In application year 2020, BWCH's infant and perinatal priorities will continue to remain focused on reducing infant mortality and morbidity. To support the NPM 4 around breastfeeding, BWCH in partnership with the Bureau of Nutrition and Physical Activity (BNPA) will continue to support breastfeeding initiatives through training, technical assistance, policy and procedures, and direct support services. In addition, BNPA through the Maternal, Infant, and Early Childhood Home Visiting (MIEHCV) grant will provide training and support additional opportunities for IBCLC certification.  Early childhood home visiting programs will continue to educate families about infant toddler development, mental health, the critical importance of bonding, injuries in the home, safe sleep, immunizations and the effects of Adverse Childhood Experiences (ACE).  BWCH plans on continuing to collect information on ACE measures by analyzing BRFSS historical and incoming ACE’s data to identify trends in populations across Arizona especially in women of reproductive age groups and young adults (18-26 years of age). Arizona will continue to monitor the incidence of NAS but strategies will be focused in the larger platform of the Opioid epidemic. To augment reduction of infant mortality and morbidity, BWCH will continue to implement the activities for the upcoming application year outlined under each of the program areas:

New Born Screening (NBS) Newborn Screening (NBS) is a coordinated system with partners who collaborate to ensure every newborn receives a screening as well as the appropriate follow up services, care and intervention. While not within the BWCH, the Office of Newborn Screening (ONBS) partners with the BWCH on many activities and initiatives. Title V funds are used to help support the work of the Newborn Screening program.  In 2020, NBS will continue its efforts to partner with High Risk Perinatal Program/Newborn Intensive Care Program (HRPP/NICP) Community Health Nurses (CHN).  This partnership will continue to support finding infants who have either not returned for the second screen or who need a repeat screen due to an abnormal prior screening. Additionally, infants with newly diagnosed conditions will be referred to the CCHN’s for extra support for the parents/caregivers in caring for their infant with a special healthcare need.   NBS will continue to provide refresher training and resources to CHN's at the annual HRPP/NICP conference.
 

Laboratory analysis remains a core function of the ONBS and the program will continue to provide data on bloodspot and hearing screening. ONBS and OCSHCN will continue to partner with data sharing and outreach projects related to sickle cell disease and sickle cell trait. Additionally, the ONBS will continue to partner with the OCSHCN on a project to lend out OAE hearing screening equipment to midwives in the community to ensure that hearing screening is available to those newborns who are born outside of a hospital. The program will support training and supplies needed to continue to offer this service.
 

The Title V program will also support the participation of ONBS staff at national conferences targeted at specific disorders identified through newborn screening such as the annual National Cystic Fibrosis Conference.

The Bureau of Nutrition and Physical Activity (BNPA) has a number of planned activities for 2020 related to the promotion of breastfeeding as funds are available. The LATCH-AZ conferences will be scheduled biannually as education and networking sessions. In addition, the International Board of Certified Lactation Consultants (IBCLCs) Mentoring Program will provide at least four education sessions designed specifically for the candidates to prepare for the examination.  A minimum of four 5-Day Breastfeeding Boot Camp will be held with at least three in Phoenix and one in Tucson to educate more individuals on breastfeeding.
 

In order to focus on the education of other community professionals, BNPA will continue to provide lactation webinars with a minimum of two in-depth sessions targeting community educators.  By 2020, there will be 15 courses available and outreach will be conducted among hospital staff. 

To support families, children and parents with newborns, BWCH and BNPA will continue to coordinate efforts to maintain the Title V toll-free MCH Helplines. The dedicated service includes Breastfeeding, Women's Infant and Children (WIC), and Children Information Center Helplines. The Breastfeeding Helpline will continue to provide 24-hour breastfeeding support in 2020.  BNPA will use information gathered from these calls to guide the development of additional training and educational materials.  The website will be evaluated to provide the most updated resources that align with the American Academy of Pediatrics and other relevant guidelines recommended by national subject matter authorities.

