Accessible and Affordable Health Care

A cross-cutting need identified in Minnesota’s needs assessment was comprehensive, quality health care services, including family planning, that are available and affordable for all. Therefore, this is a priority area for this next five-year cycle.

Comprehensive, quality health care services are important for promoting and maintaining health throughout the lifespan. Access to health care is impacted by household finances, insurance coverage, geographic availability, timeliness of entry into services and many more factors. Poor access to health care services can result in unmet health needs, lack of preventive services, hospitalization, and increased financial burden. Equally as important as access is the alarming rising costs of health care.

The highest proportion of Minnesotans without insurance live in rural areas in the northern regions of the state. Minnesotans living in rural areas experience more barriers to accessing health care as a result of decreased geographic access and health provider shortages. In 2017, there were 121 Health Professional Shortage Areas in Minnesota and 97 Medically Underserved Areas. Rural residents are especially disadvantaged in terms of access to dental care with very few dental providers practicing in greater Minnesota counties.

Additionally, racial disparities in rural communities continue to negatively impact the health outcomes of American Indians and people of color. Even when an individual has access to health care in their community, the financial burden experienced by seeing health care providers that are not within an individual’s insurance network can greatly limit options for health care.

Disparities in access to health care are felt acutely among families of children and youth with special health needs (CYSHN). In Minnesota, 8.5% of CYSHN did not receive needed health care compared to just 1% of children and youth without special health needs. The cost of health care adversely affects families of CYSHN, with 15% of these families struggling to pay for a child’s medical bills, compared to 10% of families without CYSHN. The difference may seem small, but taken into consideration with the increased likelihood of parents of CYSHN to have to cut back their work hours or stop working altogether to provide care for their child, the disparities in access to and cost of health care can have a significant impact on families and their household income.

Five-Year Strategies and Activities Moving Forward

Context for Strategy Development

As with the other priority areas, MDH brought together a multidisciplinary Strategy Team to identify a set of strategies to address issues related to Accessible and Affordable Health Care. During their discussion of the priority need, the Strategy Team dissected the issue of Accessible and Affordable Health Care into three adjectives: Accessible (able to fully utilize benefits), Available (able to reach location, i.e., “get in the door”), and Affordable (able to pay). Each of these features is intertwined with one another and embedded with issues of historic, systematized discrimination and racism.

For instance, the group discussed that while some may have insurance coverage (affordable), the location of services was too distant from their home and/or lacked transportation (available). Additionally, even if someone could get “in the door of the clinic” (available), the services provided did not meet their culturally-specific and/or disability-related health needs (accessible). These adjectives inform how the group characterized the issue, with the group insisting it is inadequate to view Accessible and Affordable Health Care merely as a measure of number of Minnesotans enrolled in an insurance plan.

Figure 1. Defining Accessible and Affordable Health Care

While the primary aim of the group was to assess strategies, members also discussed pressing current issues and their vision forward. These strategies, outcomes, and the corresponding context can be found in the Logic Model below (Figure 2) and attached in the Supporting Documents.

Figure 2. Accessible and Affordable Health Care Logic Model

Strategy A. Recognize and Reduce Systemic Racism, Discrimination, and Marginalization in Health Care

Minnesota ranks, on average, among the healthiest states in the nation. However, a closer look at the data reveals that communities of color, American Indians, lesbian, gay, bisexual, transgender and queer (LGBTQ) communities, the disability community, rural communities and low-income communities experience the highest inequities in the state. Minnesota's significant and long-lasting health inequities cannot be explained by bio-genetic factors and personal choice. These health differences have in part resulted from structural racism and discrimination, which refers to oppression that is built into systems and policies, rather than solely individual prejudice.

MDH established a Center for Health Equity (CHE) in 2013. The CHE is an active part of strategy, education, and programming for the department. More information on the CHE can be found in the Overview of the State. Additionally, MDH formed the Health Equity Advisory and Leadership (HEAL) Council to address Minnesota’s disparities in health status – particularly those persistent disparities across various ethnic, racial and regional groups. The HEAL Council represents the voices of many communities most severely impacted by health inequities across the state, including racial and ethnic minority groups, rural Minnesotans, Minnesotans with disabilities, American Indians, LGBTQ community members, and refugees and immigrants. The council assists MDH in carrying out the efforts outlined in the department’s strategic plan and its Advancing Health Equity report, including advising on specific MDH policies and programs. The council also assists MDH in developing strong performance measures related to advancing health equity. The CFH Division and Title V Program remain engaged with the HEAL Council and work of the CHE, including the MCH Director who sits on an internal advisory body to the CHE.

The first strategy aims to build off the work done at MDH to advance health equity focusing on reducing the discrimination and marginalization experienced by women, children, and families in our health care system.

Monitor and Report Data on Racial and Linguistic Diversity of Health Care Providers in Minnesota

Mounting empirical evidence offers rationale for improving the cultural competency of the health care workforce by increasing the diversity of health care providers.[1],[2],[3],[4] As a first step toward increasing the diversity of our health care workforce serving MCH populations, the state needs to develop a better understanding of the racial and linguistic diversity of providers. Within MDH, the Office of Rural Health and Primary Care Healthcare Workforce team works to collect data on racial/ethnic makeup of providers. Therefore, during FY2021, CFH intends to meet with those teams to discuss the themes from the comprehensive Needs Assessment and from the Strategy Team regarding provider diversity and determine where and how we can partner to better promote the needs of MCH populations.

Promotion and Training of Accessibility in Health Care and Other Community Settings for Children and Adults with Disabilities

Persons with disabilities, including children, are another population that experiences a great deal of discrimination in our health care system and community – which can lead to increased disparities in health and well-being. In order to reduce this discrimination, MDH is focusing on two activities during FY2021:

• Monitor and influence current and upcoming state legislation and advocacy efforts related to accessibility.
• Conduct a needs assessment related to community accessibility for CYSHN and their families and publish our findings. This will help us to better understand where in particular families are facing difficulties, and where we should focus efforts moving forward in helping to reduce barriers to creating an accessible community.

Strategy B. Expand Access to Health Care by Increasing Availability of Community-Based and Remote Services

The second strategy aims to expand access of community-based and remote services, such as telemedicine.

Provide Road Map/Technical Assistance to Expand Opportunities for Collaboration between the Health Care System and Schools

One way to expand availability of community-based services is to provide them in places where families are already located or frequently attend, such as their child’s school. Building on the relationships under the PREP, SRAE, MEPSP, and school nursing programs, Minnesota will seek to improve collaboration with schools, school nurses, and school-based clinics as primary entry points to improved health care for children. During FY2021, MDH intends to expand opportunities for collaboration between schools and the health care system through 1) better understanding the landscape of health services currently provided in Minnesota schools including barriers for access, and 2) surveying existing efforts in metro and Greater Minnesota to improve health services in schools.

During the COVID-19 pandemic, MDH staff has taken on an integral role in promoting school health for both children and families as well as teachers and staff. In partnership with the Minnesota Department of Education, local districts, and other partners, MDH staff will:

• Craft public health guidance that prioritizes the health and safety of students and teachers, both in-person and virtually.
• Provide technical assistance to school nursing, special education departments, direct support professionals, and related staff to ensure the evolving health needs of families are met throughout the school year.
• Measure the use of and promote access to well-visits, screening, and preventive care as essential components of child and adolescent health.
• Collaborate with the Department of Human Services in areas such as school-linked mental health and disability services to connect children and families with disabilities and mental health needs with interventions and support.

Assess and Promote Accessible and Barrier-Free Access to Telehealth and Other Remote Methods of Health Care for MCH Populations

Telehealth has been identified as a promising solution to meet some needs for rural and underserved areas that lack enough health care services, including specialty care. Telehealth enables patients and providers to connect through video conference, telephone, or a home health monitoring device. Some approaches to increase use of telehealth include development of policies that expand access to primary care and other health services, and reviewing existing reimbursement policies for telehealth services in order to remove barriers for health care practitioners who provide telehealth services. During the current COVID-19 pandemic, implementation of telephonic and televideo health services has expanded quickly, including use by the WIC, C&TC, Family Planning Special Projects, and FHV programs. While numerous waivers and policy changes have allowed providers and patients to utilize telehealth services during the national and state-declared peacetime emergency, it is unclear how these changes have impacted the MCH population and which policies will remain in the coming months and years. During FY2021, MDH will work to assess the use of telehealth for MCH populations. Focus will be placed on two areas:

• Analyzing and reporting on use of telehealth across state for children and families noting situations of most positive impact and where barriers exist, and
• Understanding the landscape of telehealth in MDH and other state agency structures (including policies around use of telehealth) and identifying areas for partnership.

