SPM #3 Address Social Determinants of Health Inequities

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

To gain buy-in and build internal awareness and understanding across MCH programs and the Department of Health and Senior Services (DHSS) overall, Title V MCH is implementing a core MCH training plan, including didactic and interactive experiences for leaders, team members and MCH program staff. To gain a better understanding of the impact of SDoH and how to effectively integrate strategies to address the root causes of health inequities into policies and program services and activities and to provide foundational skills, MCH leadership is working to identify workforce development training on MCH fundamentals, Life Course Perspective, SDoH, cultural competence and humility, and health literacy.

MCH leadership is reviewing existing resources, MCH Navigator trainings, MCH Leadership Competencies, and evidence-based training methods and content and developing a continuously evolving training plan to establish initial and ongoing training requirements for internal Title V MCH program staff and external contractors. The training plan will continue to be developed and implemented beyond the Title V MCH core team.

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

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

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

If Missouri is awarded the CDC SPAN grant funding for FFY24-29, DHSS will provide a lactation consultant preparation course at a centrally located site, making it available to participants from areas of the state that currently have low breastfeeding rates and disparities. Every effort will be made to encourage women of color to become peer counselors or International Board Certified Lactation Consultants (IBCLCs) in regions where disparities in breastfeeding support exist. DHSS will provide a level 1 lactation training in 2023 and a level 2 lactation training in 2024. The combination of these two courses will provide the 90 hours of lactation specific education needed to sit for the IBCLC exam. The state breastfeeding coordinator and the Bureau of Community Health and Wellness (BCHW) also plan to implement a one-year mentorship program for under-resourced applicants planning to sit for the exam. Using funding from the SPAN grant, the program will provide a scholarship to pay for the IBCLC exam. The combined result of these efforts should significantly reduce barriers to achieving the IBCLC credential. In addition to IBCLC training, if Missouri is awarded the SPAN grant for the next funding cycle, funding will also be made available for doulas and other mid-level lactation providers to receive breastfeeding training and support specific to their scope of practice. Title V MCH resources will be leveraged to support ongoing and new activities associated with the CDC SPAN grant.

The Missouri Physical Activity and Nutrition (MPAN) Program will continue collaborating with the Healthy Weight Advisory Committee, a subgroup of the Missouri Council for Activity and Nutrition. The committee provides expertise and advice to advance and monitor collaborative, sustainable, evidence-based strategies for increasing the number of children at a healthy weight. MPAN will support the Advisory Committee in efforts to increase workforce capacity to deliver weight management treatments aligned with the newly available MO HealthNet benefit for children and adults.

The School Health Program (SHP) will continue to implement the School Nurse Chronic Health Assessment Tool (SN CHAT) and broadly promote the resource as a tool for school districts to improve the quality of student health information and plan to appropriately address student health and education needs.SN CHAT has two main components; the parent interview tool and an easy to use emergency action plan for the school nurse to use with school staff. This interview tool was developed so that school nurses will be efficient in asking pertinent questions in a collaborative approach with parent. It is developed to be used in a face-to-face conversation or by phone with the parent or guardian.

The SHP is contracting with the state Missouri Action Council and its regional affiliates to offer poverty simulations for every school district in every county in Missouri during the 2023-24 school year.

As administrator of the Early Childhood Comprehensive Systems (ECCS) Health Integration P-3 grant, the Office of Childhood (OOC) at the Department of Elementary and Secondary Education will work with a contractor to provide the Safe Environment for Every Kid (SEEK) training to pediatricians and family medicine physicians across the state. SEEK is an evidence-based model developed to support primary care health providers in identifying risk factors and helping prevent child maltreatment. SEEK offers a practical model to help address SDoH and enhance primary care, ultimately improving the health and well-being of children and families. The trainings will include strategies to address targeted SDoH that are also risk factors for child maltreatment, such as parental depression, major parental stress, substance use, intimate partner (domestic) violence, food insecurity, and harsh punishment. Additional training modules will address the medical and behavioral health teams in primary care settings. Modules will include relationship building, motivational interviewing, addressing barriers to engagement, and probing suicidality. The grant will also be used to provide maternal substance use and trauma-informed care training to home visitors and other early childhood care and education professionals.

