Section III.E.2.c State Action Plan Narrative by Domain

MCH Population Domain: Cross-Cutting/Systems Building Application Year

North Dakota State Performance Priority: Vision Zero – Eliminate Fatalities and Serious Injuries Caused by Motor Vehicle Crashes – 2024 Annual Plan Narrative (October 1, 2023– September 30, 2024):

Motor vehicle crashes continue to be a leading cause of injury and death to North Dakota children. One of the most effective preventable actions one can take to decrease injury and death in a motor vehicle crash is to utilize a correct occupant restraint. Car seats decrease the risk of a fatal injury by 71% among infants and 54% among toddlers.  Booster seats reduce the risk of nonfatal injuries by 45% among four-to-eight-year-old children when compared to the seat belt alone. The North Dakota Department of Health and Human Services (NDDHHS) and the North Dakota Department of Transportation (NDDOT) recognize the impact that motor vehicle crashes have on North Dakota children, and they continue to prioritize efforts to eliminate them from occurring in the future. Both agencies along with the North Dakota Highway Patrol are working together to reach the goal of the Vision Zero plan. Vision Zero is a strategy to eliminate motor vehicle crash fatalities and serious injuries. For more information about Vision Zero, visit: https://visionzero.nd.gov/.

According to the NDDOT, 3.48 per 100,000 of North Dakota children less than 18 years of age died and 259 per 100,000 (a decrease) were injured due to vehicle crashes within the years of 2018-2022. Of those injured, the injury severities were categorized by law enforcement crash reports as:

• suspected serious injury at 17 per 100,000 population (17.3 in 2021);
• suspected minor injury at 130 per 100,000 population (126.1 in 2021); and
• possible injury at 112 per 100,000 population (125 in 2021).

Breaking the data down by age group for the years 2018-2022, children 0-13 had a death rate of 1.4 per 100,000 (1.5 in 2021) and injury rate of 106 per 100,000 (113 in 2021) compared to those in an older age group (14-17 years) with a fatality rate of 2 per 100,000 (2 in 2021) and injury rate of 153 per 100,000 (155 in 2021).

For child restraints to be effective during a crash, they must be used correctly according to the manufacturer’s instructions. Based on the 2022 fiscal year NDDHHS car seat checkup data collection through the National Digital Check Form dashboard, 65% of the car seats (2,082 applicable) inspected had at least one form of misuse associated with it.  

The strategy for this priority state measure will be to incorporate the E's of the Injury Prevention Model into the development of the activities for this action plan. The E's include Enforcement, Education, Engineering, and Emergency. 

First, to address law enforcement activities, program staff will continue communication with law enforcement agencies about child passenger safety (CPS) resources through the online CPS Resource Order Form and CPS Resource Maps. Enforcement of the CPS law is an effective evidence-based activity when it is combined with the E’s in the Injury Prevention Model (and is the most effective of all the E’s). In addition to enforcing the North Dakota CPS law, it is also important for law enforcement personnel to understand CPS best practices. Therefore, another goal will be to certify at least 10 law enforcement personnel through the National CPS Technician Certification Course. This was a recommendation that came from the National Highway Traffic Safety Administration Assessment, which was completed in collaboration with the NDDOT. As part of education and enforcement, CPS trainings are incorporated into the law enforcement academies offered in North Dakota. This training will be taught in academies in Bismarck, Devils Lake, Grand Forks and Fargo utilizing contracted partners.

Next, providing education to the public through car seat checkups is a proven evidence based educational activity which will continue to be offered to the public. Another goal for this time period is to increase car seat checkups throughout the state, especially in the west and central regions. To increase attendance at the checkups, the program will continue to promote the use of the NDDHHS CPS website (https://www.hhs.nd.gov/child-passenger-safety/assistance) that allows users to find car seat checkups, car seat classes, and car seat distribution programs. This resource will be heavily promoted through social media, and by various stakeholders throughout the year. Car seat checkups will be scheduled across the state with plans to further build infrastructure to continue offering this service. Funding from the NDDOT and the Maternal and Child Health (MCH) Block Grant will allow staff to contract with agencies to conduct regional car seat checkups and CPS outreach. Those coordinating the checkups and outreach will offer hands-on education to the public as well as mentorship/recertification activities for local Certified CPS Technicians. The goal is to increase the number of car seat checkup events offered by the NDDHHS for North Dakotans from 69 to 100 (5-year average) and to increase the number of car seats checked statewide from 747 to 772 (5-year average). Program staff will work to bring awareness to and promote the checkups to increase the attendance at these public events.

