH population.

Promoting family-friendly employment policy is a continuing strategy of Colorado MCH. In early 2020, the Colorado legislature debated a paid family leave bill that had to be tabled. Ultimately, the bill became a ballot initiative and in November 2020 passed successfully into Colorado state law as the Paid Family and Medical Leave Initiative. The new law is a state-run insurance benefit that requires employers to provide 12 weeks of paid leave in most instances, and up to 16 weeks under certain circumstances. In the coming year, state and local MCH staff will focus on supporting awareness of the new law.

There is a high level of interest in increasing co-enrollment opportunities for services and programs that support economic well-being among MCH partners. Currently, one of the local public health agencies that has selected economic mobility, Denver Department of Public Health and Environment, is participating in a cross-agency collaboration with Denver Health and other partners to expand a community-informed, quality improvement initiative known as Specialized Co-Enrollment, which aims to help pregnant individuals and households with children younger than 5 years of age enroll in food security programs for which they are eligible but not enrolled. Denver will partially fund a full-time staff person to expand the co-enrollment program to additional community-based clinic sites. 

The final strategy of the priority is to gather and share data describing the economic status and related health impacts for Colorado families, including access to family-friendly employment conditions and disparities in tax credit claims. In December 2020, Colorado MCH supported the development of a data brief describing Colorado mothers’ access to paid family leave and the relationship of paid leave to family finances and breastfeeding. The brief summarized data from Health eMoms, a longitudinal online survey, on a variety of health and social factors impacting motherhood in Colorado. Also, in a new partnership, the economic mobility team collaborated with the Colorado Department of Revenue to submit a data request analyzing tax returns by zip code to better understand patterns and inequities in Earned Income Tax Credit filing. The economic mobility team will continue to partner with CDPHE’s Center for Health and Environmental Data, the Department of Revenue, and other programs to gather and disseminate data, especially community level and disaggregated data, to illustrate and tell the story of economic well-being of Coloradans and related effects on physical and mental health and resiliency.

In March 2021, a cross-program team was established to guide implementation of the state action plan. In addition to the local public health co-lead, the team also includes the Colorado program lead for CDC’s Essentials for Childhood program, to facilitate collaboration between Essentials for Childhood and MCH shared economic mobility objectives. The division Legislative Analyst provides policy expertise and advice, and the MCH evaluation and data specialist supports measurement of progress and expertise in CYSHCN population work. The team is also consulting with the Racial Equity and Community Inclusion Specialists to expand equity and inclusion activities in the action plan identified in the Community Inclusion Roadmap.

Local public health has actively participated in decision-making throughout the planning and implementation stages. This includes a priority co-lead model with the MCH manager of the state’s largest Title V grantee, Tri-County Health Department, serving as priority co-lead with the Economic Mobility Specialist. Tri-County Health Department has experience implementing several activities in their community that are now reflected in the state action plan and brings valuable and practical experience to implementation. This partnership is also poised to inform technical assistance for local economic mobility work in additional communities.

In the spring of 2021, local public health agencies selected their priorities and developed local action plans and logic models. Three local public health agencies selected the economic mobility priority: Tri-County Health Department and Denver Department of Public Health and Environment in the Front Range metro area, and Mesa County Public Health, which represents the largest population base on the western slope of Colorado. Tri-County Health Department and Denver Department of Public Health and Environment will build on prior Earned Income Tax Credits and family-friendly employment strategies initiated through their work on infant mortality in the previous grant cycle. Mesa County brings an established place-based focus on addressing social determinants and co-enrollment to the priority work. Alignment with the Essentials for Childhood program will continue through coordinated funding and technical assistance for two local public health agencies that receive funding from both programs. Both local public health agencies are exploring shared objectives of enrollment in services that support economic well-being including WIC and SNAP enrollment and referral to free tax filing sites to claim the earned income tax credit.

Priority: Social Emotional Wellbeing

Update on PM annual objectives:

SPM 4: Percent of women of reproductive age (18-44 years) who report good mental health

The SPM 4 annual objective for reporting year 2021 is 45.0%. The annual objective for reporting year 2022 is 45.0%.

NPM 14.1 Percent of women who smoke during pregnancy

The NPM 14.1 annual objective for reporting year 2021 is 5.0%. The annual objective for reporting year 2022 is 4.9%.

ESM 14.1: Percent of pregnant people insured by Medicaid who smoke during the last three months of pregnancy

The ESM 14.1 annual objective for reporting year 2021 is 12.8%. The annual objective for reporting year 2022 is 11.1%.