BWCH will continue to implement Pregnancy Risk Assessment Monitoring System (PRAMS). BWCH will leverage Title V and other federal and non-federal funds to further support its ongoing implementation.  PRAMS will use data collected since 2017 to describe the maternal and infant populations in Arizona and to assess possible associations between perinatal health outcomes and maternal characteristics. Additional information regarding PRAMS is mentioned in the Women's Health 2018 Annual Report and 2020 Application.

MIECHV, Health Start and HRPP home visiting programs, will continue to support and inform the Title V state priority need to increase early identification and treatment of developmental delays and NPM 6: percent of children, ages 10-17 months, receiving a developmental screening using a parent completed screening tool by implementing the following measures.  BWCH will continue to convene the internal home visiting workgroup to coordinate shared vision for home visitation within the bureau, improve communication and coordination among bureau home visiting programs, and identify opportunities for collaboration. 

BWCH will identify programmatic measures and indicators that apply to all of its home visiting programs. This is an initiative from the home visiting programs housed within BWCH (Health Start, MIECHV, and CHN) and the Office of Assessment and Evaluation. The aim of this initiative is to consolidate measures; identify rich data sources; reduce unnecessary data collection; and provide consistency to data collection tools and methods at the field that will provide instant feedback to evaluate programmatic performance and outcomes of each of their programs.  BWCH will utilize the ETO Data Management system to develop reports that provide coordinated data.

Maternal, Infant, and Early Childhood Home Visiting (MIECHV) requested funds for the 2020/2021 FY.   BWCH is requesting the ceiling award amount of $11,204,224 to leverage its resources in supporting voluntary; evidence based home visiting programs in at-risk communities and coordinate services across the early childhood system.  The MIECHV Needs Assessment Update is due October 2020.  

ADHS through MIECHV funding will continue to fund evidence-based home visiting programs including Healthy Families (through Arizona Department of Child Safety), Nurse-Family Partnership (through Maricopa County Department of Public Health, Pima County Health Department, and First Things First), Family Spirit (through Coconino County and San Carlos Apache Tribe) and Parents as Teachers provided by four Native American Tribes (Cocopah, Gila River, Hualapai, and Navajo Nation).  In addition, MIECHV will continue to fund home visiting program, Health Start as a promising approach.   The MIECHV grant is proposing to serve and estimated 1624 families.  MIECHV will continue to implement evaluation and continuous quality improvement requirements and home visiting services will continue to be augmented by professional development provided through training and education, online courses, regular informative e-newsletters, and an annual conference. MIECHV will continue to support Title V National Performance measures and state priorities including: 

• Title V priority need to reduce infant mortality and morbidity and NPM 4: a) percent of infants who are ever breastfeed and b) percent of infant’s breastfeed exclusively through 6 months through the ongoing implementation of an IBCLC mentoring program.
• Title V state priority need to increase early identification and treatment of developmental delays and NPM 6: percent of children, ages 10-17 months, receiving a developmental screening using a parent completed screening tool through implementation of revised measures monitoring new home visitor ASQ training and percent of children enrolled that receive at least 1 ASQ within 1 year of enrollment.
• Title V state priority need to reduce the use of tobacco and other substances across the lifespan and NPM 14: a) percent of women who smoke during pregnancy and b) percent of children who live in households where someone smokes. MIECHV funded home visiting programs will participate in a coordinated project with Bureau of Tobacco and Chronic disease to improve the number of caregivers who engage in cessation services via ASHLine.
• Title V state priority need to strengthen the ability of Arizona families to raise emotionally and physically active children. MIECHV will continue to support the implementation of evidence-based home visiting services.

Additional activities will continue to include coordinated efforts to advance the data management system for home visiting programs in Arizona.  It is anticipated that by September 2020, all MIECHV funded and non-MIECHV funded programs which include: Healthy Families Arizona (HFA) programs, alignment with Nurse Family Partnership (NFP) data system, and state funded Health Start and HRPP/NICP will be entering data into the Efforts-To-Outcomes (ETO).

