Cross-Cutting and Systems-Building
Plan for the application year: Oct 2024 - Sept 2025
Three priority needs are addressed in the Cross-Cutting and Systems-Building domain because they apply across all population domains. The first two priorities, related to emergencies and disasters, and the public health response to the impacts of adverse childhood experiences (ACEs) and trauma, were added pursuant to the 2020 needs assessment process. An additional priority related to health equity was identified and added in 2021.
The COVID-19 pandemic spotlighted the unique impacts of public health emergencies on Alaskan MCH populations. Since 2018, Alaskan communities have experienced fires, a major earthquake, flooding, infant formula shortage, and the acute and lasting impacts of the COVID-19 pandemic. There have been outbreaks of diseases such as syphilis and human monkeypox, which tend to disproportionately impact vulnerable populations, including some that specifically affect MCH populations such as congenital syphilis. Lastly, the public health profession has been called upon increasingly to respond to emergencies driven by complex social and economic factors, including the crisis of Missing and Murdered Indigenous Women, opioid overdose mortality, and unprecedented levels of housing and childcare shortages coupled with the escalating cost of living in many Alaskan communities. These events and circumstances call for a trauma-informed, coordinated response, and WCFH is working to respond to these complex needs in a more intentional and sustainable manner. Securing additional permanent staff positions in public health is challenging, even when funding is available. Accordingly, much of this work is carried out through partnerships with internal and external contacts and agencies with dedicated staffing to work on emergency response. The Title V Director and other management and program staff will continue to advocate for MCH populations during emergency preparedness planning activities and provide education and expert consultation during active mitigation and response. Additionally, programs such as MIECHV and school health are working to integrate emergency response into their existing activities.
The following strategies are designed to support and strengthen system-wide capacity across all MCH population domains. The SPM for the strategies under this cross-cutting priority is the percentage of mothers of three-year-old children whose family has an emergency plan in case of disaster (SPM 4). The intent of this SPM is not to place a burden on mothers to single-handedly prepare for emergencies and disasters. This measure sits within the broader approach of WCFH to supporting MCH populations – particularly in the area of maternal health – which rests on the principle of increasing support including access to care and resources as well as strengthening cultural, community, and other social supports. These protective factors help to mitigate some of the most critical drivers of health disparities in Alaska, including substance use, untreated mental health conditions, and violence. These supports also make emergency planning possible for families. The indicator was selected because it is specifically relevant to disasters, but it will be monitored alongside other indicators pertaining to social support.
Although emergency planning and preparedness is thoroughly discussed in its own chapter elsewhere in this report, WCFH included some specific strategies related to this topic in the State Action Plan to link to the priority mentioned above. Additionally, WCFH staff will be able to participate in community preparedness exercises for the top five most common emergencies seen in Alaska as those are coordinated by the Emergency Preparedness program over the coming year.
WCFH and its staff will continue to provide flexible support during public health emergencies by partnering with internal and external partners to disseminate information and by advocating for MCH population needs during emergencies. WCFH will continue to promote inclusion of public health emergency response topics in workforce training efforts, including ECHOs that the Section co-leads or contributes to in some manner. ECHOs will continue to be a flexible channel for disseminating up-to-date information and resources that are responsive to workforce and community needs during all phases of public health emergencies.
MIECHV will provide support for home visitors to help prepare them to support families during the ongoing impacts of the pandemic and other public health emergencies, and to respond to emerging events and impacts.
The MCH Epidemiology Unit will continue to be available to respond to emergencies as needed. Unit staff hold diverse analytical skills which combined with the practical knowledge throughout the Section, can be mobilized flexibly to support emergency response efforts. The Unit’s staff draw on a range of data sources to provide information about impacts of emergencies on women, children, and families, including assessment of how new emergencies may exacerbate existing disparities and health concerns for these populations. The Unit has capacity to initiate and manage rapid response public surveys during emergencies when needed and will continue to be available to meet this need if it arises in the future.
WCFH will continue to provide support for schools and school nurses as needed, which in the past has included hygiene measures and staff training to respond to the psychological impacts of public health emergencies and disasters.
WCFH will continue to lend practical expertise and collaborative effort to respond to emerging public health threats like the syphilis outbreak and the specific threat of congenital syphilis on the maternal and infant populations. WCFH will also lend subject matter experts and resources to inter-agency collaborative work on complex health crises such as suicide and opioid overdose among adolescents and Missing and Murdered Indigenous Women and Girls (MMIWG).