For the upcoming reporting period, MCH Block Grant dollars will continue to support 1.0 FTE of the Maternal and Infant Wellness team at CDPHE across multiple positions; implementation of the strategies outlined in the state action plan; and contracts with local public health agencies to implement social emotional wellness local action plans. To advance and expand impact, MCH will align with and leverage funding from the Colorado-based Zoma Foundation, CDC grant that supports the Colorado Perinatal Care Quality Collaborative, state general funds to reduce maternal mortality and the ERASE Maternal Mortality grant through the Centers for Disease Control and Prevention (CDC). In addition, MCH Block Grant dollars will continue to fund a portion of a tobacco program staff position (.25 FTE) to serve as an MCH program liaison. Amendment 35 tobacco state tax revenue and a Centers for Disease Control and Prevention (CDC) grant will continue to provide annual funding for additional tobacco program staff and comprehensive tobacco program efforts, including MCH-related tobacco activities. Leveraging combined funds enables CDPHE’s Tobacco and MCH programs to extend the reach of strategic efforts that reduce the burden of perinatal tobacco use and exposure, increase positive birth outcomes and improve the health of families throughout the lifespan. Funded strategies and key outcomes are summarized below and are reflected in the state action plan for this priority.

All children, youth, and their families deserve the opportunity to thrive. Lack of social support and untreated behavioral health needs are detrimental not only to the individual who is suffering, but also to that individual's family and community. The needs assessment showed a lack of identification and connection to treatment across all MCH populations. By focusing on social emotional wellbeing across the lifespan, this priority takes a broader perspective on overall health and in particular focuses on behavioral health. The MCH program considers behavioral health to include the promotion of emotional health; the prevention of mental illnesses, substance use disorders, psychological distress and suicide; and treatments and services for mental and/or substance use disorders, and recovery supports. This framework moves beyond the absence of mental illness and instead focuses on upstream approaches to connecting people with the support and tools they need to positively manage thoughts, feelings and behaviors in order to have healthy relationships, achieve wellness and thrive in their communities.

The social emotional wellness state action plan includes three main strategies. The first strategy leverages and builds upon community partnerships to reach health care delivery systems to increase screening, referral, and connection to intervention for mental health and substance use treatment. The goal is to help systems achieve universal behavioral health screenings for all populations in a manner that is non-stigmatizing, trauma-informed, and done with cultural humility. Next, public awareness efforts will focus on reducing the stigma associated with behavioral health, and particularly associated with perinatal mental health and substance use. Lastly, the block grant dollars will be used to look at available data sources and disaggregate data to better understand the root causes of inequities related to social and emotional well-being. Strategies that are focused on the perinatal/infant population are reported here, while social emotional strategies to support youth are reflected in the adolescent health domain.

In the past five-year priority cycle, the MCH program had separate priority areas that focused on perinatal mood and anxiety disorders as well as perinatal substance misuse. This siloed framework mirrors the reality across Colorado in that mental health and substance use disorder treatment services and payment mechanisms are often separate. The delineation of these services does not reflect the experience and needs of the community members who are struggling with behavioral health issues. The reality for many is that people use substances to cope with mental health and mental health conditions are often worsened by the use of substances. Data from the Health eMoms survey that is highlighted in the “Colorado Maternal Mortality Prevention Program Legislative Report 2014–2016,” showed that substance use and mental health are often associated with one another, and some pregnant and postpartum people use substances to deal with stress or unmet mental health needs. By creating a priority and activities that center behavioral health, MCH can serve as a bridge between these worlds and help to convene the appropriate stakeholders who have previously been sitting at separate tables.

In an effort to increase screening for behavioral issues in the perinatal population, Maternal and Infant Wellness staff partnered with the Colorado Perinatal Care Quality Collaborative, to work with Colorado birthing hospitals on a series of quality improvement initiatives. Based on the maternal mortality data from Colorado from 2014-16 that indicated that overdose and suicide were the leading causes of maternal mortality, the Maternal Mortality Prevention Program and the Quality Collaborative decided to implement the Alliance for Innovation in Maternal Health (AIM) Opioid Use Disorder bundle, which focuses on universal screening for substance use in labor and delivery units. In year one of the contract which ended September 30, 2020, the Quality Collaborative ran a successful pilot project, and developed a comprehensive data management plan as well as an evaluation plan that identified goals, benchmarks, processes and validated measures to monitor progress and evaluate results of implementation. The second year of the contract began in October 2020.  Fourteen hospitals have been recruited to participate in the full implementation of the bundle. In consultation with the Maternal and Infant Wellness team, the Quality Collaborative  developed educational content for hospital staff with a focus on achieving equity and culture change, addressing stigma and bias, and best practices related to trauma informed substance use disorder screening and care. In April 2021, MCH block grant funding supported training for the hospital staff participating in the implementation of the AIM Opioid Use disorder bundle, as well as maternal health partners around the state that addressed the intersection of behavioral health, child welfare, and systemic racism.