To increase education and awareness, staff will utilize media campaign materials created in 2022 for a social media and radio campaign focusing on booster seat use. According to the National Highway Traffic Safety Administration data, in 2019, about 16% of children ages 4 to 7 were prematurely moved to seat belts, when they should have been riding in booster seats. The program will work with the NDDOT and Odney Advertising to run this campaign during National CPS Week in September.

The CPS program is responsible for coordinating National CPS Technician Certification trainings in North Dakota. Those that become certified by attending this training become certified CPS Technicians. It is important to maintain or increase the number of instructors who are able to teach the training in North Dakota to be able to offer the trainings throughout the state.  In addition to increasing instructors, the program will work to increase the number of CPS proxies in the state. Both CPS instructors and proxies are utilized to mentor and recertify existing CPS Technicians. North Dakota currently has approximately 271 certified CPS Technicians in the state, 17 instructors, and 13 proxies. Furthermore, North Dakota currently has 51 CPS Technicians working within the 13 birthing hospitals. Of this group of CPS Technicians, 21 have completed the Safe Travel for All Children: CPS Special Needs training (STAC). STAC is a training that teaches CPS Technicians about medical conditions and how to investigate and install specialized restraint systems. It is advantageous for hospital staff to have this training for when a child is born in their hospital with special needs, they can give families hands-on resources and assist them if a seat other than a conventional seat is needed. The program would like to increase the population of STAC trained CPS Technicians in each hospital and create a quality communication system with the staff.  In addition to activities listed above, the program will encourage more hospitals to offer the CPS training “Babies First Ride” to expectant parents in their communities.  Currently six of the thirteen hospitals do not offer CPS instruction such as “Baby’s First Ride” to caregivers.

The CPS on School Buses National Training has never been taught in North Dakota.  This training provides an overview of the use of child safety restraint systems on school buses with a focus on preschool-aged children and children with disabilities. It is in the plans to start offering this training to both CPS Technicians and non-CPS Technicians through two different trainings. North Dakota now has a few CPS Technicians who are trained to teach this course, so courses will start to be offered in the state at least once a year starting in 2023.

Next, to enhance engineering (child restraints), Car Seat Distribution programs will be created and maintained throughout the state. Evidence-based distribution programs will be made available to low-income families who either do not have access to or cannot afford car seats. Car Seat Distribution Programs are typically coordinated out of public health units.  All programs will maintain a Certified CPS Technician on staff that will attend an orientation program to follow the program’s policy and procedure manual. Currently, three of the four tribal communities in North Dakota have an active program. The program will work to increase the number of tribal programs to four and assist them with keeping staff certified. Car seats will be distributed to programs a minimum of two times a year. The NDDOT will provide funding to purchase the car seats.  

Lastly, the emergency component of the plan will be addressed by formalizing a relationship with NDDHHS Emergency Medical Services for Children (EMSC) staff. The plan is to certify EMSC personnel through the National CPS Technician Certification Course to create a resource individual to better address emergency transportation for children during ambulance transport in North Dakota. Once this position is certified, the goal is to create trainings for in-services and conferences, so that North Dakota EMS personnel become more confident in transporting children safely in their emergency vehicles. If for some reason, EMSC is not able to secure this position, other options will be explored to find someone who can.

North Dakota State Performance Priority: MCH Workforce Development– 2024 Annual Plan Narrative (October 1, 2023– September 30, 2024):

A well-trained maternal and child health (MCH) workforce is the first line of defense to prevent disease, protect health and keep the MCH population safe. State Title V staff are able to avail themselves of various professional development opportunities in order to build their capacity as part of the MCH workforce. State staff have many strengths including passion, dedication, and knowledge to ensure families receive high quality services; strong interpersonal abilities required for partnership building, collaboration, and integration; and the capability to manage multiple priorities. To address specific training needs, state Title V staff develop career aspiration and professional development goals that identify training opportunities to enhance needed knowledge and skills as part of their annual performance review process.

In December 2019, Title V staff completed the MCH Navigator on-line self-assessment. This self-assessment provides an opportunity for professionals to reflect on competency-based strengths and areas to grow in order to identify learning needs and reinforce new skills to improve performance. A North Dakota Workforce Snapshot was provided by MCH Navigator that supplied information regarding North Dakota’s MCH workforce composition and learning needs. In line with national data trends, North Dakota MCH staff had cultural competency as the largest gap in knowledge and skills, along with family-professional partnerships. Also consistent with national data trends, policy had the lowest knowledge and skills scores across competencies.