In partnership with the Division’s Emergency Preparedness Program, WCFH will partner to provide the MCH perspective or data analysis support related to the Jurisdictional Risk Assessment and Mass Casualty Index documents as part of the Department’s Emergency Operations
Strategy 2: In partnership with emergency response agencies, promote and disseminate information to the public about policies being implemented and changes in availability of public health services during and in the wake of a significant traumatic event or emergency.
WCFH has continued to build relationships with internal and external partners to improve the cohesiveness and flow of the public health emergency response, working to identify gaps, reduce duplication of effort, and promote understanding of MCH experiences and needs. These connections help to ensure access to timely information that can be shared with the MCH workforce and the public. The Section Chief and other WCFH leaders will continue to establish and strengthen these relationships, including meetings with the Section Chief responsible for the Emergency Preparedness program.
WCFH’s proximity to both policy and emergency response activities and to direct service providers places the Section in a unique position to serve as a conduit for information and resources. As leadership and staff are made aware of relevant information and resources, it can be strategically relayed through appropriate communication methods including mailing lists, ECHOs, partner agency contacts, and workgroups. In the past, WCFH has utilized these communication methods to provide information and updates to providers and the public about recommended safety measures and impacts to service availability. Due to this practice occurring throughout the pandemic, there are now established channels, such as ECHOs, to disseminate information. Partner agencies may also be more likely to turn to the Section for information during emergencies, and to view their WCFH staff contacts as a connection to emergency management and policy updates.
The impacts of ACEs occur across the lifespan. Since opportunities for prevention and response to ACEs vary between domains, this priority is also addressed specifically in some population domains. Strategies which apply more broadly across MCH populations are included here. The SPM for this area of work embodies a strengths-based, community-oriented approach, focusing on the protective factor of social connections, which is fundamental in the healing of trauma and prevention of many poor outcomes, including interpersonal violence: Percent of people who recently delivered a live birth who have a strong social support system during the postpartum period (SPM 3).
Strategy 3: Provide staff training in responding to ACEs/trauma and strengths-based approaches.
All WCFH staff will be encouraged to and given an opportunity to attend a 2-day Strengthening FamiliesTM training, which provides an Alaskan perspective on historical trauma and the impact of ACEs, as well as practical training on everyday actions to promote the five Protective Factors: (1) Parental Resilience, (2) Social Connections, (3) Concrete Supports, (4) Knowledge of Parenting and Child Development and (5) Social and Emotional Competence of Children. The training is open to the public and engages diverse groups of participants from many professions and backgrounds, lending an opportunity for public health professionals to connect with communities and other disciplines. This training had been in a virtual format due to pandemic safety measures but is now offered in person. Since the virtual approach has increased access to participants in rural regions, this option may also continue to be offered. Staff will be encouraged to attend whichever format is most beneficial for engagement with regional partners and/or their own telework status.
WCFH staff include many professionals who have experience working directly with traumatized populations, including the CYSHCN Director who holds an LCSW, Child and Adolescent Health Unit staff with backgrounds in social work and/or working on youth violence prevention, and the various nurse consultants in the Section who have worked in different aspects of health care. The MCH Epidemiology Unit’s Senior Epidemiologist has a scientific research emphasis on ACEs and the impacts of trauma on MCH population health outcomes. Overall competency and familiarity with these topics are increasing throughout WCFH as these key staff members continue to provide consultation and leadership on this topic. This helps to ensure that trauma-responsive practices are integrated throughout the Section’s work. These subject matter experts help to increase the reach and impact of these approaches through their involvement in workforce training. They may directly deliver trainings which are either on this topic or which model integration of trauma-informed approaches into any area of MCH service delivery. They may co-present or consult with colleagues and peers on training and presentation materials, and they may help to select speakers and topics for conferences and training events to support workforce capacity to respond to ACEs and trauma.
As part of professional development, staff are also will continue to be encouraged to attend the AK Blanket Exercise training provided by the Alaska Native Tribal Health Consortium. This training has been well-received by staff who have attended. This training covers the history of the Alaska Native people and the intergenerational trauma that has occurred in this population. ANTHC welcomes and encourages public health professionals to participate in this training activity, which recently returned to in-person delivery.
Strategy 4: Promote or provide workforce training and support for self-care and responding to vicarious trauma exposures.
A resilient workforce is better equipped to comprehend and respond to traumas in the communities served. An urgent need to improve trauma-informed support for the MCH workforce emerged during the COVID-19 pandemic, and the need is likely to remain as workers continue to serve communities that carry high trauma burdens. WCFH will include self-care and resilience sessions in its workforce training and development activities. WCFH recognizes that stewardship of vicarious trauma extends beyond employee self-care training. Leaders aim to establish a trauma-responsive work environment and agency culture that extends to interactions with colleagues and community partners. WCFH leadership will continue to respond to this need by exploring ongoing workforce wellness strategies, including activities that support staff engagement, connectedness, and work-life balance. WCFH leaders will regularly discuss workforce wellness needs and supportive interventions and strategies.
