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

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

North Dakota State Performance Priority: Vision Zero – Eliminate Fatalities and Serious Injuries Caused by Motor Vehicle Crashes – 2023 Annual Plan Narrative (October 1, 2022– September 30, 2023):

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

According to the NDDOT, 3.48 (per 100,000) of North Dakota children less than 18 years of age died (an increase from 2.6) and 268 (per 100,000) were injured due to vehicle crashes within the years of 2016-2020. Of those injured, the injury severities were categorized by law enforcement crash reports as:

• suspected serious injury at 17.3 per 100,000 population;
• suspected minor injury at 126.1 per 100,000 population; and
• possible injury at 125 per 100,000 population.

Breaking the data down by age group for the years 2016-2020, children 0-13 had a death rate of 1.46 per 100,000 and injury rate of 113.2 per 100,000 compared to those in an older age group (14-17 years) with a fatality rate of 2.02 per 100,000 and injury rate of 155.3 per 100,000.

For child restraints to be effective during a crash, they must be correctly used according to the manufacturer’s instructions. Based on the 2021 NDDoH car seat checkups data collection through the National Digital Check Form dashboard, 74% of the car seats inspected had at least one form of misuse associated with it.  

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

For law enforcement activities, the plan will be to continue communication with law enforcement agencies about child passenger safety (CPS) resources through the online CPS Resource Order Form and CPS Resource Maps.  Enforcement of the child passenger safety law is an effective evidence-based activity when it is combined with the E’s in the Injury Prevention Model (and is the most effective of all the E’s).  In addition to enforcing the North Dakota CPS law, it is also important for law personnel to understand CPS best practices. Another goal for this time period will be to certify at least 10 law enforcement personnel through the National CPS Technician Certification Course. This was a recommendation that came from a National Highway Traffic Safety Administration Assessment completed with the North Dakota Department of Transportation (NDDOT). 

As part of education and enforcement, CPS trainings are incorporated into the law enforcement academies offered in North Dakota. This training will be updated within the next year and additional trainings will be added to the Fargo and Grand Forks academies.

For education activities, the plan will be to utilize media campaign materials created in the previous year for a social media and radio campaign focusing on booster seat use. According to the National Highway Traffic Safety Administration, about 20.8% of children ages 4 to 7 were prematurely moved to seat belts, when they should have been riding in booster seats.  The program will work with the NDDOT and Odney Advertising to create the plan for the campaign.

Education to the public through car seat checkups is a proven evidence based educational activity and will be offered to the public statewide. Car seat checkups will be scheduled statewide, and the program plans to continue to build infrastructure to continue checkups throughout North Dakota. Funding from the NDDOT and the Maternal and Child Health (MCH) Block Grant will allow the program to contract with agencies to conduct regional car seat checkups and CPS outreach. Those coordinating the checkups/outreach will offer hands-on education to the public as well as mentorship/recertification activities for local certified child passenger safety technicians.  The goal is to increase the number of car seat checkups offered by the NDDH for North Dakotans from 69 to 100 (5-year average). An additional goal set for the next time period is to increase the number of car seats checked statewide from 747 to 772 (5-year average). The program will create additional educational efforts to promote the checkups to increase the attendance at these public events.

The program will explore the possibility of increasing the number of contracts to support CPS coordinators in western and central North Dakota. The goal is to increase car seat checkups throughout the state, especially in the west and central regions. To increase attendance at the checkups, the program will continue to promote the use of the North Dakota Department of Health’s (NDDoH) Child Passenger Safety website (https://www.health.nd.gov/north-dakota-child-passenger-safety) that allows users to find car seat checkups, car seat classes and car seat distribution programs. This resource will be heavily promoted throughout the year to encourage the public to access child passenger safety assistance.

The department’s CPS program is responsible for coordinating National CPS Technician Certification trainings in North Dakota. Those that become certified by attending this training become certified Child Passenger Safety Technicians. The goal of the program is to increase the number of instructors (able to teach the training) in North Dakota in order to be able to offer the trainings throughout the state.  In addition to increasing instructors, the program will work to increase the number of CPS proxies in the state.  Both CPS instructors and proxies are utilized to mentor and recertify existing CPS techs. There are currently 308 certified Child Passenger Safety Technicians in the state.

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

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

North Dakota State Performance Priority: MCH Workforce Development– 2023 Annual Plan Narrative (October 1, 2022– September 30, 2023):

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

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

The North Dakota Department of Health’s (NDDoH) Health Equity Office (HEO) worked with department leadership to require all staff participate in a one-hour Cultural Competency training in 2021.The HEO is currently developing an additional training series to increase health equity knowledge; increasing cultural competency is an outcome of this training series. All MCH staff will be highly encouraged to participate in these trainings. The first two trainings, Health Equity and Bias, are scheduled to be released by September 2022.  