In May 2021, a proposal was received to initiate a formal Academic Health Department partnership between the North Dakota Department of Health’s (NDDoH) MCH program and the NDSU DPH to enhance the knowledge and skills of the current MCH workforce, build workforce capacity, and facilitate collaboration across the academic and practice communities. This partnership provided much needed support to address NDDoH – and statewide – MCH leadership’s key concerns regarding the low percentage of MCH staff with formal public health training, low levels of preparedness to meet local and state MCH needs, limited access to expertise for quality community-based or applied public health research, and the need for MCH innovation among public health professionals in academic and practice environments. To effectively build MCH workforce and innovation capacity in North Dakota, NDSU DPH required two (2) formally trained MCH faculty with research expertise. By August 2022, these faculty had successfully developed and implemented an eight credit MCH Certification Program. Credits from this MCH Certification Program can be applied to an MPH degree. NDSU DPH will additionally commit a dedicated percentage of time supporting the data analysis and research needs of North Dakota’s MCH programs.

The North Dakota Department of Health and Human Services (NDDHHS) has a tuition reimbursement policy that may pay up to 80 percent of tuition and fees depending upon budget. The college course must be directly job related and have a stated public health purpose or benefit. This policy makes it more attainable for staff to consider enrolling in the program and advancing their learning and education. In addition to supporting state MCH staff to enroll into the MCH Certificate Program, the program is being widely announced and promoted statewide.

Regular meetings with NDSU have continued throughout the year. Staff are working diligently to complete the MCH curriculum, and courses for the new MCH Certificate program will be offered in Fall of 2023. NDSU personnel have also discussed the possibility of offering additional training opportunities (e.g., webinars, books clubs, etc.) for Title V staff who may have been hesitant about registering for a full college-level course.

In addition to the above described professional develop, state MCH staff will also be encouraged to identify and pursue state and national trainings or opportunities individualized for their programmatic expertise or areas of interest. By providing high-quality education and training, North Dakota will continue to expand and strengthen a diverse, MCH-informed workforce that understands the unique challenges that North Dakota women, infants, children, children with special health care needs and families face.

North Dakota State Performance Priority: Implement all North Dakota State Mandates for the Maternal Child Health Population– 2024 Annual Plan Narrative (October 1, 2023– September 30, 2024):

Priorities are often influenced by state mandates, which in turn, are generally reflective of expressed need within the state over time. Inclusion of these mandates epitomizes the successful federal/state partnership by honoring a state’s unique priorities. North Dakota has several mandates addressing the health of the maternal and child health (MCH) population that direct Title V work efforts and require use of significant resources for successful implementation. A list of mandates can be found in Section V., Supporting Documents, Title V-MCH State Mandates and are discussed below.

Responsibilities of the North Dakota Department of Health and Human Services (NDDHHS) are addressed in North Dakota Century Code (N.D.C.C.), Chapter 23-01. The State Health Officer (SHO) of the NDDHHS is responsible for the administration of programs carried out with allotments made to the state by Title V. The NDDHHS functions in compliance with Chapter 28-32, Administrative Agencies Practice Act, N.D.C.C. Programs funded by the federal-state Title V MCH Block Grant include: Children with Special Health Care Needs (CSHCN), child/teen passenger safety, injury/violence prevention, newborn screening, MCH epidemiology, obesity prevention, nutrition, breastfeeding, school health/nursing and infant and child death services (sudden infant death syndrome).

Several mandates in N.D.C.C. address Title V CSHCN-related responsibilities within the NDDHHS. Chapter 23-01-34 includes program administration for CSHCN, including the provision of services and assistance to CSHCN and their families and the development and operation of clinics for the identification, screening, referral, and treatment of CSHCN. Chapter 23-01-41 requires the establishment and administration of an autism spectrum disorder database. Chapter 23-41 mandates administrative duties of state and county agencies, confidential birth reports for newborns with visible congenital deformities, and services for individuals with Russell Silver Syndrome. Chapter 25-17-03 mandates treatment for individuals with phenylketonuria or maple syrup urine disease through the provision of medical food and low-protein modified food products.

Additional N.D.C.C. mandates distribution of materials relating to umbilical cord blood disposition and donation, and the development and distribution of materials as required in the Abortion Control Act (i.e., information about pregnancy and abortion, pregnancy support, adoption services). These mandates have been assigned to Title V staff.