Strategy C. Improve the Quality of Health Care by Promoting Person and Family-Centered Practices

Many people have difficulty navigating the health care system in order to get the care they need. Specific communities, such as people with disabilities and their families, people with limited English proficiency, people living in rural areas, and communities that have been historically discriminated against, require more unique approaches to accessing quality care than strategies that may be effective for the majority. Understanding that some populations may need different approaches in communication and outreach, it is important to leverage existing, trusted networks (such as Community Health Workers and other cultural brokers) in order to empower patients and families with information and tools needed to be engaged in their health care. The following activities seek to utilize these trusted health advocates as partners in Minnesota’s efforts to improve quality of health care and person-centered practices in communities.

Increase the Availability and Use of Community Health Workers and Other Cultural Brokers

Community Health Workers (CHWs) are trusted, knowledgeable frontline health personnel who typically come from the communities they serve. CHWs bridge cultural and linguistic barriers, expand access to coverage and care, and improve health outcomes.[5]

One area of focus for FY2021 is developing a partnership with Minnesota’s Community Health Worker Alliance. The CHW Alliance is a statewide organization that works to “Build community and systems capacity for better health the integration of community health worker (CHW) strategies.”[6] Staff from the CFH Division will meet with representatives from the alliance to discuss areas for alignment and partnership.

In addition to this partnership, Title V will also partner with the Birth Defects Unit within the CYSHN Section on a grant project aimed at developing community-based approaches for addressing the leading risk factors for birth defects in the state. The three-year project will use community health workers to provide educational materials and one-on-one education to women on the effects of substance misuse, chemical exposure, and intrauterine infections on prenatal development. The project will focus on women of reproductive age, including pregnant women, who are receiving care in a Twin-Cities based health care clinic or a Somali home visiting program.

Increase Access to Family Planning with Special Attention to Youth, Rural Areas, and Communities of Color and American Indians

MDH oversees the Family Planning Special Projects (FPSP) program which provides low-income, high-risk people pre-pregnancy family planning services. Funding is targeted to people who would have difficulty accessing services because of barriers such as poverty, lack of insurance, or transportation. Grants are awarded to counties, Tribal governments, or nonprofit organizations to provide family planning services in communities throughout the state. This work will continue to focus on expanding access to youth, rural areas, communities of color, and American Indians in its awarding of funds and provision of technical assistance.

Additionally, the Title V program aims to make an interagency connection with the Department of Human Services which also conducts work in the area of family planning. The relevant staff from each agency plan to meet in Year 1 and discuss methods for improved partnerships and “warm hand-offs" in family planning work.

Train Health Care Professionals on how to Interact with and Provide Care to Patients with Neurological Differences and Other Disabilities and Their Families

Patients who have neurological differences and other related disabilities, such as Autism Spectrum Disorder, may require additional accommodations related to communication when receiving care within the health care system as opposed to those without such disabilities. In addition, some people with sensory and cognitive disabilities are unable to wear a mask and practice physical distancing. During the COVID-19 pandemic, people with disabilities and their families have reported being denied medical and dental care due to the inability to mask and/or need for additional in-person supports. This is exacerbated by health care system shortage of adequate personal protective equipment (PPE), such as N-95 respirators, necessary enhanced respiratory protection when providing direct care to individuals without masks in times of significant community transmission. MDH staff produced guidance and FAQ online materials to address these issues and leads disability-specific advisory group to address ongoing concerns of the disability community during the pandemic.

Over the next five-year block grant cycle, MDH intends to work toward providing COVID-specific and general health guidance and training to health care professionals on how to better interact with this population of individuals and their families. In FY2021, MDH will begin by working with providers to assess their confidence and resources needed for them to best serve persons with such disabilities and their families (including PPE). Title V staff will then engage with the Community Forum for CYSHN/D to develop a subgroup who will take the findings from our provider assessment and research/develop competencies for providers and establish a work plan for providing trainings on the competencies.

State Performance Measure and Five-Year Objectives

As mentioned previously, the Strategy Team wished to focus the priority goals on Minnesotans accessing needed care rather than insurance coverage alone. Therefore, the Title V program will focus measurement for this priority area on the proportion of Minnesotans reporting an unmet need for medical care due to cost.

The MDH Title V program will gain access to this data through the Minnesota Health Access Survey (MHAS) hosted by the Health Economics program at MDH. The Minnesota Health Access Survey is a biennial telephone and mail survey that collects information on the health of Minnesotans and how they access health insurance and health care services. The survey measures how many people in Minnesota have health insurance and how easy it is for them to get health care.

American Indian Family Health

A significant area of need highlighted in Minnesota’s five-year comprehensive needs assessment was to reduce disparities and support the well-being of American Indian families, making this a cross-cutting/systems building priority area for the state.

Families are central to the healthy physical, social and emotional development of infants and young children. However, many Minnesota families face challenges that impact the development of their children during the critical early years of life. Stressors, such as poverty and adverse experiences, disproportionately affect children and families in economically, socially and environmentally disadvantaged communities. Frequent exposure to these stressors and adverse experiences increase the likelihood of people facing health disparities later in life.

American Indian women, children, and families experience worse outcomes than other populations in Minnesota. These disparities are caused by historical trauma, racism, and continued colonial practices and policies that act as barriers to opportunity and thriving. The American Indian child poverty rate in 2016 was 36% compared to 14% of all Minnesota children living in poverty.[7] Approximately 51.4% of American Indian children are growing up in single mother families.[8] Only 50% of American Indian youth will graduate from high school.[9] Compared to white children, American Indian children in Minnesota are 18 times more likely to be placed in out-of-home care.[10]

Minnesota’s 11 tribal nations are all distinct communities separate from one another. Each presents with their own unique assets, strengths, and challenges. However, there are some health disparities we see recurring across American Indian communities, as described below.

“We’ve had high rates, we continue to have high rates – and we’ve had resources (although not enough to really address the issues), but those resources are attached to a set of criteria and/or activities that do not work for us. For example, evidence-based programs are predominately normed on a mainstream population; and we have no other options, but to use an outside approach or not receive the resources, both of which are inequitable.” – Jackie Dionne, Director of American Indian Health at the Minnesota Department of Health

Maternal Mortality

The death of a woman during pregnancy, at delivery or soon after delivery is a tragedy for her family and her community. In Minnesota, American Indian women are 7.8 times more likely to die due during pregnancy or within one year after pregnancy when compared to non-Hispanic white women.[11]

Infant Mortality

Since 2009 and at times prior, American Indians have had the highest infant mortality rate in the state.[12] While the overall state rate has decreased, American Indian rates have risen over the past 10 years. The leading causes of death for American Indian infants are obstetric conditions, congenital anomalies, prematurity, and sudden unexpected infant deaths.

Suicide

Comparing time periods from 2008-2012 and 2013-2017, the American Indian community experienced a 61% increase in their rate of completed suicides. The Minnesota American Indian suicide rate for 2013 to 2017 was nearly two times greater than the national American Indian suicide rate of 12.5 per 100,000 (see Figure 1).

Figure 1. Minnesota Suicide Rate by Race, 2008-2012 versus 2013-2017

 

Source: Minnesota Department of Health, Suicide in Minnesota 1999-2017 Data Brief

Brief Overview of Minnesota’s Tribes

Minnesota is home to 11 tribal nations. Geographically, tribes are located throughout the state with four small Dakota (Sioux) tribes in the southern half of Minnesota, and seven larger Ojibwe (also known as Anishinaabe and Chippewa) across the northern tier.

Figure 2. Minnesota Counties and Tribal Nations, 2019

Ojibwe Tribes

White Earth’s Nurse Family Partnership (NFP) program is Minnesota’s only Tribally Maternal, Infant, and Early Childhood Home Visiting (MIECHV)-funded site. They work with MIECHV for technical assistance support and report data to NFP and MIECHV, but not to MDH other than minimum reporting requirements for state funding. Their NFP program staff share that they are maintaining enrollment numbers. White Earth also has several wrap-around programs to serve families experiencing substance use, including housing and both in-patient and out-patient treatment programs. Most of their home visitors (HVs) are non-American Indian registered nurses (RNs) or public health nurses (PHNs) from outside the community. Intensive cultural training is required for community members and non-community members working for the tribe. The community has developed a robust transportation system and billing infrastructure is good.