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

To continue building a comprehensive maternal-child public health system to address the priority needs of Missouri’s MCH population, the MCH Director will continue to:

• Build relationships with statewide MCH stakeholders;
• Provide presentations on and facilitate a simulation of the Life Course Perspective to undergraduate and graduate students and internal and external partners and stakeholders;
• Initiate and engage in discussions related to the SDoH, health literacy, health disparities, diversity, and inclusion;
• Promote trauma-responsive and culturally competent MCH programs and services;
• Contribute to Department efforts to create a diverse and inclusive work environment and incorporate the principles of cultural competence and humility, diversity and inclusion into programs and initiatives;
• Promote activities and initiatives to ensure access to care, including adequate insurance coverage, for MCH populations and to promote partnerships with individuals, families, and family-led organizations to ensure family engagement in decision-making, program planning, service delivery, and quality improvement activities;
• Explore opportunities to expand Missouri’s MCH data capacity and enhance public health surveillance/reporting systems; and
• Promote and support efforts to recruit and retain a qualified, diverse and well-trained MCH workforce.

The Child Care Health Consultation (CCHC) Program will continue to provide consultation and training for child care providers and health promotion for children in child care at both regulated and unregulated child care facilities, including those that serve families eligible for the Child Care Subsidy Program. CCHC Program services will continue to be inclusive of adults and children of all abilities. Services will address a variety of health and safety topics that affect SDoH, and will be provided at little to no cost to the child care provider and the children in their care to ensure that everyone has access to program services to improve their health and promote safe environments. LPHA staff that provide CCHC Program services will continue to assess for referral needs for health care access, including MO HealthNet for Kids, immunizations, developmental screening, and WIC. CCHC Program services will also continue to assist child care providers in the identification and utilization of community resources and organizations that address health disparities. The CCHC Program will also continue to facilitate CPR/First Aid training at little to no cost for child care providers. The CCHC Program Specialist will continue to assist LPHA staff providing CCHC Program Services in developing resources for child care providers and families and health promotion for children in child care. The resources will address SDoH inequities and social justice, and provide resources for employee and community-based assistance. The CCHC Program will continue to encourage family participation in all services, and continue to provide consultation and training for child care providers on developing and implementing procedures, and providing trainings that promote inclusivity and optimal family partnerships for the health and safety of children in child care.

The TEL-LINK Program will refer callers to MO HealthNet to improve health and reduce health disparities by increasing insurance coverage among the MCH population. The program will continue to provide outreach to the underserved population through effective marketing strategies. The ParentLink MCH WarmLine and MCH Navigators will continue to assist parents, caregivers, and families with enrollment in eligible MO HealthNet coverage plans, WIC, Supplemental Nutritional Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Missouri Child Care Subsidy Program, Child and Adult Care Food Program (CACFP), MO Low Income Home Energy Assistance Program, and other financial and social support services, as needed.

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

The Title V MCH funded Home Visiting programs’ contracted home visitors will assess all home visiting clients for insurance status at initial enrollment and periodically throughout enrollment. As need for health care coverage is identified, home visitors will assist clients/families in the Medicaid enrollment process and accessing the Affordable Care Act marketplace by linking clients to their nearest FQHC to speak with a trained navigator in order to obtain eligibility and enrollment assistance. Annual data on insurance coverage through Medicaid, private, or other insurance will be collected on children and primary caregivers enrolled in-home visiting. Insurance coverage is vital to assuring children can access adequate and equitable preventive health care including well child care. Annual performance measure data will be collected on the percentage of children enrolled in home visiting who receive the last recommended well-child visit based on the America Academy of Pediatrics (AAP) schedule. Data will be analyzed for practices indicating unrecognized racial and/or cultural bias that could result in unintentional healthcare inequity.

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

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

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

The MCH Services Program will support LPHA efforts to:

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

LPHAs will continue to:

• Screen clients for MO HealthNet or other insurance coverage;
• Screen for an identified primary care provider;
• Perform pregnancy testing, prenatal education, and OB/GYN referrals as indicated;
• Provide prenatal case management and/or referral for pregnant women;
• Assist pregnant women with MO HealthNet Program eligibility and enrollment; and
• Screen clients for an identified dental care provider and provide dental referrals as indicated.

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

In addition, the MCH Services Program will continue to contract with 111 LPHAs to address priority MCH issues in their community. The MCH Services Program worked with the LPHAs in FFY2021 to conduct a focused, local assessment of MCH priority needs, identifying at least one priority health issue aligned with the FFY 2021-2025 Title V MCH priorities, and developed a five-year, FFY 2022-2026, work plan to address the selected priority health issue(s). The LPHA work plans include evidence-based strategies to address their selected local priority health issues, including addressing SDoH, existing health inequities, and gaps/weaknesses in access to care.