To meet the requirements of N.D.C.C. Chapter 14-02.1, Abortion Control Act, Section 14-02.1-02.1, Printed Information – Referral Service, the NDDHHS developed and published an Information About Pregnancy and Abortion booklet. This publication consists of objective information on specific topics to include: information and resources on various agencies and services available to assist a pregnant woman through pregnancy (provided through an on-line directory of services); anatomical information along with colored photos of development of the unborn child at two-week gestational increments; information regarding the obligations of the father; and materials that describe various surgical and drug-induced methods of abortion as well as any risk factors associated with those methods. In addition to the required information, content was also added on the harmful efforts of tobacco use during and after pregnancy. As of August 1, 2020, the Title V MCH Grant executed a contract with FirstLink 2-1-1 to update and house the online directory of services. FirstLink 2-1-1 is a free, confidential service available to anyone 24/7/365 for listening and support, referrals to resources/help, and crisis intervention and houses a statewide Community Resource Directory. The booklet will continue to be updated on as needed basis to ensure that information is accurate, up-to-date, and evidence-based. The booklet, updated in May 2022, is available online at https://www.hhs.nd.gov/sites/www/files/documents/DOH%20Legacy/Information_About_Pregnancy_and_Abortion.pdf. Hard copy booklets are available upon request.

The NDDHHS will continue to implement a public awareness campaign to provide information, public service announcements, and educational materials regarding the state’s Safe Haven Law to the public, including medical providers, law enforcement, and social service agencies as outlined in N.D.C.C. 50-25. 1-15. This state law allows a parent or a parent’s agent (another person acting with the parent’s consent) who feels they are unable to take care of their infant, to surrender the infant without facing prosecution for abandonment. To be protected by the Baby Safe Haven Law, the child must be unharmed, under one year of age, and surrendered to an on-duty staff person working for a Baby Safe Haven approved location. For more specific information on the North Dakota Baby Safe Haven Law please visit the resource page at https://www.hhs.nd.gov/cfs/safe-haven and the Baby Safe Haven Training at: https://babysafehaven.pcand.org/.

N.D.C.C. Chapter 23-45, Umbilical Cord Blood Disposition, Section 23-45-02. Umbilical cord blood - Information pamphlet – Distribution, requires the NDDHHS to prepare a pamphlet that includes information on medical processes involved in the collection of umbilical cord blood; any risks of cord blood collection for both mother and baby; the current and potential future uses for the collected cord blood; the cost of cord blood donation; and options for ownership and future use of the donated material. The pamphlet must be available on the NDDHHS website and be distributed upon request at no charge. The NDDHHS elected to use and disseminate the pamphlet from the Cord Blood Registry titled Parent’s Guide to Cord Blood Banking (https://parentsguidecordblood.org/sites/default/files/uploaded-files/pgcb_brochure_usa.pdf). This pamphlet is free to patients, hospitals and other entities that choose to utilize the information. The Title V grant supports the costs associated with these unfunded, state mandates and MCH staff members have been assigned responsibility for these activities.

N.D.C.C. Chapters 23-01-03.1 and 25-17 mandates the North Dakota Newborn Screening program (NDNSP). Newborn screening (NBS) is performed shortly after birth to identify newborns that may have a potentially life altering and/or life-threatening disorder that could cause serious illness, disability or death if not identified and treated early. Newborn screening has three parts, blood spot, hearing and heart screening. Blood spot and heart screening are included within this mandated section. Hearing screening is not mandated in North Dakota. The national Advisory Committee on Heritable Disorders in Newborn and Children (ACHDNC) provides recommendations to state newborn screening programs which disorders should be included on their state panel. The disorders included in the recommendations supported by ACHDNC are known as the Recommended Uniform Screening Panel (RUSP). Currently, North Dakota screens for 32 of the 37 core conditions that are included on the RUSP (blood spot, hearing and heart screening are included as core conditions). As new conditions are added to the RUSP, the North Dakota Newborn Screening Advisory Committee reviews them and determines the feasibility of adding them to the state screening panel. The feasibility of screening is dependent on several factors that may include the program’s readiness to: 1) approve the screening; 2) conduct laboratory screening; 3) conduct short and long-term follow-up; 4) provide information technology support; 5) access a medical specialist specific to the disorder; 6) educate providers and community; and 7) fully implement statewide newborn screening. The approving authority for the NDNSP to add a new disorder in North Dakota is the health council. In the next fiscal year, the NDNSP will work with the NBS Advisory Committee to review the five core conditions North Dakota is currently not screening for to address program readiness and feasibility.

The NDNSP is mandated to provide education and plans to continue providing annual in-person trainings to midwives, birthing facilities and various clinics throughout North Dakota. The NDNSP hosted virtual learning sessions with Project Extension for Community Healthcare Outcomes (ECHO) and will continue to seek innovative ways to engage partners and the families served via virtual platforms.  