Fond du Lac also offers the NFP program. Their assessment of their pregnant and parenting population shows a significant number of families who are not eligible to enroll in NFP. In addition, they are finding more young parents who express a desire to include traditional practices. They continue to look for a program that can be delivered by nurses and has a cultural component. They have a very robust billing infrastructure, though some challenges persist. In addition to billing, the program is also funded through some state funding as well as tribal dollars.

Bois Forte partnered with Grand Portage as our first tribal sites receiving the Family Spirit family home visiting training in 2013. They have had consistent staff to utilize the curriculum throughout the years, but identified low fidelity as a challenge due to HV staff having to wear many hats. With evidence-based Family Home Visiting (FHV) funding, Bois Forte hired a home visitor who attended training in August of 2019. They are successfully implementing the Family Spirit program with positive response from their community and leadership. According to staff, transportation and access to resources for food, medical care, and social support are limited due to their rural location.

Grand Portage was the very first active Family Spirit site in Minnesota, enrolling their first participant in 2013. They, along with Bois Forte, were part of a pilot project and still employ one of the nurses trained in that pilot program. They have continuously utilized the program and maintain an average caseload of 5 or fewer clients. Their birthrate is 5-10 a year. Substance use disorder among pregnant/parenting women is very low. Their participants are very isolated and must often travel two or more hours each way for any specialty medical care. There is little unemployment, tribal businesses employ the majority of band members. There are two RNs staffing the health office and they address ‘womb to tomb’ healthcare issues in their community.

Red Lake has had staff trained in Family Spirit since 2014. They have not been able to maintain a broadly-integrated Family Spirit program, though one PHN utilizes the curriculum independent of model enrollment for all MCH home visits made in the home and at WIC clinics. Red Lake secured EBHV funding and are planning for an ambitious launch with four full-time community health workers (CHWs), a Health Educator, and a supervising PHN with a target caseload of 100. Comprehensive Health includes both tribal and Indian Health Service (IHS) services through clinic and in-patient facilities. Clients are seen prenatally to seven months at Comprehensive Health and then transferred to a local community clinic/hospital for final care and delivery. This tribe is located in a very isolated region of the state with limited transportation options. Many traditional health practices are resurging and the community felt Family Spirit was a good fit for their population.

Leech Lake is currently an EBFHV funded program as part of a group of counties in northwest Minnesota. This partnership has greatly improved the overall relationships between the counties and tribe. It has also provided reflective practice – a recommended but not required facet of the Family Spirit program. They utilize paraprofessionals under the supervision of an elder/LPN respected in the community. Staff turnover has been a challenge. Tribal leadership is supportive of family home visiting delivered through the Family Spirit model. More work is needed to develop reporting capabilities and complete quality improvement projects and data.

Mille Lacs is a currently funded EBFHV site partnering with Mille Lacs and Pine Counties. They have had significant staff turnover since the program began in 2015 at this site and quit offering the program until receiving EBHV funding in 2018. Relationships with their partnering counties seems to have improved. They are involved with continuous quality improvement (CQI) projects; the paraprofessional home visitors are requesting more training and have been encouraged to utilize Achieve on Demand and The Institute for the Advancement of Family Support Professionals to start.

Dakota Tribes

Lower Sioux has had Family Spirit staff trained since 2014. The person originally trained is still the supervising RN at Lower Sioux. She has utilized the curriculum but has felt overwhelmed by the implementation process on her own and struggled with program details while fulfilling many other roles at her agency. Their current home visiting is funded solely through Temporary Assistance for Needy Families (TANF) funds. In 2017, Southwest Health and Human Services (a six-county community health board) along with Lower Sioux received a DHS grant to have staff from a multitude of their agencies serving the AI population trained in Family Spirit. They continue to use the program in those areas, but have not worked closely with Johns Hopkins or MDH in reporting enrollment and staffing numbers. They will be sending an Early Head Start teacher from this group to the August 2019 training. Since that time, this teacher has had great success with enrollment using a strong cultural approach.

Upper Sioux has not had staff trained in Family Spirit or implemented other structured long-term family home visiting programs. In the past, they worked more closely with counties to provide services for their members, but are now working on building their own infrastructure and services. They are working on addressing teen pregnancy prevention and early childhood developmental and social emotional screening programs.

Prairie Island does not have FHV services, nor do they receive TANF funding. We have had little connection with their small health office.

Shakopee provides clinic services to members and employees alike. They had expressed an interest in the Family Spirit curriculum several years ago, but have never followed up with any further invites to connect.

Five-Year Strategies and Activities Moving Forward

As discussed in other priority areas of Minnesota’s five-year application plan, our Strategy Team created the American Indian Family Health 2021-2025 plan. This Strategy Team was comprised of American Indian elders, tribal/community members, tribal health leaders from both tribal and urban areas, and FHV staff serving American Indian participants. At the onset, the Strategy Team was encouraged to “think big.” Two main themes from American Indian team members that formed the focus of our meeting discussions are:

• We must acknowledge the impact of historical trauma. One participant said, “It’s the stage on which our lives are played.”
• However, we cannot stay mired in that trauma – we have to utilize our strengths to change things. We can use the strengths of culture to reclaim our place in this world. Culture does not set us apart; it helps us belong.

In addition, the goal during each of these meetings was to reach decisions based on the overarching values reached by the group; expected outcomes include dignity, virtue, and teaching our history.

Minnesota acknowledges that American Indian people carry cultural knowledge and wisdom that has sustained their communities and nations for generations, and that only through authentic engagement and partnership will we see change. We recognize that approaches need to be guided by the communities most affected, and we need to support their efforts and give them enough time and resources to see change. It will take dedication to understanding culture and history, community health board engagement, and state and federal partnerships with American Indians to make change.

A logic model has been developed to visualize our planned work and intended results (see Figure 3). A larger version of the logic model is included with the supporting documents for this application. This logic model, along with the five-year action plan table, provide a broad picture of Minnesota’s strategies aimed at addressing the issues faced by American Indian families. The discussion below includes Minnesota’s plans for implementing the strategies during FY2021 specifically.

Figure 3. Minnesota American Indian Family Health Logic Model

Strategy A. Increase Access to Culturally-Specific Health Services

Many American Indian families struggle with a health care system that does not meet their needs. Much of Minnesota’s health care and public health infrastructure is rooted in Western practices and beliefs that do not overlap with American Indian approaches or values. When culturally relevant care incorporating history and cultural context is available, capacity is often limited and people living in rural areas or lacking robust transportation options can struggle with geographical access. We plan to implement the following activities to make progress in closing this gap.

“[Women, children and families need] a caring, culturally supportive community to access that shares, cares and offers opportunities for personal and professional growth that supports them as women, as mothers, and as leaders. When a woman can move beyond the struggle of basic needs, they are capable of so much more including living a full life.” – American Indian Needs Assessment Discovery Survey Respondent

Collaborate with Partners to Support Training of American Indian Doulas and Community Health Workers

Minnesota plans to collaborate with partners to support the training of American Indian doulas and other birth workers, Indigenous breast feeding experts, and community health workers (CHWs). We will also partner with DHS to facilitate program implementation and billing infrastructure for doulas and community health workers.

• Minnesota Indigenous Breast Feeding Coalition
• American Indian Doula Groups
• Minnesota Community Health Workers Alliance
• Minnesota Breastfeeding Coalition
• Northwest Indian Community Development Center
• Nitamising (a developing Indigenous birthing and lactation group)

Support Family-Centered Evidence-Based Programs and Practices that are Normed in the American Indian Community

Family Spirit is a family home visiting model developed by, with, and for American Indian families.[13] It utilizes a multigenerational strengths-based approach that incorporates American Indian cultural values and an indigenous conceptualization of health and well-being. Six tribes currently have or are implementing the Family Spirit model. For most sites, funding is braided between TANF and evidence-based FHV state funding. We plan to continue supporting all tribal home visiting programs during FY2021.

Throughout FY2019 and FY2020, Minnesota has collaborated with the Johns Hopkins Center for American Indian Health to provide a one-year FHV Community of Practice offering monthly training and technical support sessions for all of our tribal communities. While this Community of Practice focuses primarily on the Family Spirit curriculum, it is open to any tribal site providing a different FHV program, such as NFP, as well as sites not currently offering an FHV program. Sessions are followed up with continuous quality improvement activities, which are supported by Johns Hopkins and MDH staff. Throughout FY2021, we will continue to evaluate this program and explore how we can continue to draw upon the expertise of Johns Hopkins University to provide maternal and child health service support to American Indian communities.

