Toxic Stress, Trauma, ACEs and Resilience: OCCYSHN Plan

(October 2024 – September 2025)

 

Strategy 1.1:

We will promote trauma-informed care for CYSHCN and their families by incorporating a family-informed, trauma-informed lens to our workforce development activities.

 

A note on the Blueprint for Change: OCCYSHN’s work intersects with every element of MCHB’s Blueprint for Change (BFC). Each State Performance Measure 1 activity described below addresses one or more of the BFC’s “critical areas”: health equity, family and child well-being and quality of life, access to services, and financing. A crosswalk of OCCYSHN activities and BFC principles is included in Supplemental Document 1.

 

Activity 1.1.1. Develop OCCYSHN Internal Capacity

1. OCCYSHN will improve staff knowledge, skills and attitudes about trauma-informed care through technical assistance, training, and staff discussion.

Timeline: 10/1/24 – 9/30/25

 

Activity 1.1.2. Develop Expertise on Pediatric Medical Trauma and CYSHCN
OCCYSHN will:

1. Continue to add high quality, family-friendly resources and information about pediatric medical trauma to the Oregon Family to Family Health Information Center (ORF2FHIC) website.
2. Disseminate information and resources for families on reducing or addressing medical trauma, using newsletters and social media.
3. Post information about pediatric medical trauma to Basecamp, the statewide public health home visiting workforce’s virtual platform for information and resources.
4. Collaborate with a doctoral Occupational Therapy student from Pacific University to create a toolkit for parents of children who use enteral feeding. The toolkit will center patient and family experience with the often-traumatic process of placing nasogastric tubes and will focus on ways to mitigate that trauma. This student is the adult sibling of a young adult affected by this particular type of medical trauma; this work is their capstone project.
5. Use a trauma-informed approach to developing and presenting ORF2FHIC trainings about health emergencies and disaster planning for families of CYSHCN.

Timeline: 10/1/24 – 9/30/25

 

Activity 1.1.3. Workforce Development

OCCYSHN will:

1. Promote the use of the Family-Centered Shared Care Planning Assessment (FCSCPA) tool in communities of practice with LPHAs, to support trauma-informed care (NPM Activity 11.3).
2. Deliver presentations across systems that promote the underlying values of shared care planning (SCP), including trauma-informed care, which is defined in the FCSCPA.
3. Continue to support families navigating the complex systems serving CYSHCN as part of a trauma-informed approach to care coordination. To that end, promote SCP, OCCYSHN’s community health worker curriculum, and our Pilot: CHWs Improving Care Navigation for Latino families of CYSHCN (NPM Activity 11.3).
4. Promote access to culturally responsive care as a trauma-informed approach to serving CYSHCN and their families.
5. Incorporate Parent Partner perspective into Autism Assessment Capacity Project and ACCESS to inform providers about preventing trauma during the diagnostic process (SPM Activity 3.2.2).

Timeline: 10/1/24 – 9/30/25

 

Culturally and Linguistically Responsive Services (CLAS): OCCYSHN Plan

(October 2024 – September 2025)

 

Strategy S2.1.

We will improve CYSHCN and their families’ access to culturally sensitive and responsive care through workforce development.

A note on the Blueprint for Change: OCCYSHN’s work intersects with every element of MCHB’s Blueprint for Change (BFC). Each State Performance Measure 2 activity described below addresses one or more of the BFC’s “critical areas”: health equity, family and child well-being and quality of life, access to services, and financing. A crosswalk of OCCYSHN activities and BFC principles is included in Supplemental Document 1.

 

Activity 2.1.1. Workforce Development

OCCYSHN will:

1. Continue to adapt our community health worker (CHW) curriculum content to meet the unique cultural and linguistic needs of specific diverse communities.
2. Collaborate with the OHA Transformation Center on integration of the CHW workforce into primary care settings serving CYSHCN.
3. Align with state-level efforts to expand and develop the CHW workforce and to increase representation and improve access to culturally and linguistically appropriate services.
4. Promote access to culturally responsive, trauma-informed care for CYSHCN and their families (SPM Activity 1.1.3).
5. Participate in the National CHW Center for Research and Evaluation Advisory Group. The group is comprised of CHWs and long-time allies that promote the use of CHW Common Indicators. These process and outcome indicators demonstrate the impact of CHW’s work Such data might serve to garner more resources for CHWs in the future.
6. Integrate OCCYSHN’s CLAS-related needs assessment findings into dissemination efforts, including presentations, outreach, and training for the CYSHCN-serving workforce. These efforts increase awareness of the need for culturally responsive health care, including the CHW’s role in providing that.

Timeline: 10/1/24 – 9/30/25

 

Activity 2.1.2. Promotion of Culturally Appropriate Health Care

OCCYSHN will:

1. Seek to test its adapted transition from pediatric to adult health care provider trainings with a provider or clinical staff audience.
2. Partner with OHSU’s Department of Pediatrics’ Pediatric to Adult Transitions in Health Care (PATH) Program to pilot the training with providers and/or clinic staff who participate in PATH.

Timeline: 10/1/24 – 9/30/25

 

Activity 2.1.3. Multicultural Organizations

OCCYSHN’s Systems and Workforce Development unit will:

1. Continue to include representation from culturally-specific organizations on the Babies First!/CaCoon advisory board and other workgroups related to CaCoon program planning and implementation (NPM Activity 11.4).
2. Continue to partner with Next Door, Inc. to adapt community health worker (CHW) course content and delivery modes to meet the specific cultural and linguistic needs of the local Latino population.
   
    

The Oregon Family to Family Health Information Center (ORF2FHIC) will:

1. Continue efforts to build/nurture connections with culturally specific community-based organizations (CBOs) to increase awareness of CYSHCN issues and ORF2FHIC services.
2. Proactively communicate with culturally specific CBOs at least twice yearly. Continue to translate or adapt ORF2FHIC tip sheets or toolkits for CBOs at no cost. Collaborate on development of new culturally appropriate materials, trainings, and Table Talks.
3. Hold “meet and greets” with at least three to five new culturally specific CBOs that serve children and families in rural areas.
4. Seek opportunities to attend events and meetings, especially health fairs in Black, Latino, Chinese, and Vietnamese and Russian communities.
5. Maintain connections with Oregon’s six refugee resettlement organizations and the state’s Office of Refugee Health via email and social media.
6. Host a second annual information-sharing meeting with Oregon’s six refugee resettlement organizations.
7. Identify potential collaborators from organizations serving refugee communities to develop a “Welcome to Oregon” toolkit specifically for families of CYSHCN.