Although many of WCFH’s strategies address disparities and target marginalized populations, the COVID-19 pandemic brought to light a need to provide more focused attention to this area. These strategies focus attention and provide continuity across domains. Infant mortality disparities are a bellwether of population health equity, and this is the rationale for the SPM linked to the health equity priority established in 2021: The Infant mortality disparity rate ratio of Alaska Native to white infants (per 1,000 live births).
Strategy 5: Collaborate with Medicaid to improve reimbursement and/or increase access to services.
Alaska’s Medicaid program has faced significant cuts and continues to have small staffing capacity. Given that capacity and the enormous workloads and pressure to cut costs, partnership with Medicaid for Title V is essential. WCFH leadership sees this as an important strategy to continue to prioritize. Given that over half of all births in Alaska are covered by Medicaid, this agency and program has the unique ability to impact a large percentage of the MCH population. Over the coming year, WCFH will collaborate with Medicaid and the Division of Public Assistance on outreach and evaluation of postpartum Medicaid extension.
Through multidisciplinary review of maternal, infant and child deaths, MCDR analyzes access to perinatal and preventive care and makes recommendations which target systemic barriers to care. Through its recommendations, MCDR will continue to provide evidence to underscore the need for Medicaid coverage of specific services which have the potential to reduce preventable deaths. MCDR data on contributing factors to maternal mortality will be used as appropriate to monitor and evaluate the impacts of the recently signed legislation to extend postpartum Medicaid coverage.
The PRAMS and CUBS surveys both collect self-reported data on receipt of Medicaid services. Results are often presented by Medicaid status to highlight disparities and inform the Medicaid program where gaps exist, particularly related to utilization of health care. As well, the MCH Indicators program always presents data, when possible, by Medicaid status (for example, in the MCH Indicators Dashboard) so that the Medicaid program can easily see how outcomes for their population compares to people not using Medicaid. Starting in 2023, the MCH Epidemiology Unit will provide the analyst time to conduct the annual data linkage of birth and death certificates to Medicaid data to create a “Medicaid” variable as part of the vital records statistical data file.
The Oral Health program has partnered with the Center for Medicaid and CHIP Services to support Alaska’s participation in the CMCS Affinity Group Advancing Prevention and Reducing Childhood Caries in Medicaid and CHIP. This partnership, scheduled for a 5-year duration, will identify gaps in care and access to care, and address these with evidence-based strategies to improve oral health access in Alaskan children with Medicaid from the ages of 0 – 6.
WCFH updated the Title V-Medicaid MOU in 2019 to include the addition of a statement indicating that representatives from the Medicaid Program, including the Medicaid Medical Director and EPSDT Manager, will advise programs within WCFH on activities that affect the population served by Medicaid, including reviewing publications that include Medicaid data or providing feedback on recommendations being put forward by the MCDR Committee. Input from Medicaid agency representatives is critical to ensuring that the MCDR committee recommendations related to deaths of women and children covered by Medicaid are appropriate and attainable. Medicaid staff will also continue to participate on WCFH-led steering committees related to CYSHCN, oral health, among others.
Also laid out in the current MOU, WCFH will meet with Medicaid (as part of the pediatric team) monthly to ensure a regular method of communication. WCFH and Medicaid will work together to promote early and continuous prenatal care that includes screening and assessments according to standards set out by the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics. WCFH will continue to seek ways to promote maternal depression and ACEs screenings during pediatric visits up to one year postpartum, a service that was authorized for Alaska Medicaid reimbursement in April 2021.
WCFH Title V staff, including the CYSHCN Director, will continue to meet with the CHIP Director, EPSDT Director, and another group led by the Alaska Children’s Trust, to look for different ways to collaborate across agencies to improve enrollment in Denali KidCare, Medicaid, and other public assistance benefits. The goal of these workgroups is to reduce the number of uninsured children in Alaska who are eligible for Denali KidCare by identifying the resources and barriers that either help or hinder how someone applies for benefits. The collaboration across agencies has the potential to improve access and equity for all Alaskan children who need healthcare services.
The COVID-19 pandemic has shed light on opportunities for improving access and reducing rural disparities by providing tele-health services. Medicaid and WCFH partnered in 2020 to implement telehealth clinics in WCFH. WCFH will continue working with Medicaid to expand and promote these services, to include other MCH services in Alaska.