Strategy B. Mandate Cultural Proficiency, as Defined by the Community

Participants in our Strategy Team discussed the lack of awareness and understanding surrounding American Indian history and culture among non-American Indian people. From the not-so-distant past to today, American Indian communities have been forced to operate within a context of inaccurate and reductive portrayals of their history and culture. They have been forced to live within boundaries set by people who neither knew nor understood them. This misinformation persists today through policies and structures set by uninformed government leaders and employees, regardless of whether or not it is done intentionally. Minnesota state employees who misunderstand American Indian history and culture perpetuate mistrust among these communities, who are directly impacted by this ignorance both personally and systemically. Unless this cycle of misinformation is interrupted, it will continue to harm American Indian communities.

Cultural and historical proficiency – as defined by American Indian communities – should be mandated for state employees that interact with or impact American Indian families. To ensure their history and culture are conveyed accurately and meaningfully, American Indians should direct the development and delivery of trainings, educational materials, and benchmarks for proficiency.

Convene a Group of Stakeholders and MDH Staff to Review Currently Available Training

We plan to review the current “Tribal State Relations” training, which is offered in partnership with the University of Minnesota, with the MDH American Indian Health Director to assess continued relevance and document goals related to employee participation. This will involve reviewing the number of employees who have attended the training, continuing to monitor employee attendance, and developing a virtual training format that can be offered safely during the COVID-19 pandemic. We will also develop pre- and post-training evaluations in order to assess training efficacy.

We are planning to make these changes with the assumption that when state employees know better, they do better. We trust that state employees will apply this knowledge to their work in our tribal communities, but we will also continue assessing for opportunities to increase post-training accountability.

Collaborate with Minnesota DHS to Develop Specific Training for those Working with Tribal Communities

Staff members at the Department of Human Services are currently making great strides to develop accurate and meaningful trainings for employees working with American Indian populations. In FY2021, we will work with DHS staff to adapt this training to the standards and criteria set by American Indian elders and community members.

Strategy C. Shift Power and Policies to Address Structural Racism

“The only good Indian is a dead Indian.” – Gen. Phillip Sheridan, 1869 at a Tribal Leadership Meeting in what is now Oklahoma

When this opinion was voiced in 1869, it was neither scandalous nor controversial. These words reflect a common prejudice that shaped the treaties between the U.S. government and tribal leadership at the time and pervades government systems to this day. Many of Minnesota’s laws and policies are inherently biased and perpetuate structural and systemic racism. These range from macro-level policies that make it more difficult for American Indian people to be hired to micro-level standards that create obstacles to grant funding for American Indian-led public health organizations.

Evaluate satisfaction and efficacy of project pilot to shift Ending Health Disparity Initiative (EHDI)/TANF/MCH bi-annual reports to oral and in-person methodology

Since September 2019, MDH piloted a program adaptation that allows for more flexibility in grant reporting and accommodates cultural differences. Numerous aspects of MDH’s funding and reporting processes are based in Westernized administrative practices. One notable example of this is the requirement that program updates are to be delivered in the form of written reports. While American Indian FHV staff are more than capable of meeting this requirements, multiple American Indian grantees have communicated they appreciate having the option to provide updates through oral reports. American Indian culture is rooted in oral communication more so than written communication; this is a small gesture Minnesota can make to honor cultural differences and preferences for the grantees working so hard to serve Minnesota’s families. When grantees are given the option to provide updates orally, they have the opportunity to share stories of participants’ progress and challenges within the program rather than answering prescribed questions. They are also able to engage in a conversation with grant managers that allows for more nuance and detail. These conversations are best held in-person, which provides vital opportunities to build trust and relationships and improve technical assistance strategies. However, they can be substituted with virtual/phone conversations when necessary to accommodate COVID-19 restrictions.

Develop Request for Proposal Processes that Demonstrate a Knowledge of American Indian Communities, their Norms, and Values

Through 2021, we will be critically analyzing our current Request for Proposal (RFP) language and processes to remove barriers to funding that currently exist for American Indian applicants, and we will learn from recent emergency COVID-related grants to American Indian organizations, which deviated from the standard processes. This will involve conducting literature reviews to identify best practices for operationalizing health equity in the funding process and assessing past RFP language for opportunities to improve. We will partner closely with the MDH Center for Health Equity to develop best practices around RFP development.

State Performance Measure and Five-Year Objectives

As previously stated, structural and systemic racism plays an integral role in perpetuating poor health outcomes among American Indian populations. This includes the micro-level standards that govern how MDH interacts with and receives information from tribal communities. Tribal leaders across the state have told us they are concerned that the structures and policies within MDH do not address the cultural context of providing services in American Indian communities. To address our limitations, MDH must identify, within its programs, the barriers that prevent meaningful engagement. To help identify and overcome these barriers, MDH will focus on developing personalized technical assistance plans with each tribe in order to provide meaningful services that meet their needs in a culturally relevant way. We will also engage leadership at the agency to work towards addressing policies that are barriers for tribal communities. While not all tribes may choose to participate, it is important to provide the opportunity for support.

Housing

Priority Need: Increase safe, affordable and stable housing for all people in Minnesota

Housing was consistently one of the most reported needs of children, women, and families throughout our needs assessment process. While it was mentioned 752 times in the Discovery Survey, making it the second most commonly stated need from respondent’s overall- people that identified as African American/Black, American Indian, and Hispanic identified housing as the number one need in their communities. Housing safety, affordability and stability were the three most commonly mentioned themes related to housing.

Housing is connected to every aspect of people’s lives and is a critical factor in financial security, academic success, and the health and wellbeing of children, women, and families. Research shows that kids are more likely to do well in school if they aren’t worrying about where they will sleep, and adults are more likely to get and keep jobs, achieve financial security, and have good health and well-being when they have a secure home.[14] Every person living in Minnesota should have a safe, affordable place to live in a thriving community -but not all do.

“[Women, children, and families need] safe, affordable housing. There are many other important things needed to live life to the fullest. But without a safe place to sleep, it’s hard to do anything else.” – Needs Assessment Discovery Survey respondent

Safe Housing

Most Americans spend about 90% of their time indoors, with an estimated two-thirds of indoor time in the home. Infants and young children spend even more time indoors and at home, making them especially vulnerable to household hazards. Homes that are not free from physical hazards contribute to infectious and chronic diseases, injuries and poor childhood development. [15] During the current pandemic, the importance of having a safe home is even more critical, as other locations like schools, libraries, community centers, and places of worship have been closed or access severely limited.

Affordable Housing

As the cost of owning a home increases in Minnesota, there are less affordable rental homes and apartments every year. Minnesota has seen dramatic rent increases over the past few years with rents rising hundreds of dollars a month, sometimes doubling, leaving renters unable to afford their homes. This often leads to displacement, with people needing to double up with family and friends, seek temporary shelter, live in their cars, or live on the streets until they can find a new apartment. Homelessness can cause interruptions in employment, education issues for kids, and poorer health outcomes. If and when families do secure housing, over half of the lowest-income families in Minnesota spend more than 50% of their income on housing costs.17

Multiple generations of Minneapolis residents were (and are) affected by discriminatory federal housing policies, zoning regulations, and lending practices that aimed to keep certain people in certain areas in specific types of housing. Redlining from early in the 20th century left a lasting effect on the neighborhoods of Minneapolis, with the zoning map for much of the city remaining largely unchanged from the era of intentional racial segregation. Since the year 2000, white and Asian households in Minneapolis have seen an increase in household income, while Black households have experienced an approximately 40% decrease in income during the same time period.[16] Rising housing costs in the face of decreased income means that for many residents of Minneapolis, particularly people of color, few, if any, have access to affordable housing. While these examples are specific to Minneapolis, housing disparities adversely impact much of the state.