• The Jackson County Health Department has chosen Addressing SDoH inequities among women of childbearing age as their selected priority health issue. The LPHA created and adopted a Policy Action Plan to impact racial disparities and inequities. The health department provides evidence-based trainings, curriculums and practices on racial disparities and inequities to internal and external providers and partners. In an effort to communicate regularly and effectively with regional decision-makers, the health department’s Community Engagement & Policy Division sends quarterly newsletters to municipal, county, and state policymakers, University Health leadership, and other community stakeholders, including an overview of the department’s activities during the previous quarter, new policy or issue briefs, relevant public health policy or legislative updates, and relevant news stories. Policy newsletters were sent in January 2023 and April 2023 to 189 regional stakeholders. In addition, the health department provides regularly scheduled public health orientation, to include an overview of the health department’s capabilities, programs and services, and centering equity in all activities, to newly elected Jackson County Legislators and University Health Administrators and Board Members.

The Safe Cribs for Missouri Program will continue to ensure culturally and linguistically appropriate resources and educational materials are available to participating agencies for promoting Sudden Infant Death Syndrome (SIDS) prevention and safe sleep environments during initial and follow-up educational sessions provided with crib placements.

The Office on Women’s Health (OWH) will promote diversity and inclusion across all of its programs. The maternal mortality team and Pregnancy Associated Review (PAMR) Board will review all maternal deaths for contributing SDoH and bias and/or discrimination. Data will be used to identify issues and support recommendations to end bias and discrimination and promote trauma-responsive and culturally competent care and services. In the women’s health programs, the OWH will ensure materials developed and distributed include evidence-based information to address gaps/weaknesses in access to care and health disparities. The violence prevention team will work across topic areas to promote diversity among community health workers. By addressing health disparities and the SDoH, the OWH will prevent violence and reduce maternal mortality.

Newborn screening touches nearly every baby born in Missouri regardless of their socioeconomic status and/or cultural background. The Newborn Blood Spot Screening Program will continue to strive to understand the parent’s experience with newborn screening by implementing an improved survey process. The parent survey will include questions that assess for various barriers to seeking needed repeat screens or additional testing. The survey will ask for voluntary demographic information to ensure data is gathered from diverse participants. Determining areas of the newborn screening population where access or information is lacking will help improve outreach strategies and enhance capacity to provide more meaningful education to parents. The newborn screening team will continue to seek out and participate in opportunities to further understanding of ways to provide more culturally and linguistically inclusive services to the broadly diverse population affected by newborn blood spot screening.

The Missouri Newborn Hearing Screening Program (MNHSP) will increase the incorporation of CLAS into the program’s mission to assure all babies born in Missouri receive a hearing screening and appropriate follow-up to increase the likelihood that children with hearing loss achieve communication skills. The MNHSP and its collaborating partners, the Family Partnership Program and the Missouri State University MOHear Project, will work to reflect commitment to diversity and inclusion. The MNHSP will recruit at least two more parents of children who are deaf or hard-of-hearing (DHH) or adults who are DHH to the program’s advisory committee, a standing committee of the state Genetics Advisory Committee. Additionally, the MNHSP will recruit a pediatrician to the standing committee to assist with incorporating medical home approaches in MNHSP activities.

The Childhood Lead Poisoning Prevention Program (CLPPP) will focus on available data analytics to identify gaps in care and disparities in blood lead testing across the state. Once identified, outreach strategies will be implemented and resources distributed to address disparities on a priority basis. CLPPP will also work with national partners to develop and distribute culturally and linguistically diverse resources related to lead poisoning prevention. CLPPP plans to conduct a health literacy review on several documents and provide translated copies of documents on the website to address linguistically diverse populations. Three documents will be reviewed for health literacy and translated into other languages based on identified needs.

The Office of Dental Health (ODH) will continue to promote diversity and inclusion across all programs. Based on responses received from the LPHAs regarding the primary languages of their most frequent clientele, the ODH had several pieces of oral health literature translated into seven different languages. These pieces of oral health literature are available for the LPHAs to download and print. As funding allows, the ODH will print a few of the highly requested items and make them available for ordering.

The Adolescent Health Program (AHP) is undergoing a strategic planning process and plans to organize future Council for Adolescent and School Health (CASH) activities using SDoH categories. The categories will be used to plan future professional development opportunities and identify areas for growth and ways to organize future efforts for the AHP and CASH.

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