Both the EPSDT and CHIP Director positions turned over in 2024. While the CHIP Director continues to participate in monthly meetings while her prior position is vacant, there remains a gap in capacity. Similar to the new Medical Director, WCFH staff will provide an overview of Title V when these positions are filled with new team members. WCFH staff will support them in their new roles to ensure continuity in collaborative efforts.
Strategy 6: Provide staff training and development opportunities in health equity and valuing diversity.
A wealth of trainings continue to be available virtually, and staff are encouraged to utilize these as opportunities arise, particularly when offered by federal partners in conjunction with funding programs as these trainings are tailored to relevant areas of practice. WCFH program staff often share training opportunities with one another, and with external partners through email listservs. The Section will also continue to offer sessions that directly address equity and anti-racism and/or integrate these topics into other topic areas during the Annual AKPQC/MCDR Joint Summit, ECHOs, and other training events.
With funding from the CDC’s Statewide Perinatal Quality Collaboratives Cooperative Agreement, the AKPQC plans to support a statewide implicit bias training for perinatal and neonatal providers within the next year. While this was a goal the prior year, procurement delays have hindered WCFH ability to secure a trainer. Respectful maternity care was a session at a prior AKPQC/MCDR Summit, and there seems to be more interest in professional development in this space. Addressing bias is essential to respectful care. Persons who use drugs often face discrimination within the healthcare setting. Many decline to seek healthcare services due to the treatment they have had in previous medical settings. Pregnant persons who use substances may not feel comfortable disclosing substance use, especially if they have experienced stigma related to their substance use during a previous encounter. Providing implicit bias training can reduce biases and promote access to services. It is important that hospital staff understand personal biases as these biases can impact care received. Bias, along with institutional barriers, can also interfere with proper identification of needs and access to needed services after delivery, for postpartum individuals as well as infants, impacting outcomes over the lifespan. By training staff in implicit bias, there can be a focus on harm reduction and eliminating bias and discrimination.
Moving the knowledge gained and shared through these activities into practical application is the next challenge. Managers and supervisors will provide mentorship and guidance to their teams and hold one another accountable. They will participate and support staff participation in equity development workgroups with other sections and partners as opportunities arise. At all levels, staff development will be addressed and supported through the supervisory relationship and a continuous learning culture promoted within and between the section’s programs. As with trauma-informed approaches, health equity and anti-racism training and workforce development are most effective when integrated across teams and throughout all activities, rather than delegated to specific team members or programs. Once a basic level of familiarity with concepts and history has been achieved, workforce development in this area is most effective when concepts are integrated into trainings on other MCH topics rather than stand-alone trainings, and when applied and actively evaluated through continuous quality improvement cycles.
The Title V MCH Director will also continue to participate in the Division’s Inclusive Communications work group which is led by the Public Health Deputy Director. This group aims to provide training, technical assistance, and standardization of inclusive language within the Division.
Strategy 7: Conduct ongoing assessment of equity impacts of Title V strategies across domains.
The Title V program will continue its process of examining all Title V strategies through an “equity lens.” This process involves ongoing conversations about each strategy during quarterly update meetings about the strategy’s potential impacts on equity. Discussions include an examination of strengths, opportunities, and any areas where strategies may increase disparities (e.g., by focusing on subpopulations which may have greater access or privilege). Once per year, the quarterly meeting will focus entirely on these discussions. The remaining three quarters will provide opportunities to revisit or add to them, as needed.
Strategy 8: Promote equitable use of resources to work towards elimination of structural racism.
WCFH commits to exploring new strategies for channeling resources to community-based and minority-led projects to address the needs of vulnerable populations. Whenever possible, WCFH will engage youth, self-advocates, parents and community members in leadership and decision making with respect to the use of resources to target health disparities. WCFH will provide information to support equitable policies and funding that improve access to services for minorities and disadvantaged populations.
Strategy 9: Collect, analyze, and disseminate data and information on health equity topics.
The MCH Epidemiology Unit’s CSTE fellow who led the development of the Overcoming ACEs with Resilience (OARs) survey moved to a permanent epidemiologist position with the Section of Chronic Disease Prevention and Health Promotion in September 2023. Fortunately, his new position focuses on injury prevention and includes a large ACEs component. Although he took the OARs survey program with him and he continues to work on data analysis and dissemination of findings, the Senior MCH Epidemiologist will continue to provide mentorship and serve in an advisory capacity for OARs, and the MCH Epidemiology Unit Manager will continue to participate on the DPH ACEs data workgroup, which serves as the OARs Steering Committee. The MCH Epi Unit will also be helping to administer additional funding from the Alaska Mental Health Trust over the next year to conduct a second round of OARs.