Timeline: 10/1/24 - 9/30/25

 

Activity 2.1.4. OCCYSHN Equity Workgroup
OCCYSHN’s Equity Workgroup will continue to foster internal learning, facilitate reflection on OCCYSHN’s equity efforts, and monitor OCCYSHN’s progress on plans to promote culturally sensitive care for CYSHCN. The Equity Workgroup will:

1. Identify opportunities for alignment between OCCYSHN activities and the Blueprint for Change.
2. Evaluate the Equity Workgroup’s structure and function and adjust as needed.
3. Recruit and retain members from all OCCYSHN work units.
4. Meet quarterly to discuss an equity-related topic (research papers, videos, etc.) relevant to CYSHCN, and discuss how to apply our learning to our work.
5. Present to OCCYSHN staff quarterly on equity-related topics.
6. Monitor OCCYSHN progress on CLAS-related activities using our internal reporting tool.
7. Respond to staff requests for support on any Equity, Diversity, and Inclusion (EDI) efforts.
8. Ensure that EDI remains an integrated priority across all OCCYSHN efforts.

Timeline: 10/1/24 – 9/30/25

 

Activity 2.1.5. Policy
Equity and justice remain a central focus of policy efforts on behalf of CYSHCN. OCCYSHN will:

1. Serve on local, state, and national advisory groups, committees, and work groups, including OHSU’s Legislative Advisory Committee. Inform policy with potential to impact Oregon CYSHCN. (See OCCYSHN Advocacy and Committee Participation, Supplemental Document 1.)
2. Inform implementation of Oregon’s Medicaid 1115 Waiver (approved in 2023). Help define eligibility and operationalize expansion of Medicaid for young adults with special health needs aged 19 through 25 years, and guide implementation of Early and Periodic Screening, Diagnostic and Treatment (EPSDT) (waived in Oregon prior to 1/1/23).
3. Continue work on the Medical Legal Partnership program in OHSU’s Neonatal Intensive Care Unit, expanding service to families cared for by the Division of Hematology/Oncology, with a focus on the Sickle Cell Anemia Clinic.
4. Collaborate with Oregon Law Center to identify barriers for CYSHCN and their families (including low-income and/or migrant families) to accessing special education information and services.
5. Improve access to developmental and behavioral health services for CYSHCN by partnering with payers and providers statewide (Supplemental Document 1).
6. Continue partnering with payers and providers statewide to improve access to durable medical equipment for CYSHCN.
7. Monitor legislation and provide input, comment and testimony on issues affecting CYSHCN during the 2024 session of the state legislature.

 

Additionally, OCCYSHN’s Director will:

1. Serve as state medical director for universally-offered home visiting program for newborns.
2. Serve as president of the American Academy of Pediatrics (AAP) through calendar year 2024, and past-president for 2025. The AAP strategic plan includes a primary focus on health equity, and his involvement will elevate and inform OCCYSHN’s work.
3. Serve as OHSU Department of Pediatrics Vice-Chair of Community Health and Advocacy. Continue to work with the Vice-Chair for Diversity, Equity and Inclusion to lead work in the Department of Pediatrics and the Institute on Development and Disability focusing on health equity. Much of the work will focus on training programs and curricula across the OHSU campus, including inter-professional education.
4. Serve as a Commissioner on the Oregon Health Evidence Review Commission, providing a strong focus on equity in child health at the state policy level.

Timeline: 10/1/24 – 9/30/25

 

Activity 2.1.6. Assessment

1. OCCYSHN will implement CLAS-related assessment activities as described in NPM Activity 11.8.

Timeline: 10/1/24 – 9/30/25

 

 

Social Determinants of Health and Equity: OCCYSHN Plan

(October 2024 – September 2025)

 

A note on the Blueprint for Change: OCCYSHN’s work intersects with every element of MCHB’s Blueprint for Change (BFC). Each State Performance Measure 3 activity described below addresses one or more of the BFC’s “critical areas”: health equity, family and child well-being and quality of life, access to services, and financing. A crosswalk of OCCYSHN activities and BFC principles is included in Supplemental Document 1.

 

Strategy S3.1:

We will increase access to care and supports by investigating barriers that inhibit CYSHCN and their families’ timely access, and we will develop family-informed activities to reduce or eliminate the barriers.

Utilizing an equity lens, we will work with our state and county partners to identify systems-level disparities. We will leverage our partnerships with local public health authorities, OHA and other state-level systems to collaboratively develop and implement interventions that mitigate those inequities.

 

Activity 3.1.1. Barriers to Receipt of Care

1. We will use the root cause analysis findings coupled with our 2025 needs assessment results to inform our 2026-2030 planning.

Timeline: 10/1/24 – 9/30/25

 

Activity 3.1.2. Systems and Policy

OCCYSHN will:

1. Continue collaborating with public health, health care providers, and community partners in the Columbia Gorge region to integrate bicultural, bilingual traditional health workers into cross-sector care coordination teams for Spanish-speaking children and youth and their families.
2. Collaborate with Title V MCH and Medicaid per our Memorandum of Understanding.
3. Play a central role in defining eligibility guidelines and implementing expansion of Medicaid eligibility for young adults with special health care needs aged 19 to 26 (NPM Activity 12.2).
4. Inform implementation of EPSDT provisions (NPM Activities 12.2 and 12.4). This will occur through collaboration with Oregon Medicaid, OHA Rules Advisory Committees, and the Health Evidence Review Commission. 
5. Implement and evaluate the impact of an innovative, effective alternate payment mechanism (APM) to support primary care diagnostic evaluations for autism spectrum disorders (SPM 3.1.1). OCCYSHN will lead work with Oregon Medicaid and two Coordinated Care Organizations to implement that APM.
6. Support the ACCESS Project, reducing barriers to autism evaluation for families of children through age five (SPM 3.2).
7. Promote the Family-Centered Shared Care Planning Assessment (FCSCPA) tool to operationalize addressing SDOH and equity in shared care planning.
8. Collaborate with Oregon Law Center to identify and address inequities in Medicaid benefits.

