SPM #3 Address Social Determinants of Health Inequities.

The Centers for Disease Control and Prevention (CDC) defines Social Determinants of Health (SDoH) as “conditions in the places where people live, learn, work and play that affect a wide range of health risks and outcomes.” SDoH include factors like socioeconomic status, education, neighborhood and physical environment, employment, social supports, and access to quality health care. From the Life Course Perspective, addressing SDoH is integral to improving health and reducing longstanding disparities in maternal and child health. Many disparate health outcomes persist in maternal and child health, including a higher risk of maternal mortality among Black women and a higher risk of infant mortality among Black infants, and a deeper understanding of SDoH and the root causes of health inequities is imperative for promoting and improving the health of Missouri’s mothers, infants and children.

To gain buy-in and build internal awareness and understanding across MCH programs and DHSS overall, the Title V Program is developing a core MCH, health equity, and social justice training plan, including didactic and interactive experiences for leaders, team members and MCH program staff. To gain a better understanding of the impact of SDOH and how to effectively integrate strategies to address the root causes of health inequities into policies and program services and activities and to provide foundational skills, Title V Program leadership is working to identify workforce development training on MCH fundamentals, social determinants of health, health equity, and racial and social justice. The Title V MCH Director is working with a graduate intern to review existing resources, MCH Navigator trainings, MCH Leadership Competencies, and evidence-based training methods and content to develop a training plan and establish training requirements for internal Title V MCH Block Grant-funded program staff and external contractors, The training plan will be implemented in FFY 2022 as a pilot phase with the Title V Core team.

In alignment with the new DHSS Culturally and Linguistically Appropriate Services Standards Policy, the diverse populations served by Title V will be considered at all stages of Title V program and service delivery, and Title V funded MCH programs will consider the needs of their target population(s) and how programs will be inclusive of and non-stigmatizing towards program participants. All programs and services will be culturally and linguistically aware and appropriate, to provide effective, equitable, understandable, and respectful quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs. Special focus will be given to marginalized and underrepresented populations and communities. The Culturally and Linguistically Appropriate Services (CLAS) standards will be applied as general guidelines for all programs and services to provide a uniform framework for developing and monitoring culturally and linguistically appropriate services that are broadly inclusive of diverse racial, ethnic, sexual, and other cultural and linguistic groups.

The person-centered approach ultimately sees human beings as having an innate tendency to develop towards their full potential. The key principles of person-centered care include: valuing people – treating them with dignity and respect by being aware of and supporting personal perspectives, values, beliefs and preferences; autonomy - providing choice and respect for choices made; life experience - understanding the importance of a person’s past, their present-day experience, and their hopes for the future; understanding relationships - collaborative relationships , social connectedness and opportunities to engage in meaningful activities; and environment - organization-wide commitment to individual and organizational learning underpinned by person-centered principles. Title V funded MCH programs and services will incorporate the key principles and apply the central themes believed to help achieve person-centered care: 1) congruence – being completely genuine; 2) empathy – striving to understand a person’s experience; and 3) Unconditional positive regard – being non-judgmental and valuing.

Information regarding services provided to address the social determinants of health inequities for children and youth with special health care needs and their families can be found in the CSHCN Population Domain and Family Partnership section narratives.

The State Breastfeeding Coordinator will continue to partner with the University of Missouri on breastfeeding research to determine interventions that would decrease disparities in breastfeeding of women of different races, ethnicities, and low socioeconomic status. With leveraged funding from the CDC 1807 grant, the state will provide a lactation consultant preparation course yearly for the next 3 years in areas of the state that currently have low breastfeeding rates and disparities in the care available to women of color. Every effort will be made to encourage women of color to become peer counselors or International Board Certified Lactation Consultants (IBCLCs) in regions where disparities in care exist.

The School Health Program (SHP) will implement the School Nurse Chronic Health Assessment Tool (SN CHAT). The SN CHAT helps school nurses gather information about students who have chronic health conditions. School nurses can use this tool to guide conversations in person or via phone with a student’s parent, guardian, or caregivers; learn about the health needs of an individual student; determine if they should create an individualized healthcare plan (IHP) and/or emergency action plan for a student; and consider many of the social determinants of health in developing a coordinated plan of care. SHP piloted the SN CHAT in the 2020-2021 school year, and will promote the resource broadly as a useful tool for school districts to improve the quality of student health information and plan to appropriately address student health and education needs.

Other Title V Program Activities Related to the Cross-Cutting & Systems Building Domain

The Child Care Health Consultation (CCHC) Program providers will continue to assess for referral needs at every training and consultation, referring children, providers, and parents to resources, including Medicaid, as needed to improve health care access.

The TEL-LINK Program will refer callers to Medicaid/MO HealthNet services to increase insurance coverage. The program will continue to provide outreach to the underserved population through effective marketing strategies.

The Newborn Health program will continue to partner with a wide-variety of community health providers to distribute the Pregnancy and Beyond booklet, which contains information about financial resources for pregnant women and children, including MO HealthNet.