The screening and follow-up of newborns is performed in collaboration with the University of Iowa State Hygienic Laboratory and the University of Iowa Hospitals and Clinics, as well as Special Health Services (SHS). Intermediate and long-term follow up after NBS continues to be addressed in SHS by:

• providing follow-up contacts, resource information and care coordination for children with abnormal newborn screening results.
• providing financial support for metabolic disorder clinics that result in coordinated disease management.
• providing no-cost or at-cost medical food and care coordination for newborns and individuals with phenylketonuria (PKU) and maple syrup urine disease (MSUD).
• providing diagnostic and treatment services for children birth to age 21 who meet medical and financial eligibility criteria. 

Along with the follow-up calls for babies with abnormal newborn screening results, SHS assists families with referrals for services, care coordination, and support. Information is provided regarding the SHS Financial Coverage Program as well as other state-wide resources (e.g., WIC, North Dakota Medicaid, Early Intervention) to assist the family in meeting their needs, and to provide them support and direction during a time that can be very stressful and overwhelming. After a diagnosis from blood spot screening is confirmed, the baby enters the long-term follow-up program until the age of six and the family is contacted on a quarterly basis for the first year of their child’s life and annually thereafter. This ongoing communication with the family helps to ensure the child remains healthy and the family has access to all the resources that they find valuable such as insurance, medication, transportation, and community supports.

On January 1, 2020, reporting for critical congenital heart disease (CCHD) was mandated and the NDNSP began doing long-term follow-up for patients of a reported CCHD diagnosis in the fall of 2022. Long-term follow-up will continue in the next fiscal year and collaboration will continue with pediatric cardiologists throughout the state to ensure the follow-up meets the needs of the families and the specialists.

The NDNSP works closely with the North Dakota Early Hearing, Detection and Intervention (EHDI) program which is based out of the North Dakota Center for Persons with Disabilities (NDCPD) at Minot State University. The NDCPD is the NDDHHS bona fide agent that applies for funding opportunities relating to EHDI. The NDNSP Director is the State EHDI Coordinator and is the liaison between the state and EHDI program. The NDNSP and EHDI programs provide education and trainings to birthing facilities and various clinics throughout the state. This collaboration benefits both programs, the families that are served and the health care professionals providing the services directly to families. This partnership will continue in the next fiscal year and both programs will seek opportunities to collaborate more closely on educational efforts for those served.

Financial eligibility for the SHS Financial Coverage Program is legislatively mandated at 185% of the federal poverty level. All current NBS conditions are approved medical conditions for SHS coverage. Title V supports staff to manage the NDNSP including a Program Director, Long-Term Follow-Up Coordinator, and administrative support. In addition, Title V funds support contracts for a Medical Director and metabolic disorder clinic. A portion of Title V funds and state funds will continue to support medical consultation and genetic counseling services for children with abnormal newborn screening results.  

Federally, the MCH Block Grant enables the state to address the following on behalf of CSHCN and their families:  1) to provide and promote family-centered, community-based, coordinated care (including care coordination services) for children with special health care needs and to facilitate the development of community-based systems of services for such children and their families, and 2) to provide rehabilitation services for blind and disabled individuals under the age of 16 receiving benefits under title XVI, to the extent medical assistance for such services is not provided under title XIX. Specifics regarding the SHS role in providing rehabilitation services is described below.

North Dakota is a 209(b) state, which means Supplemental Security Income (SSI) beneficiaries under 16 years of age are not automatically eligible for North Dakota Medicaid. If assets are an issue affecting North Dakota Medicaid eligibility, children eligible for SSI can be covered under the children and family coverage groups where asset testing is not required. The state CSHCN program pays for or provides rehabilitative services for eligible children that are served by Title V to the extent services are not provided by North Dakota Medicaid. State CSHCN program staff conduct outreach, information and referral activities targeted to the SSI population. On a monthly basis, Disability Determination Services provides referrals electronically to the state CSHCN program. In response, state CSHCN staff provide a direct mailing to families notifying them about potential programs that could be of assistance. This assures that children are consistently being referred to the Title V program and that families receive information about program benefits and needed services.

The Title V and CSHCN Directors assure compliance for these state mandates and oversee staff assigned to carry out the roles and responsibilities related to the mandates. Title V staff share program accomplishments and challenges at bi-monthly Title V meetings. These meetings serve as an avenue for program updates, sharing and collaboration.