There are intergenerational consequences of losing homes, particularly through eviction, that last for decades, and evictions are disturbingly concentrated: nearly half of all evictions experienced by people living in Minnesota over the past three years occurred in just two zip codes, and people living in these zip codes experience high rates of poverty, and people of color comprise more than half of the population.17

Homelessness in Minnesota has increased 10% since 2015.[17]

African Americans make up 39% of homeless adults, but only 5% of adults statewide. American Indians make up 8% of homeless adults, compared to 1% statewide. Of all age groups, children and youth age 24 and under are the most likely to be homeless in Minnesota.20

Figure 1. One-night Study Counts of the Minnesota Homeless Population, 1991-2018

As a state, Minnesota has a high rate of homeownership on average. However this isn’t experienced equally by all. Minnesota has the highest disparities in home ownership in the country with 76% of white households owning a home and less than 23% of African American/Black households owning a home.[18]

Stable Housing

The overall number of Minnesotans experiencing homelessness increased by 10% from 2015 to 2018, with a 13% increase seen in Greater Minnesota compared to 9% increase in the 7-county metro. Nearly half of the state’s homeless population (46%) is comprised of homeless children and youth age 24 and younger with 32% being children age 17 or younger (with their parents). While the number of homeless children and youth remained steady from 2015 to 2018, they are the most disproportionally affected by homelessness relative to their make up as a proportion of the state’s overall population. Another key finding of the state’s most recent homelessness report is that there was a 62% increase from 2015 to 2018 in the number of people experiencing homelessness who were not in a formal shelter (e.g. doubled up/couch hopping, living in cars, staying in encampments), with a 93% increase in informal shelter in the Twin Cities metro and 36% increase in greater Minnesota.4 These estimates do not include people on American Indian reservations, a separate report on this is forthcoming. Homelessness and health are interconnected: with poor health being both a cause and result of homelessness.[19]

Five-Year Strategies and Activities Moving Forward

Context of Housing Strategies

MDH convened a multidisciplinary Strategy Team to identify a set of strategies to address issues related to housing. The Strategy Team met in person and by phone to focus on four primary areas of work: funding, person-centered services, innovative housing solutions, and policy change. The discussion below includes Minnesota’s suggested plans for implementing the strategies. During FY2021, due to the impact of the COVID-19 pandemic, Minnesota will focus on developing our plan and logic model by refining the suggested activities outlined below.

COVID-19 Pandemic's Impact on Minnesota’s Housing Strategy

The impacts of the COVID-19 pandemic on housing are significant. Minnesota has seen an increase in unsheltered homelessness since the beginning of the pandemic, culminating in the largest encampment in the state’s history at Powderhorn Park in Minneapolis, where the best estimate showed 282 people living together outdoors. The increase in unsheltered homelessness is attributed in part to people not feeling safe in congregate shelter, and also displacement of those who were doubled up or precariously housed before the pandemic. The pandemic has also impacted those in shelter, as shelter providers statewide have taken considerable measures to decompress shelters and move at-risk individuals into non-congregate protective housing options. And finally, for those who are currently housed, the concerns around eviction and foreclosure are growing. To address this, Minnesota announced on July 14th, 2020 that it would be dedicating $100 million in housing assistance to homeowners and renters in the state. Funding for the COVID Housing Assistance Program (CHAP) comes from the federal CARES Act.

MDH is part of an interagency, cross-sector action team for housing and homelessness during the COVID-19 pandemic, and also has an internal MDH team dedicated to the homelessness and sheltered response. The Title V Needs Assessment Coordinator was reassigned in March 2020 to lead this work, and will likely be deployed through the end of 2020. Because the work has shifted to the immediate needs of responding to the impact of the pandemic on housing stability, safety, and affordability, the Title V work will be responsive to the capacity of the Division of Child and Family Health as their staff are reassigned.

Strategy A: Expanding Funding Opportunities

Suggested activities from strategy development work:

• Work with healthcare providers and systems to encourage investment in housing 
• Expand funding for school districts to screen students for housing needs and provide housing resources 
• Create funding streams for health outcomes in housing programs 
• Provide expanded screening and supportive services for families with pregnancy through pre-K 
• Foster inventive housing ideas with grants that are given out 
• Fund/elevate housing solutions that draw upon community/cultural strengths (e.g. cohousing, doubling up) 

Strategy B: Person-Centered Approach/Services

Suggested activities from strategy development work:

• County/City/State 1-application for services that shares data 
• Grants and funding allow for continued support even when outcomes improve
• An individual approach to housing needs is taken
• Fund systems that follow people over time and across circumstances
• Implement 3-year housing plan of action (case management)
• Allow for more service time 
• Maintain a shareable database of housing programs 
• Care conference model across programs for benefit renewal

Strategy C: Create/Innovate Housing

Suggested activities from strategy development work:

• Partner to increase on-site childcare 
• Remove barriers to home ownership 
• Intentional intergenerational communities as cooperatives (instead of 55+) 
• Creatively increase affordable housing 
• Rehabilitate older buildings and turn them into intergenerational cooperative housing 

Strategy D: Focus on Policy Change

Suggested activities from strategy development work:

• Increase access to emergency assistance sooner/earlier 
• Universal definition of homelessness/housing security (choose the one that is the least stringent!) 
• Require a racial impact assessment tool for decisions, policies, changes (voice for racial justice has existing tool) 
• Create goals that are specific to communities (ex: reduce homelessness in American Indian community by 50%) 
• Examine housing laws related to occupancy laws and create new laws that are more specific to community needs based on the cultural values of the different communities represented in Minnesota
• Advocating for improved housing policy at local, state, and federal level 

State Performance Measure and Five-Year Objective

Because of the impact Minnesota’s COVID-19 pandemic response will have on our ability to address the priority of housing in FY2021, Minnesota has chosen a process measure that focuses on developing our plan for addressing housing over the next five years. We expect our SPM to change in year 2 of this cycle as staffing returns to normal and our work in year 1 focuses the work.

For FY2021, MDH will continue to engage with state, local, and community-based partners to address housing and homelessness as part of the COVID-19 pandemic response. This work will inform the development of a longer-term work plan specific to children, families, and communities. CFH Title V Leadership will coordinate with the MDH Heading Home Alliance workgroup to develop their Housing work plan.

Mental Well Being

Priority Need: Ensure all people living in Minnesota have the opportunity to manage day-to-day stress, have meaningful relationships and contribute to their family and community, including building resilience in those who experience childhood trauma.

Mental well-being was one of the greatest concerns across all population domains in Minnesota’s 2020 five-year needs assessment. Given the breadth of factors that influence mental well-being, nearly every domain in the Title V plan also addresses mental well-being in some way. Additionally, the Governor identified mental well-being of children and youth as a priority for the Children’s Cabinet.

Minnesota recognizes mental well-being as more than the absence of illness. Mental well-being is about having fulfilling relationships, utilizing strengths, contributing to community and being resilient, which is the ability to bounce back after setbacks. Mental well-being is a core ingredient for success in school, work, health, and community life. Poor mental well-being, with or without the presence of mental illness, is a risk factor for chronic disease (cardiovascular, arthritis), increased health care utilization, missed days of work, suicide ideation and attempts, death, smoking, drug and alcohol abuse, physical inactivity, injury, delinquency, and crime.

The need is great. Mental health research conducted by Dr. Corey Keyes, found an estimated 20% of the adult population of the United States, and less than 40% of adolescents age 12-18 have optimal mental health (37% of students did not and 2% did meet criteria for depression with depression).[20],[21] Other data show comparable results: 41.4% of children ages 6-17 were reported by parents to be flourishing based on NSCH data including three items rating the child’s interest and curiosity in learning new things, ability to finish tasks, and staying calm and in control when faced with a challenge. Over one-third of adults over age 45 in the United States (42 million Americans) experience chronic loneliness. A recent national study reported that the loneliest include Generation Z and Millennials, single parents, students and the unemployed. Minneapolis rates were comparable to national averages.[22]

Mental Well-Being Disparities

Mental well-being is not experienced equitably throughout the state’s population. For example, data from the Minnesota Student Survey (MSS) shows Minnesota youth experiencing economic hardship report dramatically lower rates of well-being than youth not experiencing economic hardship. Youth who identify as LGBTQ also report dramatically lower rates of well-being than their straight peers. Mental well-being is measured in the MSS by combining multiple components of well-being to create an overall well-being score (i.e., positive identity, social competency, personal growth, empowerment, social integration, educational engagement, and positive family, community, teacher and peer relationships).

There are large disparities in the number of mental well-being components reported by race/ethnicity by Minnesota adolescents. Almost half of non-Hispanic white students reported have eight to ten of the mental well-being components, less than 30% of American Indian students reported the same. Overall non-Hispanic whites report experiencing higher rates of all well-being components, with the exception of educational engagement, which is higher among Hmong and Asian/Pacific Islanders.

Figure 1. Mental Well-Being Score – Percentage of 8th, 9th, and 11th Grade Students reporting Mental Well-Being Components by Race/Ethnicity, 2019

Empower community to build capacity and resilience

Mental well-being happens in and through community. Minnesota intends to promote (or increase) and protect mental well-being by building positive relationships, social connections and drawing on community assets, especially the capacity to create the unique changes needed in each community.