The MCH funded Home Visiting Program’s contracted home visitors will assess all home visiting clients for insurance status at initial enrollment and periodically throughout enrollment. As need for health care coverage is identified, home visitors will assist clients/families in the Medicaid enrollment process and to the Affordable Care Act marketplace by linking clients to their nearest Federally Qualified Health Center (FQHC) to speak with a trained navigator in order to obtain eligibility and enrollment assistance. Annual data on insurance coverage through Medicaid, private, or other insurance will be collected on children and primary caregivers enrolled in home visiting. Insurance coverage is vital to assuring children access adequate preventive health care including well child care. Annual performance measure data will be collected on the percentage of children enrolled in home visiting who receive the last recommended well child visit based on the America Academy of Pediatrics (AAP) schedule.

The SHP, as a member of the Medicaid Advisory Council, will continue to collaborate and partner with the MO HealthNet Managed Care plans, Department of Social Services (DSS), FQHCs, state agencies and programs, as well as funding organizations to provide information, tools, and resources to school nurses. These materials equip school nurses with information about health care plans and services to aid them when assisting parents and families obtain adequate health insurance coverage, and access health care services and health plan benefits. SHP will use data shared by DSS to review the reported number of children enrolled in MO HealthNet/Medicaid annually for trends and comparison to the trending number of students reported as uninsured from school nurse reporting. With the passage of legislation to expand Missouri Medicaid eligibility to healthy adults, SHP will work with school nurses to provide information and resources to support them in assisting families with Medicaid/MO HealthNet enrollment. SHP will support school nurses in assessing student insurance status and assisting families with MO HealthNet applications and accessing benefits through a variety of training opportunities.

The SHP and the Title V MCH Director will participate in the Show-Me School-Based Health Alliance as a partner on the steering committee. This Missouri affiliate of the National School-Based Health Alliance will work with partner organizations and community stakeholders to increase the number of school based clinics and expand the clinic service offerings. Missouri has seen the number of school based health centers rise from five in 2017 to 106 (not including satellite clinics). The Alliance will also work to enhance the access to health care services for all students since a barrier to care has been when students miss school for medical appointments and parents miss work to take students to appointments.

The SHP collaborates with school health staff in local education agencies (public, private, parochial, and Charter schools) to collect annual reporting utilizing an online database. This system has been in place for over a decade and the information is used to identify trends, facilitate planning of state resources, and ensure up-to-date communication with lead nurses in Missouri schools. The SHP uses the data to monitor staffing of school health services and to identify school districts without designated school health services staff. The program is then able to offer additional supports and technical assistance to assure a minimum level of health services are available. The database also collects district-level data for students with health insurance. SHP reviews this data to identify resource and information needs of school nurses. The program also uses this information as an indicator for reporting to state and local leaders on the status of healthcare access in schools and communities. SHP will continue to engage school nurses to utilize the reporting system ad investigate options to update the database to improve collection, access and data sharing.

The MCH Services Program will support local public health agency (LPHA) efforts to:

• increase the number of clients that receive a risk assessment or screening and referral for Medicaid eligibility;
• assure that all women of childbearing age receive preconception care services that will enable them to enter pregnancy in optimal health; and
• develop and promote strategies to increase the proportion of women receiving prenatal care beginning in the first trimester.

LPHAs will continue to:

• screen clients for MO HealthNet or other insurance coverage;
• screen for an identified primary care provider;
• perform pregnancy testing, prenatal education, and OB/GYN referrals as indicated;
• provide prenatal case management and/or referral for pregnant women;
• assist pregnant women with Medicaid/MO HealthNet program eligibility and enrollment; and
• screen clients for an identified dental care provider and provide dental referrals as indicated.

The MCH Services Program and the Title V MCH Director will continue to facilitate collaboration between the Department of Health and Senior Services, DSS, and the LPHAs to provide MEDES (Missouri Eligibility Determination and Enrollment System) updates, maintain open and effective interagency communication, promote adequate health insurance coverage, and improve health care access for MCH populations.

In addition, the MCH Services Program will continue to contract with 111 LPHAs to address priority maternal child health issues in their community. The MCH Services Program has worked with the LPHAs to conduct a focused, local assessment of MCH priority needs, identifying at least one priority health issue aligned with the FFY 2021-2025 Title V priorities, and developed a five-year, FFY 2022-2026, work plan to address the selected priority health issue(s). The LPHA work plans include evidence-based strategies to address their selected local priority health issues, including addressing social determinants of health, existing health inequities, and gaps/weaknesses in access to care.

• The Jackson County Health Department has chosen as their selected priority health issue Address Social Determinants of Health Inequities among preconception/prenatal/postpartum women of childbearing age. They plan to create a Policy Action Plan that impacts racial disparities and inequities for their health department to adopt and follow. They also plan to provide evidence-based trainings, curriculums and practices on racial disparities and inequities to internal and external providers and partners.

Through the Inclusion Services (IS) project, the Inclusion Specialists will continue to provide referrals to appropriate services, including services provided by local public school districts, as a part of child-specific action plans.