In the coming year Maternal and Infant Wellness staff will partner with Illuminate Colorado, a community organization whose mission is to strengthen families and prevent child maltreatment. Illuminate Colorado’s Substance Exposed Newborns Steering Committee is made up of statewide stakeholders and community members who are tasked with identifying and implementing strategies to reduce the number of families impacted by substance use during pregnancy and to improve outcomes for families across the lifespan. In alignment with the MCH program’s upstream approach, MCH staff will chair a workgroup that will analyze state level policies and make recommendations on how to move forward policies that would best support MCH populations. MCH staff will also work with Illuminate Colorado and other community partners to consult on provider education and workforce development initiatives, and the rollout of the Child Abuse Prevention and Treatment Act (CAPTA) plans of safe care requirements. Additionally, the MCH co-leads for this priority will help chair a workgroup of the Marijuana Education Oversight Committee within the Governor’s Office to develop cannabis prevention resources for the perinatal population.

In addition to the substance misuse strategies focused on opioids, this priority also includes tobacco prevention strategies for the perinatal population. For the upcoming reporting period, the QuitLine will continue to offer a suite of evidence-based phone and digital tobacco cessation services for pregnant people, including a tailored pregnancy/postpartum protocol. The Baby and Me Tobacco Free Program will also continue to serve pregnant people and their partners across Colorado by providing perinatal smoking cessation services. Baby and Me Tobacco Free is piloting the use of new digital services to expand reach and impact of treatment services that can be safely and conveniently delivered using fully-remote technology. CDPHE will continue discussions with Medicaid to explore avenues to expand the accessibility and sustainability of Baby and Me Tobacco Free through an interagency partnership.

Comprehensive tobacco treatment benefits, including individual, group and telephonic counseling and FDA-approved medications, are available to all Colorado Medicaid members with no cost sharing or prior authorization barriers. Tobacco treatment services offered through the QuitLine, Baby and Me Tobacco Free, and Medicaid are available to any pregnant person or partner who is seeking help for any form of nicotine use or dependence, including e-cigarette use.

In addition to substance misuse prevention strategies, this priority includes a pregnancy related depression public awareness campaign that was initially launched as a pilot in 2016. The campaign exceeded its goal number of unique visitors who accessed the campaign landing page. Given the successful uptake of the campaign, MCH funds continue to support this work. The Spanish campaign materials were updated in 2018, and the English campaign is currently being revamped with input gathered from community stakeholders. MCH staff are exploring opportunities to partner and align with efforts through the Office of Behavioral Health  at the Colorado Department of Humans Services, including their public awareness campaign entitled “Tough as a Mother,” geared towards reducing the stigma associated with substance use during pregnancy. The campaign helps parents access needed care and empowers providers to talk with patients in a supportive way about their substance use. Given the clear opportunities for state partnership and alignment of messaging, MCH and the Office of Behavioral Health are eager to work together to leverage resources and reach a greater audience in the coming year.

The MCH program will be investing in strategies that use available state data to highlight equity issues and increase transparency. With the support from the MCH program, CDPHE’s Center for Health and Environmental Data recently published a report based on Health eMoms data entitled “Postpartum Behavioral Health in Colorado.” The report takes a unique approach to data collection by following multiple birth cohorts over a period of 18 months, and gathering a wide range of data about their experiences such as  experience with providers and the health care system, sources of support, and stressors faced by birthing parents. This report will be shared widely and stakeholders may use it to drive policy and programming. The ongoing aim of this strategy is to continue to co-create data products that are meaningful to a wide variety of stakeholders and community members.

CDPHE is exploring the formation of an advisory board supported through funding from the MCH program and Illuminate Colorado to create a space for community members with lived experience related to pregnancy, parenting and behavioral health issues. Given that substance use in pregnancy remains a highly stigmatized issue, the group will have unique expertise and perspective related to discrimination in the healthcare system. This group will be able to consult on many MCH initiatives, including the AIM Opioid Use Disorder bundle implementation with Colorado Perinatal Care Quality Collaborative. The vision is that the group will have an important voice in the co-creation and implementation of initiatives that are designed to benefit pregnant and parenting families with behavioral health issues.