Timeline: 10/1/24 – 9/30/25

 

Activity 3.1.3. Strengthen and Leverage Existing Relationships

OCCYSHN will contribute to local, state, and national level efforts to address SDOH for CYSHCN. For a list of groups on which we participated in the block grant report year, see Supplemental Document 1. We will continue working with those groups and seek other collaborative opportunities with the potential to serve CYSHCN. In addition, we will:

1. Strengthen relationships with local, state and federal officials through connections with professional medical societies, a seat on OHSU’s Legislative Advisory Committee, and close collaboration with OHSU Government Relations.
2. Lead efforts to improve access to developmental-behavioral pediatrics diagnostic and therapeutic services, strengthening relationships with health systems, providers and advocates.
3. OCCYSHN’s Director will continue serving as medical director for Oregon’s new universally-offered infant home visiting program.
4. Collaborate with Medicaid to implement changes resulting from the 1115 Waiver process (SPM Activity 3.1.2).
5. Build and strengthen relationships with LPHAs, community health and service providers, and community-based organizations.
6. Hold regional meetings with LPHAs to assess their local needs and assets for serving CYSHCN.
7. Continue to strengthen and leverage relationships with high-level stakeholders working to develop the CHW workforce.
8. OCCYSHN’s director will conclude his presidency of the American Academy of Pediatrics (through 2024) and assume the role of past-president (through 2025). This includes implantation of the AAP’s Health Equity Work Plan, and the AAP Board of Directors’ Strategic Initiative on Equity, Diversity, and Inclusion.

Timeline: 10/1/24 - 9/30/25

 

Strategy S3.2:

OCCYSHN will increase access to community-based autism diagnostic services through implementation of community-based autism evaluation teams.

 

Activity 3.2.1. ACCESS (Assuring Comprehensive Care through Enhanced Service Systems for Children with Autism Spectrum Disorder)

OCCYSHN will:

1. Support sustainability of ACCESS teams to improve equitable access to care and services for children and families in rural Oregon. This includes those families who experience specific barriers to care related to the social drivers of health.
2. Pursue alignment between ACCESS and the Portland metro area’s Autism Assessment Capacity Project (AACP).
3. Support development of new ACCESS teams and increase the number of children and families served in rural and semi-rural areas of the state.
4. Provide technical assistance and training to new and existing ACCESS teams using the ECHO virtual learning collaborative model. Conduct individualized virtual visits and an annual statewide meeting.
5. Engage autism subject matter experts to participate in ACCESS ECHO sessions.
6. Continue to facilitate individual professional interest groups for ACCESS Parent Partners and ACCESS medical providers, to promote shared learning among peers.

Timeline: 10/1/24 – 9/30/25

 

Activity 3.2.2. ACCESS Family Involvement

The family perspective and voice are integrated into the ACCESS project. A Family Involvement Program representative will:

1. Participate in all ACCESS project planning, resource development, and ECHO sessions.
2. Attend virtual learning collaborative ECHO sessions for ACCESS participants. Offer family perspective and reflections.
3. Provide new resources for providers to share with families at each session.
4. Work with ACCESS Parent Partners to develop a family-focused didactic presentation for ACCESS teams.
5. Offer technical assistance to ACCESS teams on recruiting, selecting, and supervising Parent Partners.
6. Convene an every-other-month meeting of all ACCESS Parent Partners, the Family Involvement Manager, and the ACCESS project manager for communication, mutual support, and resource sharing.

Timeline: 10/1/24 – 9/30/25

 

Activity 3.2.3. ACCESS Equity

OCCYSHN will:

1. Support development of new ACCESS teams and increase the number of children and families served in rural and semi-rural areas of the state.
2. Encourage ACCESS teams to recruit and retain a diverse group of providers and Parent Partners.
3. Include topics related to CLAS, SDOH and health equity in ACCESS ECHO sessions.

Timeline: 10/1/24 – 9/30/25

 

Activity 3.2.4. Systems and Policy

OCCYSHN will:

1. Integrate equity topics into OCCYSHN’s 2025 Cross-Systems Care Coordination conference and invite diverse community-based groups to attend.
2. Address equity by expanding cross-sector care coordination in OCCYSHN’s Pilot: CHWs Improving Care Navigation for Latino Families of CYSHCN. The care coordination provided includes a focus on SDOH (NPM Activity 11.7).
3. Inform and promote Medicaid expansion for youth with special health care needs (YSHCN) to age 26. Expansion will address SDOH for YSHCN and increase the traditional health worker (THW) workforce that supports them. (THW is the broad category of navigators that includes CHWs.) 
4. Promote Early Periodic Screening, Diagnosis, and Treatment (EPSDT) as a mechanism to improve health equity by ensuring CYSHCN receive all the care and services they need.
5. Collaborate with and support the work of the Autism Assessment Capacity Project (AACP), which includes training the pediatric workforce in the Portland Metro area to evaluate young children for autism (SPM Activity 3.2.1).
6. Support ACCESS teams, based on community-specific needs (SPM Activity 3.2.1).
7. Ensure ACCESS and AACP are coordinated and aligned.
8. Complete AACP evaluation activities by March 2025.
9. Raise awareness about ACCESS services by disseminating information to state agencies, CCOs, primary care providers, and public health home visitors (SPM Activity 3.2.1).

Timeline: 10/1/24 – 9/30/25

 

Strategy S3.3:

Activity 3.3.1. Assess Emergency Preparedness

To improve statewide emergency planning and preparedness for CYSHCN and their families OCCYSHN’s Family Involvement Program and the Oregon Family to Family Health Information Center (ORF2FHIC) will:

1. Leverage ORF2FHIC’s connections with families and dissemination channels (newsletters, social media) to share information and training opportunities on emergency preparedness.
2. Identify opportunities for policy input at the state level and recruit families (especially families of medically complex children) to contribute.
3. Maintain and bolster the ORF2FHIC website with practical, family-centered resources including the UCEDD’s Ready Now toolkit and the American Academy of Pediatrics’ Disaster Preparedness for CYSHCN toolkit. 
4. Offer the training Practical Emergency Preparedness for Busy Families, virtually and in person. 
5. Advise development of the annual Safe and Secure Summit, an event featuring health and safety related workshops and exhibits for families of Oregon CYSHCN.
6. Promote HERO Kids Registry (NPM Activity 11.10) as a means of helping families reunify in the event of an emergency.
7. Host two Table Talks (one in English and one in Spanish) on the subject of emergency preparedness for families of CYSHCN.