Mental well-being requires a sense of purpose and power. To truly experience mental well-being we need to feel and have the power to shape our world and change our lives and conditions for the better. For many, historical trauma is a reality that takes away our sense of purpose and power and continues to be part of our lived experience and reality.

Community capacity or leadership is foundational for a promotion and prevention approach to mental health. The World Health Organization supports the importance of considering community in mental health promotion, asserting that the community’s levels of empowerment, ownership, and control of their own destiny are the most important strategies for mental health promotion. Community capacity, the ability in a given community to solve collective problems and improve community well-being, is linked to decreased rates of mental illness, antisocial behavior, neighborhood violence, homicide, and suicide. Youth in communities with greater social capital develop trust and reciprocity earlier, a developmental process that is important for building relationship and resilience. Community capacity mitigates health consequences of social isolation; even isolated people do better in communities with greater capacity.[23],[24],[25] Minnesota’s efforts to build capacity for mental health promotion and prevention ties in with the Triple Aim of Health Equity, in that we are working to 1) expand understanding about what shapes mental health, 2) expand community capacity to create change (e.g., leadership development), and 3) focus on policy as key drivers of change.

Expanded Understanding

Expanding understanding about the breadth of strategies to promote mental health and well-being across all of the ecological domains – individual, family, organization, community, and society – is critical. In the last 20 years, research from multiple fields has expanded our understanding of mental health, including the impact of social conditions on mental health. Research on early childhood has demonstrated lifelong impact of early childhood environments on health and development. Adverse childhood experiences (ACEs) research connects family and community trauma with mental and physical health outcomes throughout the life course. Brain science explains the chemical mechanisms through which environments influence biology. Epigenetics further validates the dynamic relationship between our environment and genetics across generations and history.

Despite growing concerns about mental health, and increased evidence and understanding about the impact policies and systems have on our mental health, policy level strategies to promote mental health are not adequately reflected in our communities. There is also a need to expand public understanding about the individual and family strategies that can promote mental well-being. Public perception of mental health historically has largely focused on mental illness, individual responsibility and medication; whereas scientific evidence identifies a broad array of factors that influence mental health.[26] Because of these dual needs to support mental health in our communities, our Strategy Team identified strategies that aimed to address both sides -- increasing awareness of self-care strategies of the individual level and promoting policy changes to promote well-being at the community and societal level.

Nurturing Relationships and Social and Emotional Skills

Positive relationships are central to mental well-being. Social isolation is a greater risk factor for mortality than smoking, obesity, lack of exercise, and air pollution.[27] Relationships provide meaning, facilitate social/emotional skill development and contribute to feelings of belonging. Lack of positive relationships and isolation are detrimental to mental well-being. Positive relationships are not automatic; families and communities need information, resources, and other supports to help cultivate and sustain them.

Relationships shape youths’ skills, identity, hopes and other components of well-being. Statewide, data from the Minnesota Student Survey shows that 92% of youth report at least one caring adult in their life. Youth with a caring family member are the least likely have to poor health outcomes and engage in risky behaviors. For example, youth were 8 times less likely to have suicidal attempts or thoughts in the past year when they have at least one caring family member.

Everyone needs opportunity to learn and practice skills to manage life and engage in the world. Skills to manage stress, find balance and focus, and engage socially are critical components that should be cultivated throughout the lifespan in both formal and informal settings. Skills and experiences that help people feel valuable and engaged in their family, community and economy are also critical.

Five-Year Strategies and Activities Moving Forward

The Mental Well-being Strategy Team identified three strategies and a number of supporting activities to build capacity in promoting mental well-being across the population at the state and local levels. Selected strategies are based on these recommendations and include those activities that also align with other state plans, such as the Children’s Cabinet and MDH strategic plan. A logic model has been developed to visualize our planned work and intended results (see Figure 2). The discussion below includes Minnesota’s overview of the initial strategies that will be implemented in FY2021.

Figure 2. Minnesota Mental Well-Being Logic Model

Strategy A. Help Communities Build Capacity and Resilience

This first strategy builds the understanding that local communities have the power to shape mental well-being across socio-ecological domains and across the lifespan, but need the capacity to address these needs. This includes information and resources, and support from the state where needed. As communities in Minnesota continue to learn about trauma and resilience, this strategy is about developing shared knowledge across communities and resources for communities to improve mental well-being. In addition, this will help establish effective support roles for state institutions in community resilience work.

Partner with Key Stakeholders to Develop Shared Objectives and Establish the Minnesota Community Learning Resilience Cohort

MDH will leverage existing partnerships between the University of Minnesota Extension, MDH partners (Statewide Health Improvement Partnership (SHIP), Injury and Violence Prevention, and Public Health Practice), and a statewide non-profit organization, called Family Wise, to establish a community resilience learning cohort (CRLC). The CRLC will identify and recruit geographically and demographically-diverse communities, including Tribal Nations, invested in ACEs and community resilience work. The partners will conduct an assessment of established community based strategies for primary prevention and leverage opportunities for new evidence-based strategies to be utilized in community. Together, the CRLC will learn about the community resilience efforts in each community to date, develop a shared narrative for community resilience and well-being, and identify specific opportunities for MDH and the University of Minnesota Extension to effectively partner with local communities to support community resilience.

Develop an Outreach Plan for the Existing MN Thrives Tool

MN Thrives is an online platform for community leaders to share information about projects and initiatives aimed at promoting mental health and well-being. A small team of leaders from the Minnesota Mental Well-being and Resilience Learning Community will outline an outreach plan to promote utilization of the MN Thrives tool. The purpose of this tool is to support statewide networking and assessment of community resources, which will build community capacity to identify their local strengths and gaps. MN Thrives tool will also serve as a resource to develop a community assessment tool to identify types of resources communities have. In addition, as communities implement the assessment process, MDH will prompt communities to add their community assets to the MN Thrives, to serve as a living online inventory. MDH Injury and Violence Prevention will guide the assessment process in partnership with the above noted CRLC.

Train Key Stakeholders on Several Community-Based Programs to Build Support for Expanding these Models Statewide

The Mental Well-Being Strategy Team identified need for community resources and community building opportunities. The Mental Well-being and Resilience Learning Community has highlighted different examples of community strategies in Minnesota to promote mental well-being each month since 2017 (e.g., Family Wellness Recovery Action Planning, and Living Life to the Full). Though several programs have garnered significant community interest, local leaders have identified a need for additional training and financial support to make these available and sustainable. With increased awareness of the models among key leaders, we can better identify opportunities to incorporate these into existing grants or programs.

Strategy B. Implement a Public Health Communications Campaign on Mental Well-Being across the Life Span

This strategy is aimed at increasing awareness of key factors and strategies to promote mental well-being in order to influence individual and family behavior, as well as build public support for mental health promotion activities. Expanded awareness about mental well-being, and a public health approach to mental well-being, is important for local leaders as well as the general public.

Expand Understanding of Key Research and Current Strategies to Support Social Connectedness and Other Factors that Influence Mental Well-Being

We want to build on and expand understanding about the value of social connectedness for mental well-being, along with key strategies for individuals, families, organizations and communities. This information is particularly relevant in the new environment that has resulted from the COVID-19 pandemic. During FY2021, MDH staff will develop research to practice briefs on social connectedness and other selected strategies to promote mental well-being, highlighting examples of community-based strategies. A communications plan will be developed and implemented for each brief. We intend to use examples of community based strategies submitted in the MN Thrives tool and in the Mental Well-being and Resilience Learning Community.

Partner with the Preschool Development Grant Staff on Shaping the Trauma-Informed Toolkit and Training Modules

The COVID-19 pandemic has accelerated the need to ensure that people have information about trauma and how to address it at every level. The PDG trauma-informed toolkit project will be an online resource and a set of training modules for early childhood providers and parents. MDH will contribute to the PDG planning efforts and help to ensure that mental well-being practices and tools are included, such as information and resources about: social connectedness, mindfulness and nature. The current plan is to link this content to the PDG community hubs (described in more detail in the Child Health 2021 Application Plan). MDH staff will use this to content to support holistic approach to the community hub services.