Health Start is evidence informed home visiting program that utilizes community health workers/promotoras (CHWs), nurses, and behavioral health professionals to provide education, support and advocacy services to pregnant and postpartum women and their families in targeted communities across Arizona. The CHWs reflect the culture of their communities and receive extensive training on pregnancy, child growth and development and community resources. Women and families enrolled in the program receive home visits by CHWs at least once per month during their pregnancy and regular visits after the birth of their children up to two years of age. Health Start is funded by the Arizona Lottery which provides approximately $2.4 million per year.

In FY 2020, Health Start will continue to provide these services and in addition, provide enhanced education, brief intervention and referrals to treatment for mothers and families who use alcohol, tobacco and/or other drugs to assist with decreasing the opioid crisis. Health Start will continue to implement an evidence-based home visiting model, Family Spirit in 4 sites including - the San Carlos Apache Tribe to provide Health Start-Family Spirit services. Health Start will work on the implementation of the new ETO data management system which will include the revision of data collection forms and processes.

The High Risk Perinatal/Newborn Intensive Care Program (HRPP/NICP) will continue to contract with medical transport companies to provide air and ground transport for high-risk pregnant women and neonates in need of inter-facility transport to a higher level of care. Transport providers obtain authorization and administrative specialty program direction from a board certified maternal fetal medicine specialist or neonatologist contracted with ADHS. HRPP/NICP provides financial assistance for qualifying maternal or neonatal transports and requires contracted transport companies to write-off the remaining balances after the established family liability has been met.

HRPP/NICP will continue to contract with hospitals certified by the Arizona Perinatal Trust (APT) to provide the appropriate level of neonatal care. HRPP also will continue to contract with neonatology groups to provide risk appropriate medical care to enrolled infants during hospitalization. HRPP/NICP provides limited financial assistance for families who have no other form of payment.

Community Health Nurses (CHN) will continue to provide support to families during the transition of the infant from the NICU to home. CHNs will continue to conduct developmental (Ages & Stages), physical and environmental assessments; the Edinburgh Postnatal Depression Scale (EPDS) screening; inter-conception education and support and make referrals to community services. HRPP will continue to work with the BWCH Office for Children with Special Health Care Needs (OCSHCN) to link families with services for children with special health care needs and the Newborn Screening Program (NBS) for infants who require a second screening. HRPP will continue to collaborate with MIECHV Strong Families Arizona Network to provide professional development for CHNs.

As a result of the increase in infants born with substance exposure, HRPP participates in discussions with 'SENSE' (Substance Exposed Newborn Safe Environment) led by the Arizona's Department of Child Safety (DCS) to identify opportunities for collaboration. The primary goal of SENSE is to ensure substance exposed infants and their families are provided with a coordinated and comprehensive array of services to address the risks of in-utero substance exposure. HRPP will also work with the Office of Injury Prevention to continue implementing Community Health Nursing as a strategy in the State Opioid Response grant.

Arizona's Child Fatality Review (CFR) program is included in the Children's Health 2018 Annual Report and Children's Health 2020 Application with exception to the Safe Sleep and Sudden Unexpected Infant Death (SUID) efforts listed here. This upcoming application year the CFR program will offer continued education and training on the use of SUID doll reenactments to better assist agencies with understanding the manner and cause of an infant's death. Arizona Revised Statute 36-3506 requires law enforcement to utilize the Infant Death Investigation Checklist as a part of their investigations involving infants.  Arizona will adopt the CDC’s SUIDI reporting form and distributed to law enforcement agencies, medical examiners, and other first responders as follow up from the SUIDI death investigation and Doll Reenactment training.

In-person attendance will continue to each contractor’s CFR meeting by the Program Manager, with follow-up training and education offered.