Timeline: 10/1/24 – 9/30/25

 

 

Foundations – Policy and Systems Plan (October 2024 – September 2025)

 

Foundations – Policy and Systems Strategy #1:

Strengthen economic supports for families through policy development, implementation, and promotion (e.g., EITC, child tax credit, subsidized childcare, Paid Leave Oregon).

 

State level activities/timeline:

1. Continue to partner with OHA’s Employee Resource Groups, MCH and CP&HP management to assess, develop, and implement equitable and family friendly policies for OHA/PHD employees (e.g., Oregon Paid Leave, flexible scheduling, etc.).

Timeline: 10/1/24 - 9/30/25

2. Continue to use findings and recommendations from environmental scan of ongoing efforts to strengthen economic supports and policies for the MCH population across state and local Public Health – including MCH programs, to identify opportunities with partners and to determine where this work settles into existing staff roles and capacity. Continue to develop partnerships and policy priorities to advance MCH role in economic support policies and initiatives.

Timeline: 10/1/24 - 9/30/25

3. Continue to engage families and partners in the MCH community to identify ways in which Title V can support SDOH-E, including policy and systems to strengthen economic supports for families through conducting the Title V needs assessment with contractor, Oregon State University.

Timeline: 10/1/24 - 9/30/25

 

Local level activities/timeline:

The following activities will occur during the state fiscal timeline (7/1/24 - 6/30/25):

Lincoln County: Plans to develop and implement an internal policy to support chest/breastfeeding friendly practices for staff, including the development of a chest/breastfeeding space in main HHS office. HHS would like to document the process of developing this policy and space to act as a resource for community employers.

 

Foundations – Policy and Systems Strategy #2:

Develop and/or strengthen systems and partnerships to promote food sovereignty, and address food security and systemic barriers to accessing food resources.

 

State level activities/timeline:

1. Partner with state-level organizations to support cross-collaboration with food security initiatives:

• O-SNAC (Oregon State Nutrition Action Committee for SNAP-Ed) through attendance at quarterly meetings and collaboration with Title V activities
• Nutrition Council of Oregon to support nutrition security initiatives and collaborations through bi-monthly meetings.
• Provide expertise to OHA’s Medicaid 1115 Waiver, Health Related Social Needs nutrition services.
• NW Portland Area Indian Health Board to support the NW Tribal Food Sovereignty Coalition (NTFSC) and food sovereignty activities among Oregon tribes.
• Develop new partnerships as identified to address food security initiatives.

Timeline: 10/1/24 - 9/30/25

2. Support the NW Tribal Food Sovereignty Coalition (NTFSC) to support food sovereignty activities among Oregon Tribes, building on their community-centered education approach of food preservation.

Timeline: 10/1/24 - 9/30/25

3. Explore sustainability for food security policy and systems work at state and local level.

Timeline: 10/1/24 - 9/30/25

4. Support the local grantees to implement and strengthen food security screening and referral systems, including partnership development.

Timeline: 10/1/24 - 9/30/25

 

Local level activities/timeline:

The following activities will occur during the state fiscal timeline (7/1/24 - 6/30/25):

• Five grantees have selected strategy 2 under Foundations Policy and Systems: Develop and/or strengthen systems and partnerships to promote food sovereignty, and address food security and systemic barriers to accessing food resources.
• Baker County, Clackamas County, Linn County, and Confederated Tribes of the Umatilla Indian Reservation are participating in cross-sector coalitions such as food policy councils or other community partnerships to address food access barriers. Screening and referral systems may be included in their work.
• Harney County and Confederated Tribes of the Umatilla Indian Reservation will work with community members directly with food access and food and nutrition education.

 

Foundations – Policy and Systems Strategy #3:

Foster cross-system coordination and integration to ensure screening and referral for SDOH, and equitable access to needed services for the MCAH population.

 

State level activities/timeline:

1. Continue to identify opportunities for MCH participation in state level, cross-system efforts to screen for SDOH needs and refer to social safety net supports, including local Title V representation in Community Information Exchange (CIE) networks. 

Timeline: 10/1/24 - 9/30/25

2. Support local partners to build capacity in trauma-informed SDOH needs screening implementation.

Timeline: 10/1/24 - 9/30/25

 

Local level activities/timeline:

The following activities will occur during the state fiscal timeline (7/1/24 - 6/30/25):

• 2 grantees (Jackson and Lane) will continue to build and strengthen community partnerships, developing systems for SDOH screening and referral. Jackson will continue to work on developing a communication system through an electronic medical record in order to integrate communication between home visiting nurses and medical care teams in the community; Lane County will strengthen local relationships through supporting the home visiting innovation team, which brings together local home visiting programs and local partners.

 

Foundations – Policy and Systems Strategy #4:

Develop and implement systems that actively promote equitable, anti-racist, and trauma-informed workplaces, institutions, and services.

 

State level activities/timeline:

1. Work with MCH teams to develop specific, achievable equity goals including providing technical assistance and other resources to help accomplish these goals.

Timeline: 10/1/24 - 9/30/25

2. Review/update SOAR goals and provide any needed technical assistance to MCH program teams on developing/achieving these goals.

Timeline: 10/1/24 - 9/30/25

3. Assess the implementation of trauma-informed and accessible meeting guidelines and work with MCH team leads to make improvements where needed.

Timeline: 10/1/24 - 2/28/25

 

Local level activities/timeline:

The following activities will occur during the state fiscal timeline (7/1/24 - 6/30/25):

• Columbia County is currently in the process of completing the Trauma Informed Care Assessment, and the information gathered from this assessment will be used to develop the first iteration of staff trainings. The information gained from the assessment will support the establishment of TIC trainings.
• Coos County will continue to add equity lens’ to the newly developed CHW Equity Handbook.
• Josephine County will assess what translation services are available, and contract with a translation agency to improve language accessibility on the county’s public health website.