Identify Opportunities to Develop and Implement More Formal Marketing Campaign(s) on Mental Well-Being, Trauma, and Resilience

Professional anti-stigma campaigns have been effective at raising awareness about mental illness, and on how to start conversations about mental health in order to encourage help seeking behaviors. A Minnesota example is the Make-It-Ok campaign, which includes individual personal stories and videos designed to reach a variety of audiences from different ages and cultural communities. Some counties and local organizations have developed tools to promote evidence based positive psychology tools. During the department’s response to the COVID-19 pandemic, the MDH Behavioral Emergency Preparedness unit partnered with Twin Cities Public Television to develop a short series of videos about mental health resources for different communities. MDH also has been working on a project to develop a series of short videos about how people are promoting their mental well-being. While these are valuable, a coordinated plan and assessment of effective messaging about mental well-being, trauma and resilience would be valuable – especially for establishing a baseline regarding current level and scope of public understanding across different communities. To build toward a comprehensive plan, MDH staff will take the following actions:

• Explore opportunities with PDG staff and pending advisory council for the trauma-informed toolkit, to develop a communications plan that identifies effective messages and modalities to share information about trauma and resilience with the general public and early childhood providers. For example, questions continue to arise about: the best ways to communicate with parents about trauma, what information might be triggering, and what strategies are most helpful for parents of young children.
• Develop a plan with local thought leaders and researchers on a campaign around healthy relationships with technology for different populations across the lifespan.
• Partner with cultural and faith community liaisons and grantees working on COVID-19 response work to complete and promote videos about mental well-being strategies during the pandemic.

Strategy C. Advocate for Legislative Policies that Promote Mental Well-Being for Everyone

This strategy builds on the understanding that policies at every level share the conditions for mental well-being, and are essential for population change. The aim is to build state and community capacity to identify, prioritize, and implement policies that promote mental well-being.

Partner with the MDH State Health Improvement Partnership, Minnesota Public Health Law Network, and MDH Healthy Minnesota Partnership to Identify Legislative Priorities to Support Well-Being

During FY2021, MDH staff will help partners assess the state landscape for mental well-being related policy initiatives and stakeholders, related research and reports that support proposed policies, and share local policy initiatives as identified.

MDH will also utilize the Minnesota Mental Well-being and Resilience Learning Community to identify examples of relevant policies, inviting presenters to provide relevant policy examples that support their work and proposals with the learning community and MDH partners (e.g., Live More Screen Less policy proposals related to technology use in schools).

Finally, MDH will contribute to the pending Trust for Public Land and Child and Nature Network- Green Schoolyard Advisory Committee, in partnership with the Minnesota SHIP, DNR, and MDE, to inform strategies to support local action.

Include Public Health-Focused Recommendations in the 2021 State Mental Health Advisory Council Report

During FY2021, MDH staff will convene others members of the State Mental Health Advisory Council’s Family Prevention and Promotion sub-committee to identify priority proposals for the annual council report. This report goes to the Governor and Legislature and contributes to building support for identified policies.

Partner with the Statewide Health Improvement Partnership (SHIP) in Identifying Policies and Practices that Promote Mental Well-Being across the Population

SHIP is an initiative that supports every county in the state to improve health through a policy, systems, and environmental approach. SHIP supports community-driven solutions to expand opportunities for active living, healthy eating and commercial tobacco-free living, helping all people in Minnesota prevent chronic diseases including cancer, heart disease, stroke and type 2 diabetes. Over the next several years, SHIP will be incorporating community resilience and well-being into the portfolio of strategies that communities can advance. Staff from the CFH Division will participate in the SHIP Advisory Committee and planning process. MDH staff will continue to refine policy examples for this process. In addition, MDH will partner with the University of Minnesota extension and SHIP to explore application of a recently completed ecological model for mental health to the policy discussion for community well-being.

State Performance Measure and Five-Year Objective

Minnesota has chosen to focus on the percentage of adolescents who have positive mental well-being as a State Performance Measure for the next five year cycle beginning with FY2021.

With so many factors that make-up mental well-being it is difficult to succinctly answer questions about population mental well-being with existing data. There are multiple composite measures of mental well-being proposed in the research and many commonly agreed upon components of mental well-being.[28] Ten components of mental well-being are captured in the Minnesota Student Survey: positive identity, social competency, personal growth, empowerment, social integration, educational engagement, and positive family, community, teacher and peer relationships. Positive mental well-being is measured by combining multiple components of well-being to create an overall well-being score. We are choosing this measure because of how richly it captures the multi-factorial nature of mental well-being.

Figure 3 shows the percentage of Minnesota 8th, 9th, and 11th grade students who report experiencing each mental well-being component. These data capture Minnesota youth experiences, which are shaped by the opportunities and resources in their community. This offers some tangible ways to think about mental well-being and can point to opportunities to improve mental well-being by ensuring the environment supports these skills and experiences for all youth. By 2025, Minnesota aims to increase the percentage of adolescents who report positive mental well-being by 5%.

Figure 3. Percentage of Minnesota Youth reporting Mental Well-Being Components, 2019

Parent and Caregiver Support

A major factor in a parent/caregiver’s ability to provide a safe and healthy home for their children is having needed resources and supports available to them. It is particularly important for parents to get support when they feel overwhelmed or stressed. According to the Zero to Three National Parent Survey, almost half (48%) of parents of young children don’t feel they are getting the support they need when they feel stressed – with moms being more likely to say they have inadequate support than dads (57% vs. 39%).[29]

“The fact that fully half of parents say they aren’t getting the support they need presents a risk and an opportunity. We know from decades of research that, especially during times of stress, the more parents feel supported the better able they are to provide a caring and healthy environment for their children, who then fare better on a variety of academic and social well-being measures into the long-term.”45

Because many families have reported needing more social and emotional support in parenting, this was identified as a cross-cutting priority need for our next five-year block grant cycle.

Across the nation and the state, there are likely many reasons why parents and caregivers feel they receive inadequate support in parenting. Partners participating in the Strategy Team related to this priority area reported some of the following contributors to the problem:

• Many parents/caregivers report feeling isolated because they do not have a support system (formal or informal) built around themselves.
• Employers do not provide the wages, flexibility, or paid leave needed to support parents/caregivers.
• There is a lack of resources available to parents from diverse geographic or cultural/racial backgrounds related to parenting support and education.
• There is a societal-level stigma against asking for help that prevents parent/caregivers from seeking support or resources – this stigma is particularly pertains to seeking emotional/mental health support, and is especially prevalent in certain racial/ethnic groups. For instance, the 2017-2018 National Survey of Children’s Health (NSCH) found that 83.7% of all children have parents who have received emotional help with parenthood. Emotional help received is significantly higher for children who are non-Hispanic white (90.6%) compared with non-Hispanic Asian (69.9%), Hispanic (69.9%), and non-Hispanic Black children (52.6%) (see Figure 1).

Figure 1. Children with Parents who have Emotional Help with Parenthood, by Race

Parents and caregivers of children and youth with special health needs (CYSHN) are especially impacted by having inadequate support. They report spending a number of hours having to coordinate their child’s health care, subsequently then also reporting that they are more likely to have had to quit or change their jobs. Parents of CYSHN are also less likely to have someone they can turn to for day-to-day emotional support even though they express higher levels of stress (aggravation) in parenthood.

The COVID-19 pandemic has magnified many of the issues parents and caregivers face around receiving inadequate support. Many have lost their jobs or have been furloughed due to the closure of businesses, adding significant financial stressors to their plate. Others have had to significantly cut hours or quit their jobs in order to care for their children on a day-to-day basis. In addition to the multiple roles they filled before the pandemic, many parents/caregivers have had to take on the role of at-home educator or child care provider. Many formal and informal supports that families had in place before the pandemic were no longer accessible in the new era of physical distancing – leading to even greater feelings of isolation among parents and caregivers. For parents and caregivers of CYSHN, the pandemic has only magnified the lack of support and isolation that many were feeling.

Parents need a network of supportive relationships, strategies for coping with stress, resources, knowledge, and an understanding of child development. Unfortunately, a lack of these critical supports can cause otherwise well-intentioned parents to become overwhelmed and at times result in abuse or neglect. Parents and caregivers who have resources and support are more likely to provide safe and healthy homes for their children and families and reduce the need for out of home placement following confirmed instances of abuse of neglect. [30]

Five-Year Strategies and Activities Moving Forward

A Strategy Team was assembled to identify a set of strategies for the Minnesota Title V program to help ensure parents and caregivers receive needed supports. A logic model has been developed to visualize our planned work and intended results (see Figure 2). A larger version of the logic model is included with the supporting documents for this application. This logic model, along with the five-year action plan table, provide a broad picture of Minnesota’s strategies aimed at improving parent and caregiver support. The discussion below includes Minnesota’s plans for implementing the strategies during FY2021 specifically.