Safe Sleep priorities for 2020 will focus on the following strategies; The Safe Sleep Task Force will continue to partner with the Collaborative Improvement and Innovation Networks (CoIIN) to accelerate improvements that prevent and reduce infant deaths through collaborative learning, quality improvement and innovation.  Arizona plans to reduce safe sleep related deaths by improving safe sleep practices to decrease the safe sleep SUID mortality rate by 5%. Arizona also plans to work toward the reduction of disparities between White and Non-Hispanic Black and American Indian/Alaska natives by 3%. Arizona continues to work on the following CoIIN drivers: birthing hospitals, home visiting and licensed and unlicensed child care. Arizona will also continue to partner with other community partners on providing education to families that are at highest risk.  Arizona's Drivers include: Add safe sleep modeling to annual skills training; Use safe sleep Bassinet Cards as visual reminders for nursery staff; Standardize safe sleep messages for all home visiting; Standardize education and training for home visitors on current AAP guidelines; Develop standardized safe sleep message with input from community partners; Partner with community tribal elders on AAP guideline; Engage grandparents and caregivers on the recommended AAP guidelines; Provide training for nursing and medical schools and help hospitals establish policies. Thru the CoIIN initiative and the partnerships there was a consensus that it be recommended that all birthing hospitals participating in the distribution of the crib cards develop a safe sleep policy to further educate staff and ensure the same standard of care.  The goal is that 75% of all birthing hospitals participate in the distribution and education of the crib cards. Lastly, current local AAP providers are developing a CBT on Safe Sleep for pediatricians to improve professional practice that will help providers earn credit for Maintenance of Care (MOC) part 4.

In 2020 Arizona will support Neonatal Abstinence Syndrome (NAS) efforts. Arizona will attend meetings and collaborate with stakeholders to discuss ideas and next steps around the coordination of systems of care for substance exposed newborns and their mothers.  Arizona will assist with any future media campaigns to ensure that they include reducing shame and stigma by utilizing a trauma informed approach to providing services for pregnant women and their families. Arizona will continue efforts to implement the two year Arizona NAS Action Plan in conjunction with other key state agencies and stakeholders that was developed as part of a Learning Lab project under the National Governors Association in 2018. In 2020, Arizona will focus on action steps under the plan that provide for the improvement and enhancement of data collection of NAS and substance exposed newborn cases, development of NAS training webinars for healthcare providers and community stakeholders and the development of a NAS online course for home visitors. In addition, Arizona will provide targeted home visits to those families with infants that were substance exposed. Arizona will distribute the NAS Local Partner Training Kit that includes provider and patient/client informational flyers through the county health departments to reach local medical providers and the rural communities.  Arizona will also continue to work with the Arizona Statewide Task Force on Preventing Prenatal Exposure to Alcohol and Other Drugs to increase awareness of Substance Exposed Newborn (SEN) Guidelines for medical providers. Arizona will continue to promote universal screening for substance use disorders among pregnant women and all women of reproductive age in an effort to increase awareness and decrease the number of substance exposed newborns.

ADHS will continue to implement the Prescription for States grant from the CDC focused on the prescription drug abuse crisis. As part of this grant, ADHS works in collaboration with various state agencies, county health departments, local substance abuse coalitions, and other key partners on the implementation of the state's Prescription Drug Misuse and Abuse Initiative.

ADHS will continue to provide technical assistance to six (6) county health departments on the implementation of this initiative through the use of a toolkit that contains an assortment of program materials. This includes providing assistance with increasing public awareness related to prescription drug misuse and abuse, encouraging the adoption of safe opioid prescribing practices by healthcare providers, distributing and encouraging the use of the Arizona Opioid Prescribing Guidelines, the Guidelines for Identifying Substance Exposed Newborns, and the online continuing medical education course on safe opioid prescribing practices.

BWCH will also continue to convene the People of Color, Infant Mortality workgroup.  The internal workgroup is currently comprised of the Bureau Chief, the MCH Block Grant Manager and representatives from the Offices of Women’s Health, Children’s Health, Injury Prevention, Assessment and Evaluation, Office for Children with Special Healthcare Needs.  The goal of the group is to convene a group of stakeholders with a vested interest in addressing the underlying factors associated with health disparities in infant mortality rates among American Indians, Hispanic/Latinos and African Americans in Arizona.