 

Foundations – Policy and Systems Strategy #5:

Strengthen policies and systems that provide equitable access to safe, stable, and affordable housing for the MCAH population.

 

State level activities/timeline:

1. Continue to strengthen partnerships with state/community-based programs and agencies around opportunities for MCH Title V to support housing stability and equitable access to healthy affordable homes for all Oregon families.

Timeline: 10/1/24 - 9/30/25

2. Continue to build, support and integrate MCH and housing strategies at both the state and local levels. The goal is to build out specific ways in which the MCAH Title V program can support safe, stable, and equitable housing for the MCH population.

Timeline: 10/1/24 - 9/30/25

3. Continue to seek funding and other supports needed to implement the partnerships, policy and systems changes identified for focus.

Timeline: 10/1/24 - 12/31/24

4. Provide information on MCH and housing strategies and support to local grantees to expand interest in using MCH Title V grant funds to support work on the MCAH housing strategy.

Timeline: 10/1/24 - 9/30/25

 

Local level activities/timeline:

The following activities will occur during the state fiscal timeline (7/1/24 - 6/30/25):

• Strategy not selected by local grantees.

 

Critical partnerships:

Strategy 1: Local Public Health Authorities, Tribes, CCOs, Division of Early Learning and Care, Early Learning Hubs, Oregon Department of Human Services, OHA Transformation Center, OHA Office of Health Information Technology, Trauma Informed Oregon, Connect Oregon (UniteUS), Help Me Grow, Aunt Bertha, Oregon Primary Care Association (SDOH screening), 211info, OHA Social Determinants of Health workgroup, Healthy Families Employee Resource Group, ODHS Self Sufficiency Program, Community Partner Outreach Program, Prenatal to 3 Policy Impact Center

 

Strategy 2: Public Health Division – other programs including those working on the 1115 Medicaid waiver, WIC program, Health Promotion and Chronic Disease Prevention; OHA Health Policy and Analytics, OHA Health Services Division, Oregon Department of Human Services, Oregon State University Extension SNAP-Ed, Oregon Department of Education, Child Nutrition Programs, NW Portland Area Indian Health Board, NW Tribal Food Sovereignty Coalition, Nutrition Council of Oregon members, Association of State Public Health Nutritionist, Local grantees and tribes working on this strategy.

 

Strategy 3: Local Public Health Authorities, Tribes, CCOs, Division of Early Learning and Care, Early Learning Hubs, Oregon Department of Human Services, OHA Transformation Center, OHA Office of Health Information Technology, Trauma Informed Oregon, Connect Oregon (UniteUS), Help Me Grow, Aunt Bertha, Oregon Primary Care Association (SDoH screening), 211info, OHA Social Determinants of Health workgroup.

 

Strategy 4: Local MCH programs often combine efforts with other public health programs, and in many instances, rely on partnering with their local health commissioners.

 

Strategy 5: Oregon Housing and Community Services, Oregon Dept of Human Services, Healthier Together Oregon, Community agencies working on housing for families, Oregon Department of Early Learning and Care, Oregon Coordinated Care Organizations, Oregon’s Medicaid program 1115 waiver, Oregon Governor’s housing and homelessness work; Oregon Public Health Division Social Determinants of Health and Equity Coordination Workgroup, Oregon Medicaid Transformation Center.

 

Foundations – Workforce Capacity & Effectiveness Plan (October 2024 – September 2025)

 

Foundations – Workforce Capacity & Effectiveness Strategy #1:

Advance the skills and abilities of the workforce to deliver equitable, trauma informed, and culturally and linguistically responsive services.

 

State level activities/timeline:

1. Identify ongoing support needs for MCH staff for continued growth on anti-racism and trauma-informed workplace/care principles.

Timeline: 10/1/24 - 9/30/25

2. Review and respond to local grantee plans to identify potential TA needs. 

Timeline: 10/1/24 - 9/30/25

3. Identify areas of TA with other Title V priority area workgroups. 

Timeline: 10/1/24 - 9/30/25

 

Local level activities/timeline:

The following activities will occur during the state fiscal timeline (7/1/24 - 6/30/25):

• Coos County will provide training and education for perinatal providers and community partners including anti-racism trainings and other SDOH areas. The prior year’s CHW-wide assessments (HV staff included) indicated areas of equity that need further education to advance equity.
• Benton County will identify and schedule a provider to deliver trauma-informed care training for the MCH staff and develop strategies to enhance trauma informed care practices in the workplace and in the MCH program and begin implementing them.
• Malheur and Morrow County will participate in TA opportunities to improve knowledge and skills in equity, trauma/ACEs, and CLAS (including home visiting staff). Opportunities for training will increase staff retention and improve outreach and services to culturally diverse communities.
• Multnomah County will assess workforce standards currently in place and develop an action plan to provide anti-racism training and education for perinatal providers and community partners.
• Confederated Tribes of the Warm Springs will close the information gaps on doula reimbursements, as well as provide lactation classes for new families. Lactation support has been a challenge, and continued support of doulas in perinatal health has been very helpful in this area.

 

Foundations – Workforce Capacity & Effectiveness Strategy #2:

Implement standards for workforce development that address bias and improve delivery of equitable, trauma-informed, and culturally and linguistically responsive services.

 

State level activities/timeline:

1. Continue to support MCH program teams on Equity SOAR goals and implementation plans.

Timeline: 10/1/24 - 9/30/25

2. Create a web-based searchable database of racial equity, trauma-informed, and accessibility related trainings and resources that will be accessible to MCH staff and partners.

Timeline: 10/1/24 - 12/30/24

3. Continue to provide educational opportunities and in-depth discussion spaces on current equity and trauma-informed workplace topics and challenges.  

Timeline: 10/1/24 - 9/30/25

 

Local level activities/timeline:

The following activities will occur during the state fiscal timeline (7/1/24 - 6/30/25):

• Strategy not selected by any local grantees.

 

Foundations – Workforce Capacity & Effectiveness Strategy #3:

Support efforts to expand capacity and improve diversity in the workforce.

 

State level activities/timeline:

1. The State MCH team will continue to work closely with local grantees to provide support and technical assistance where needed.  