Figure 2. Minnesota Parent and Caregiver Support Logic Model

Strategy A. Advocate for the Redesign of a Network of Policies and Programs to Better Support Families

The first strategy aims to work toward redesigning policies and programs at the state level so that the system is set up in a manner where families are better able to receive needed support. This includes promoting family home visiting services as a part of a comprehensive early childhood system, and advocating for policies that support the well-being of parents and caregivers beyond the early childhood stage.

Coordinate between Title V and FHV Initiatives to Serve More Families through FHV

A major activity aimed at helping promote a comprehensive system that supports families is Family Home Visiting (FHV).

“Home visiting has been demonstrated to be an effective method of supporting families, particularly as part of a comprehensive and coordinated system of high-quality, affordable early care and education, health and mental health, and family support services for families of children from the prenatal through the pre-kindergarten stages.”[31]

FHV helps ensure pregnant women receive adequate prenatal care, learn about healthy development in utero, in infancy, and beyond, and promotes responsive relationships. Then, as children and families develop, FHV helps ensure families with young children receive individualized social, emotional, health-related, and parenting supports, and are connected with community resources that help stabilize and empower families.

Within MDH, the FHV Section primarily administers FHV services by providing systems-level supports and oversight to grantees and local implementing agencies – including local public health (LPH) agencies, tribal governments, and non-profit organizations. State and federal grants fund traditional and evidence-based home visiting (EBHV) services across Minnesota, including the federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program. In addition to the state and federal funding described above that specifically is allocated for home visiting, LPH agencies also use portions of their Title V funding to support FHV services.

A major goal of Minnesota’s next five-year block grant cycle is to better coordinate between the MDH Title V program and FHV Section to ensure we are reaching the most at-risk families with home visiting services.

This goal directly aligns with the goals of Minnesota’s MIECHV program grant, which are to:

• Strengthen and improve the state’s infrastructure, activities, and programs carried out under Title V;
• Improve coordination of services for at-risk communities; and
• Identify and provide comprehensive home visiting services to improve outcomes for eligible families who reside in at-risk communities and continually monitor service delivery.

We have already begun to strengthen this partnership through the work we have done to combine and coordinate our Title V and MIECHV needs assessments and through the involvement of FHV Section leadership and staff in our strategy development work. Moving forward into FY2021 specifically, we plan to begin work around the following activities:

• Understanding home visiting services provided via Title V funding. Based on their annual work plans and reporting, we know that LPH agencies use some Title V funding to support home visiting services. However, we would like to develop a more formal understanding of the number of families served and types of visits provided, and will partner with the FHV Section to explore this further.
• Improving coordination of services for at-risk communities. We intend to participate in interagency and cross-divisional conversations to provide consultation to and collaboration with early childhood system stakeholders. This includes promoting FHV in interagency initiatives, such as the Preschool Development Grant and Help Me Connect (discussed in the Child Health Domain), and having discussions on how to collaborate across programs within MDH that serve young children (i.e., WIC, the Follow-Along Program, Positive Alternatives, and CYSHN Long-Term Follow-Up).
• Assessing whether we are reaching at-risk families who would benefit the most from home visiting services. Through our interagency and cross-divisional work, we will build the partnerships needed to better ensure we are reaching the most families possible. This means ensuring that FHV is available in all regions of the state, and that programs are enrolling appropriate numbers of families (including appropriate numbers of families from diverse racial/cultural groups).

Advocate for Policies that Promote and Support the Well-Being of Parents/Caregivers

MDH will also convene partners and work with them to advocate for policies that promote and support the well-being of families. This approach will be developed over the course of this five-year block grant cycle, and will start with the following activities during FY2021:

• Identify and participate in statewide working groups, councils, or committees that aim to improve support for parents and caregivers.
• Build a better understanding of the landscape around issues that impact the well-being of parents and caregivers (and therefore families), including student loan forgiveness, work flexibility, living wages, and paid parental leave.
• Create and distribute infographics/reports on the above topics so they can be used by our partners when advocating for change.

Strategy B. Build Capacity of Public Health Professionals and Family Home Visitors to Help Improve Mental Health, Well-Being, and Resilience of Families

Public health professionals and family home visitors play a vital role in improving the health and well-being of families. During the next five years, Minnesota intends to build capacity of public health professionals and family home visitors to help improve the mental health, well-being, and resilience of families. Since two-thirds of the block grant funding goes to LPH agencies, we intend to first focus on LPH staff who are providing services to families through family home visiting, CYSHN follow-up, and other family serving initiatives.

Provide Training and Support the Implementation of Best Practices amongst Public Health Professionals and Family Home Visitors

The main activity aimed at building capacity of public health professionals is providing training and supporting the implementation of best practices. By building capacity, we mean that we not only plan to provide trainings to LPH agencies but also will provide the needed technical assistance and other support to help ensure they are implementing the best practices – using a continuous quality improvement approach. We will focus on the following topic areas: trauma-informed care, Reflective Practice, intimate partner violence, depression, opioid drug use, and adverse childhood experiences (ACES). In order to most effectively support the implementation of best practices, MDH will partner with the Minnesota Departments of Education and Human Services in developing the trainings and resources. Many of these trainings are already being provided to LPH professionals, so we will work across the Division to better partner with one another in providing trainings and capacity building for LPH.

Strategy C. Build Supports for Multi-Faceted Ways for Parents/Caregivers to Connect with One Another

With our third strategy, Minnesota aims to develop innovative ways that parents and caregivers can connect with each other, addressing the social isolation that families can feel if they do not have adequate supports in place. This strategy has especially become relevant during the COVID-19 pandemic since typical in-person support options are no longer available or safe.

Maximizing Technology to Increase Options for Families to Communicate with One Another

Encompassing over 86,000 square miles, Minnesota is the 12th largest state based upon total geographic area. Even before the physical distancing limitations posed by the COVID-19 pandemic, Minnesota’s sheer size meant that sometimes families would need to travel great distances to be able to connect in-person with others. The pandemic has only exacerbated this issue, making it even more important for us to find new ways for families to connect with one another – such as via technology. As discussed in the CYSHN domain, MDH has partnered with the Minnesota Department of Human Services to fund grants for family-led organizations to offer peer-to-peer opportunities for families. A major component of this grant program is encouraging organizations to pursue or develop electronic or other innovative ways to connect families with one another in physically distant ways. These grants are projected to start in September 2020.

Connecting Families to Family-to-Family Support

Family-to-family support is a vital part of a comprehensive system of care. Though discussed in detail in the CYSHN domain, family support branches beyond that provided to parents and caregivers of CYSHN. There are many different opportunities for parents to connection to family support – such as through the education, child welfare, mental health, and other family-serving systems. In Minnesota, family-to-family support is provided by Head Start, Early Childhood Family Education, the University of Minnesota’s Extension Offices, Family Wise, mental health providers, and many other community-based organizations. During FY2021 and in upcoming years, MDH will work to develop a better understanding of the different organizations providing family-to-family support, will ensure information about these resources is included in centralized resources (such as Help Me Connect), and will work with LPH agencies, tribal nations and non-profit agencies doing family home visiting, to connect more families to appropriate options for family support.

State Performance Measure and Five-Year Objective

Minnesota has chosen to focus on the percentage of children with parents who report being able to cope with the demands of parenthood as a State Performance Measure for the next five year cycle beginning with FY2021. When parents and caregivers receive adequate support, they are more likely to be able to cope with the day-to-day demands of parenthood and build a safe and healthy home environment for their family.

According to the 2017-2018 NSCH, only 65.2% of children in Minnesota are living with parents who report they are coping with the day-to-day demands of parenting very well. By 2025, Minnesota aims to increase the percentage of children with parents who are coping very well with the demands of parenthood by 5% (i.e., approximately 68.5% of children will live with parents who are coping very well by 2025).

Disparities exist in parent coping levels based on the certain characteristics of the child. For instance, children and youth who have special health needs; those with emotional, behavioral, or developmental (EBD) problems; and those who are non-Hispanic Asian are less likely to have parents report they are coping with demands of parenting very well (see Figure 3). Because the NSCH works off of a small sample size, some of these differences should be interpreted with caution. Minnesota intends to continue to explore disparities related to this SPM in the future as more data becomes available.

Figure 3. Children with Parents Who Are Coping Very Well with Demands of Parenthood

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