Strategy 10. Conduct multidisciplinary reviews to identify factors in maternal and child mortality and make culturally appropriate, actionable recommendations to reduce preventable mortality and eliminate disparities.
Across the board, racial disparities are observed for all leading causes of preventable mortality in the Alaskan MCH population, including suicide, SUID, accidental injury, and violence. Alaska’s multidisciplinary maternal mortality and child fatality review programs are administered by the Alaska Maternal Child Death Review Program (MCDR), which is housed within WCFH in the MCH Epidemiology Unit. Since the addition of Alaska’s Title V health equity priority, and with the support of several cooperative agreement awards, this program has centered health equity through several programmatic improvements. Changes have included improvements to representation of Alaska’s diverse cultures within the committee, expansion of interdisciplinary representation, consultation, and partnerships with minority-led community-based agencies, committee member training on equity topics and underrepresented cultures, and qualitative and quantitative analysis projects to identify and describe underlying factors in preventable mortality disparities.
MCDR utilizes an evidence-based process for multidisciplinary review of all maternal deaths (during or within one year of pregnancy, from any cause, and regardless of the outcome of the pregnancy), and all deaths of Alaskan infants, children, and adolescents. Review of child and adolescent mortality is primarily funded by Title V while review of maternal deaths and Sudden Unexpected Infant Deaths (SUIDs) are also supported by CDC and OASH funds. Through efficient and comprehensive death review, MCDR endeavors to use data to develop substantive public health recommendations that influence legislation, policy, and practice changes resulting in reduced infant, child, and maternal mortality.
In the 2024 legislative session, both the Alaska House and Senate passed updates to the state statute which governs public health review organizations in Alaska, including MCDR. One of the major changes made to the statute is the removal of the requirement that 75% of committee participants be health care providers. Once this bill is signed by the Governor (expected in summer 2024), the MCDR program will begin updating and revising the committee membership process to ensure the committee is more multidisciplinary and representative of communities disproportionately impacted by premature mortality. The program also anticipates creating new committee member orientation materials and trauma-informed training to better support all committee members.
MCDR has received CDC funding to support the review and categorization of SUIDs for the past ten years and received a new five-year grant award in 2023. The new funds will support a contracted case abstractor, along with a portion of MCDR staff time to gather case records, facilitate reviews and conduct data analysis.
CDC grant funding supports the maternal mortality review program, including case abstraction and utilization of the Maternal Mortality Review Information Application (MMRIA) database to capture maternal mortality data and recommendations. The CDC award also supports a partnership with the Alaska Hospital and Healthcare Association (AHHA) to support the review process and engage facility contacts in MCDR activities, including recommendation implementation. This work will all continue in the upcoming year. MCDR funding through OASH, Office on Women’s Health, supports implementation of MCDR recommendations to prevent maternal deaths from violence. In the coming year, these funds will be used to support the work of culturally matched, community-based doulas, with an emphasis on providing doula training using Alaska specific curriculum, along with other efforts to expand knowledge and awareness of these services. Culturally specific birth support services have been recognized for the potential to increase maternal safety and wellbeing, not only during childbirth but also holistically throughout the perinatal period. The Alaska Native Birthworkers Association will continue to be a key partner in this work.
MCDR delivers presentations, collaborates with the AKPQC on provider training, and shares information throughout the year, with health equity and the impacts of institutional racism and social determinants of health being central to virtually all discussion of preventable mortality within the MCH population.
Strategy 11. Engage with diverse contacts and audiences to increase awareness about maternal and child mortality and promote implementation of prevention recommendations.
MCDR recently submitted an application for funding for another cycle of the CDC Enhancing Reviews and Surveillance to Eliminate Maternal Mortality (ERASE MM) grant, which includes additional focus over the next five years on community engagement, disseminating information about the program and findings, and receiving and acting on input from disproportionately impacted populations. Part of the funding is used to support a new non-permanent Mental Health Clinician position embedded in MCDR to do some of this work. While this position is funded primarily to support maternal mortality reviews, by being a part of the MCDR staff, it will also be able to speak to other components of the program when meeting with communities. One new strategy being planned by the Mental Health Clinician is to travel to communities outside of Anchorage to conduct listening sessions to hear directly from community members about their concerns and questions related to maternal mortality and to learn what types of prevention recommendations resonate most strongly.
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