Timeline: 10/1/24 - 9/30/25

2. Having identified primary areas of workforce capacity needs, the state team will continue to research, plan, and implement strategies in these three areas:  
   • Support and enhance the skills and stability of the current Title V public health and tribal grantee MCH workforce in Oregon (ensure that the current workforce is culturally and community-responsive).
   •  Support the development of systems that create diverse, trauma-informed, and supportive workplaces for Oregon’s MCH workforce.  
   • Nurture new potential recruits to the MCH workforce who reflect the diverse communities that we serve (creating pathways)

Timeline: 10/1/24 - 9/30/25

 

Local level activities/timeline:

The following activities will occur during the state fiscal timeline (7/1/24 - 6/30/25):

• Marion County will support CHWs and doulas working with the MCH population in becoming an OHA certified Traditional Health Workers. Training for certification will begin this fall, and they plan to finish certification by the end of the grant period.

 

Critical partnerships:

MCH Workforce Development Center, local grantees, agencies, and organizations identified as potential partners during our Workforce Development Inventory.

 

Foundations – Community, Individual, and Family Capacity Plan (October 2024 – September 2025)

 

Foundations – Community, Individual, and Family Capacity Strategy #1:

Support/fund programs - such as home visiting - that engage families and build parent capabilities, resilience, supportive/nurturing relationships, and children’s social-emotional competence.

 

State level activities/timeline:

1. Partner with the Oregon’s Maternal and Child Health Section’s Home Visiting Teams to support implementation of public health nurse home visiting programs.

Timeline: 10/1/24 - 9/30/25

2. Partner with the Center for Coordinating Oregon Home Visiting Systems to support coordination and collaboration among Oregon’s Home Visiting programs.

Timeline: 10/1/24 - 9/30/25

 

Local level activities/timeline:

The following activities will occur during the state fiscal timeline (7/1/24 - 6/30/25):

• Baker Country: Ongoing participation in the Home Visiting Network to support coordination among different home visiting programs in the community so that clients can have access to the program that best suits their needs. The Network is currently interested in developing a shared community resource directory.
• Cow Creek: The Cow Creek Public Health Division is expanding their programs and services to meet the relational and public health needs for their Tribal families. This funding will be used to support their effort in engaging young families and those expecting new babies and engage them in public health services across the life span by promoting strong relationships that are culturally appropriate.
• Gillam County: Continue to lay the groundwork to bring the Babies 1st! home visiting program to Gilliam County. Full program implementation is anticipated by July 1, 2024.
• Jackson County: Stabilize funding support for nurse home visiting in Jackson County.
• Jefferson County: Continue to build capacity for increased coordination of home visiting services (Babies First, CaCoon, Family Connects) and other family support services (Oregon MothersCare, Perinatal Care Coordinator/CHW).
• Lane County: Referral catchment and outreach is to be conducted based on locally identified priority populations for those families with the most potential to benefit from intensive support by a home visitor. With more support for the Babies First! program, historically underserved families are able to receive much needed Home Visiting support.
• Malheur County: Enhance access to parenting education and support by referring Family Connects clients to long-term home visiting services (Building Home Families, HFO, TFP, Babies First!).
• Marion County: Support outreach to provide more services though the Babies First! and CaCoon home visiting programs.
• Multnomah County: Partner with African Family Holistic Health Organization (AFHHO) to enroll pregnant women into the Healthy Birth Initiative program. HBI and AFHHO will work together in building community between both organizations.
• North Central Public Health: Increase engagement of CHWs in home visiting sessions.
• Washington County: Sustain existing home visiting programs (Babies First, CaCoon, NFP).

 

Foundations – Community, Individual, and Family Capacity Strategy #2:

Build community capacity for improved health, resilience, social/cultural connection, and equity.

 

State level activities/timeline:

1. Engage with state level inter-agency collaborations and cross-systems initiatives that work to prevent/address trauma and ACEs and promote resilience; and promote social determinants of health and equity at the community level.

Timeline: 10/1/24 - 9/30/25

2. Continue to expand partnerships and links with initiatives within MCH, CP&HP and OHA/PHD that fund community-based organizations elevate family/community voice, and/or enhance partnerships to build resilient, trauma-informed communities.

Timeline: 10/1/24 - 9/30/25

3. Support the development of systems and programs that enhance community capacity and are accountable to the people they serve, particularly communities of color.

Timeline: 10/1/24 - 9/30/25

 

Local level activities/timeline:

The following activities will occur during the state fiscal timeline (7/1/24 - 6/30/25):

• Clackamas County: Create opportunities and spaces for connection to community, spirituality and culture through community-based classes and events.

• Columbia County: Work with community partners to set up systems and collect data related to youth immunization.
• Coquille Tribe- Create opportunities and spaces to connect to community, spirituality, and culture. Convene partners to address trauma and promote resilience.
• Confederated Tribes of Warm Springs: Conduct community classes to teach families to make and safely use baby boards – a traditional infant care practice.
• Multnomah County: Work with Future Generations Collaborative, an Indigenous led program focused on providing prevention and support for community members impacted by FASD. Activities include healing through culture with activities focused on early childhood education and collaboration, culturally specific baby shower, legislative advocacy, and culturally specific programming.

 

Critical partnerships:

Strategy 1: Oregon’s Department of Early Learning and Care, the Center for Coordinating Oregon’s Home Visiting Systems, Oregon Maternal, Infant, Early Childhood Home Visiting (MIECHV) team, Family Connects Oregon team, MCH Nurse Consultant Team.

 

Strategy 2: Local Public Health Authorities, Tribes, MCH Health Equity Workgroup, PHD Community Engagement Community of Practice, community-based organizations, PHD Director’s Office, Trauma-Informed Oregon, OHA Trauma-Informed Policy workgroup, Injury and Violence Prevention Section, Adolescent ScreenWise and Reproductive Health Section, Health Promotion and Chronic Disease Prevention Section, fiscal staff, community members.

 

Foundations – Assessment & Evaluation Plan (October 2024 – September 2025)

 

Foundations – Assessment & Evaluation Strategy #1:

Ensure all Title V performance measurement and evaluation includes a health equity focus which leads with race and ethnicity to identify and address disparities.

 

State level activities/timeline:

1. Where possible, report Title V performance measures by race and ethnicity, disability, gender, age, sexual orientation, socioeconomic status, nationality, and geographic location. Annually examine available disparities in performance measures to allow for targeting of programs and interventions.

• Review TV NPMs SPMs NOMs ESMs for disparities, produce report of relevant findings.
• Annual review of ESM framework to include racial equity focus of new measures where relevant.
• Develop THEO reporting process to reflect equity lens.

Timeline: 10/1/24 - 9/30/25

2. Expand the use of a rigorous evaluation framework and continuous quality improvement across SDOH, Equity, CLAS, and Trauma strategies/Provide evaluation technical assistance to programs that use Title V funding.

• Develop and implement the next stage of Babies First! evaluation, part of which is to include engagement of clients and impacted communities and families.
• Provide consultation with foundations strategy leads to provide technical assistance with evaluating foundations activities.

Timeline: 10/1/24 - 9/30/25

 

Local level activities/timeline:

The following activities will occur during the state fiscal timeline (7/1/24 - 6/30/25):

•      Strategy not selected by any local grantees.

 

Foundations – Assessment & Evaluation Strategy #2:

Conduct continuous needs assessment and/or analysis to add to the Foundations of MCAH (SDOH, Equity, CLAS, and Trauma/ACES) knowledge base and improve effectiveness of Title V interventions and innovations.

 

State level activities/timeline:

1. Conduct community needs assessment and/or surveys.
   • Work in partnership with OSU to gather community voice information from communities of color and other marginalized communities.

Timeline: 10/1/24 - 9/30/25

2. As necessary, develop policy briefs using state and local data; present to policy makers to inform policy, funding, and program decisions impacting children, youth and families.
   • Attend monthly policy team meetings to provide data consult and produce data briefs as necessary.
   • Provide AE&I consultation to equity efforts across the section, including through the Policy and Equity teams.

Timeline: 10/1/24 - 9/30/25

3. Engage impacted communities to ensure that needs assessment results and/or other MCH data is accessible and useful to them.

• Develop a strategy for disseminating MCAH data and jointly interpreting it with impacted communities.

Timeline: 10/1/24 - 9/30/25

4. Review all Title V programming to ensure that Oregon Health Authority REAL D protocols for data collection are used wherever possible, or that there is a plan in place to transition to use of the protocols.

Timeline: 10/1/24 - 9/30/25

5. Conduct exploratory analysis of specific foundational topics.

Timeline: 10/1/24 - 9/30/25

 

Local level activities/timeline:

The following activities will occur during the state fiscal timeline (7/1/24 - 6/30/25):

• Strategy not selected by any local grantees.

 

Foundations – Assessment & Evaluation Strategy #3:

Assess local needs and conduct quality improvement to ensure alignment of Title V efforts to the needs of diverse MCAH communities in Oregon.

 

State level activities/timeline:

1. Develop partnerships with culturally specific and/or responsive organizations and their constituents to engage them in all phases of MCAH research, assessment, and planning activities.

• In partnership with Oregon State University, engage and collaborate with community partners in each stage of the 2025 Title V Needs Assessment. Community partners will be engaged in the planning, data collection, data synthesis, and data interpretation stages of the needs assessment.
• Partner with Babies First! and CaCoon to develop next phase of evaluation plan which is to include client feedback.
• Ongoing partnership with section surveys and programs to engage community in A&E.
• Develop a strategy for disseminating MCAH data and jointly interpreting it with impacted communities.

Timeline: 10/1/24 - 9/30/25

 

Local level activities/timeline:

The following activities will occur during the state fiscal timeline (7/1/24 - 6/30/25):

• Lane County: Assess client experience of participation in home visiting.
  • Continuing and building on client feedback through surveys
  • Identify and implement any opportunities for CQI.
  • Disaggregate survey responses by race/ethnicity to determine reach to diverse communities.
• Tillamook County: Conduct local level community needs assessment with a focus on identifying disparities by race/ethnicity, disability, geography, etc.
  • Perform a comprehensive program assessment that examines current services delivered, identifies the gaps in services between the various home visiting programs offered in the county, and identifies the priority needs of the communities served.
  • Offer assessment to all active home visiting clients, with a goal response rate of at least 50%.

 

Foundations – Assessment & Evaluation Strategy #4:

Engage families and communities in all phases of MCAH assessment, surveillance, and epidemiology, including interpretation and dissemination of findings.

 

State level activities/timeline:

1. Fund impacted communities to participate in research and assessment activities.

• In partnership with Oregon State University, provide funding to impacted communities for assessment of needs, through the 2025 Title V needs assessment community listening sessions.

Timeline: 10/1/24 - 9/30/25

2. Include communities or individuals involved in research activities as equal partners in decision making (including resource allocation) based on the research outcomes.

• In partnership with Oregon State University, engage communities/individuals in decision making during the 2025 Title V needs assessment, through their inclusion in the advisory group and the prioritization process.

Timeline: 10/1/24 - 9/30/25

 

Local level activities/timeline:

The following activities will occur during the state fiscal timeline (7/1/24 - 6/30/25):

• Strategy not selected by any local grantees.

 

Critical partnerships:

CSTE/CDC Applied Epidemiology Fellowship; CDC MCH Epidemiology Program Sponsored Assignee to Oregon; Association of State Public Health Nutritionists; Lane County Public Health; Tillamook County Public Health Oregon State University

 

Other Title V work in the Cross-Cutting/Systems Building Domain:

(Plan- October 2024 – September 2025)

 

Oregon’s MCAH Title V program will continue to provide a broad range of support to policy and systems, workforce, assessment, and epidemiology. and individual/community capacity efforts across this domain through our upstream Foundations of MCAH work.

 

Additional planned work in this domain for the coming year includes:

• Continued involvement in the implement of Oregon’s groundbreaking 1115 Medicaid Waiver including the expansion of services for youth with special health care needs, implementation of the Health-Related Social Needs services, and implementation of expanded services for transition-age CYSHCN and continuous enrollment for children through age 6.
• Continued support for the implementation of the full EPSDT program for Oregon’s children, and related family and provider communications.
• Development and initial implementation of our family/community and equity centered 5-year Title Needs Assessment.
• Title V Nutrition Consultant manages a grant received from Association of State Public Health Nutritionists (ASPHN), Building State Capacity for Nutrition Integration, which has nutrition and food security as a component of project. The funder of ASPHN is the Maternal and Child Health Bureau.
• Analysis of race/ethnicity oversample data from the National Survey of Children’s Health to identify inequities in maternal and child health outcomes in Oregon.

 

Other Title V Programmatic Efforts -

In addition to investments in the three state-specific cross-cutting priorities, Oregon’s Title V program also invests in cross-cutting system-building activities including MCAH and CYSHCN data infrastructure (epidemiology, assessment, evaluation, and informatics), communications, workforce development, and partnerships to develop MCAH policy and coordinated systems which go beyond any one priority or domain. This work is essential to carry out the core public health functions of Title V in support of Oregon’s MCAH populations as outlined below. The work, housed within the Center for Prevention & Health Promotion (CP&HP) under the Title V MCH Director, and the Oregon Center for Children and Youth with Special Health Needs (OCCYSHN) under the Title V CYSHCN Director, will continue during the upcoming grant year and is described below.

 

Policy and System Development:

• MCAH: The Title V program’s work in policy and system development includes support for adolescent health staff working on coordinated school health, confidentiality of adolescent health services across systems, and providing adolescent health expertise to cross-agency and community policy and systems initiatives. Title V MCAH policy staff work with multiple agency and health system partners to improve quality, coordination, and accessibility of a broad range of services and policy initiatives that impact health and development of the MCAH population. They also coordinate and serve on the Title V-Medicaid MOU team. Positions supported include the Title V Director, the MCH Policy Lead/Title V Coordinator, the MCH Health Educator, the Adolescent Health Policy Analyst, the Title V Adolescent Health Coordinator, as well as staff working on intimate partner violence, ACEs, health equity, perinatal access and quality of care, safe sleep, oral health, a variety of other child health policy initiatives, as well as emerging issues such as maternal morbidity/mortality and the opioid epidemic.
• CYSHCN: OCCYSHN advocates for systems-level improvements for CYSHCN at every level (See Supplemental Document 1). We increase awareness about the challenges facing Oregon CYSHCN, their families, and their care providers. Our staff sits on state and local level advisory boards, committees, and workgroups to ensure the needs of CYSHCN, and their families are represented. We also play an active role in OHSU’s efforts to serve CYSHCN. OCCYSHN staff tracks the work of state and regional committees (e.g., Oregon Health Policy Board, Early Learning Division, Oregon Department of Education, Oregon Department of Human Services, Systems of Care Advisory council) and attends state conferences (e.g., Oregon State of Reform Health Policy Conference, Coordinated Care Organization annual conference) to inform strategic advocacy. We provide input on policy development with potential to impact CYSHCN, and we offer oral and written testimony at local, state, and national levels. We disseminate information critical to CYSHCN-serving agencies and organizations through our website and Facebook pages.
• OCCYSHN’s Systems and Workforce Development unit tracks and reviews systems and policy developments and identifies opportunities to inform change.  Participating in policy workgroups is essential to promoting integrated systems for CYSHCN. OCCYSHN will continue to seek such opportunities in 2024-25.

 

Communications, Outreach, and Community Engagement:

• MCAH: Title V supports a state-level health education and communications specialist who works on dissemination of MCAH data and educational messaging, social media outreach, as well as cultural and linguistic accessibility of MCAH materials, and communications consultation to Local Public Health Authorities.  The communications specialist is also the primary MCH liaison to the state Public Health Division team that manages the state website, as well as to the publications team. Her work ensures that MCAH programs and materials are easily accessible to the public. Title V also supports two MCH specialists at Oregon’s 211info line to provide MCH warm-line information and referrals, as well as enhanced anticipatory guidance and linkage to services for MCH clients. Reports on the MCH outreach and community engagement conducted through 211info are delivered quarterly to a steering committee made up of representatives from MCH, immunizations, adolescent and reproductive health, and WIC. Working with 211info across the different programs that impact our MCAH populations ensures that clients receive comprehensive and integrated services when they contact our MCH warm line.
• CYSHCN: OCCYSHN’s Communications Specialist collaborates with staff to ensure strategic and effective communication. She collaborates with staff to develop and disseminate OCCYSHN program guidance and products. She manages OCCSYHN’s web and social media presence, and edits written public input. The Communications Specialist promotes health literacy standards both internally and with LPHA partners. OCCYSHN’s Assessment and Evaluation unit and Family Involvement Program engage families of CYSCHN to help inform OCCYSHN’s work with family perspective.

 

Epidemiology, Assessment, Evaluation, and Informatics:

• MCAH: Title V supports the MCH epidemiologist, research analysts, data management and informatics staff who conduct research, surveillance, and epidemiology (including PRAMS, ECHO, BRFSS, Oregon Student Health Survey, Birth Anomalies Surveillance System, and Oral Health Surveillance System), ongoing needs assessment, evaluation, and data collection/management and MCAH data dissemination functions across MCAH populations and programs. A critical project that crosses SSDI and Title V work continues to be the online Title V database that is available to all Title V grantees (local public health and Tribes). This database allows grantees to enter their Title V reports, plans, measures – as well as to record how much of their Title V funds will be directed to work in each Title V priority area. Title V staff can review and analyze grantee plans, as well as extract reports on strategies and priorities being undertaken across the state. The work of the SSDI program as well as other MCH Data work is described in detail in section III.E2.b.iii.
• CYSHCN: OCCYSHN supports an Assessment and Evaluation (A&E) unit, which is the data center of OCCYSHN. A&E is comprised of an A&E Manager, a senior program evaluation associate, a research associate and one research assistant. A&E is responsible for conducting ongoing and five-year assessment of the needs of Oregon CYSHCN and their families, monitoring, and evaluating block grant strategies, and coordinating with other OCCYSHN units to disseminate findings. A&E ensures that OCCYSHN’s goals and block grant strategies are guided and informed by empirical findings. OCCYSHN also continues to provide financial support to the THEO data system into which public health nurses record required home visiting program data, including CaCoon data.

 

Infrastructure and Finance:

• MCAH: Title V provides infrastructure support for management, as well as fiscal, communications and clerical staff that support both the grants management functions and clerical support needs of the Title V Director and other Title V staff.
• CYSHCN: OCCYSHN employs management, fiscal, and clerical staff required to support the Director and other OCCYSHN staff.