In May 2021, a proposal was received to initiate a formal Academic Health Department partnership between the NDDoH MCH program and the North Dakota State University Department of Public Health (NDSU DPH) to enhance the knowledge and skills of the current MCH workforce, build workforce capacity, and facilitate collaboration across the academic and practice communities. This partnership will provide much needed support to address NDDoH MCH leadership’s key concerns regarding the low percentage of MCH staff with formal public health training, low levels of preparedness to meet local and state MCH needs, limited access to expertise for quality community-based or applied public health research, and the need for MCH innovation among public health professionals in academic and practice environments.

To effectively build MCH workforce and innovation capacity in North Dakota, NDSU DPH requires two formally trained MCH faculty with research expertise. These faculty will help develop and deliver an NDSU MCH specialization for Master of Public Health (MPH) students and MCH content for workforce development and continuing education. They will additionally commit a dedicated percentage of time supporting the data analysis and research needs of North Dakota’s MCH programs. A formalized contractual agreement with NDSU has been implemented to ensure the objectives outlined in the proposal is successfully implemented. The outline of the proposal is as follows:

1. Develop/deliver MCH training program
   1. Program will emphasize public health and MCH leadership competencies
      1. Continuing education opportunities for current MCH staff
      2. Public Health Certificate in MCH leadership for current MCH staff and others interested in graduate-level education in MCH public health
      3. Master of Public Health (MPH) in MCH to provide comprehensive education and training in core public health and MCH leadership competencies
   2. With adequate faculty, we can apply for federal MCH training grants to expand the program

2. Provide MCH data analytic and research support
   1. Analyze and disseminate NDDoH MCH-related data
      1. Data used to monitor health status and health risk factors in North Dakota
      2. Analysis for required state and federal reporting
   2. Partner on studies of the causes and consequences of poor outcomes (e.g., maternal morbidity, poor birth outcomes, youth substance use) to inform MCH policy, programming, and prevention strategies
   3. Data analysis and grant-writing expertise for obtaining additional federal grants to study pressing MCH issues in North Dakota

The MCH Certificate Program is pending University approval; however, students can register for the General Public Heath Certificate Program and start taking classes in fall 2022 and transfer to the MCH Certificate Program in the spring of 2023 (the first class of the Public Health and MCH Certificate Programs are the same). The MCH Certificate Program will consist of twelve university credits and will be centered around public health management and policy, community health leadership, the foundations of MCH, and MCH epidemiology.

The NDDoH has a tuition reimbursement policy that may pay up to 80 percent of tuition and fees depending upon budget. The college course must be directly job related and have a stated public health purpose or benefit. This policy makes it more attainable for staff to consider enrolling in the program and advancing their learning and education. Currently, three MCH staff have submitted their application for acceptance into the fall 2022 Public Health Certificate Program. In addition to supporting state MCH staff to enroll into the MCH Certificate Program, the program is being widely announced and promoted statewide.

Another workforce development opportunity has been realized through the North Dakota Public Health Association (NDPHA). The Association is organized into sections, each representing a discipline of public health. This past year, a MCH section has been added and several state MCH staff are involved, including the Title V Director. MCH workforce development is a key priority for this section and hosting quarterly “MCH Brown Bag Lunch and Learns” is one strategy being implemented. The first MCH Brown Bag was held on March 30, 2022. The North & South Dakota Perinatal Quality Collaborative (NSDPQC) Coordinator provided an overview of work aims and efforts and shared opportunities for potential collaboration. Additional presentations are in development.    

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

North Dakota State Performance Priority: Implement all North Dakota State Mandates for the Maternal Child Health Population– 2023 Annual Plan Narrative (October 1, 2022– September 30, 2023):

Priorities are often influenced by state mandates, which in turn, are generally reflective of expressed need within the state over time. Inclusion of these mandates epitomizes the successful federal/state partnership by honoring a state’s unique priorities. North Dakota has several mandates addressing the health of the maternal and child health (MCH) population that direct Title V work efforts and require use of significant resources for successful implementation. No changes have occurred since the 2019 legislative session when the North Dakota Century Code 50-25.1-15. Abandoned Infant was amended directing the North Dakota Department of Health (NDDoH) to develop a public awareness campaign to provide information, public service announcements, and educational materials regarding abandoned infants and approved locations for abandoned infants. The MCH Public Health Specialist is led the efforts for this mandate. A list of mandates can be found in Section V., Supporting Documents, Title V-MCH State Mandates and are discussed below.

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

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

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

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

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

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

N.D.C.C. Chapters 23-01-03.1 and 25-17 mandates North Dakota’s Newborn Screening (NBS) Program. Newborn screening provides critical intervention to newborns who may be born with disorders that require immediate intervention. Currently, North Dakota screens for 51 conditions. The list of disorders is periodically reviewed and new conditions are added as new testing and follow-up methods become available. Conditions that are added to the panel are recommended by a national panel and are approved by the State Health Council. The screening and follow-up of newborns is performed in collaboration with the State Hygienic Lab and the University of Iowa Children’s Hospital in Iowa, as well as Special Health Services (SHS). Intermediate and long-term follow up after NBS has primarily been addressed in SHS by:

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

Along with the follow-up calls for babies with abnormal newborn screening results, SHS assists families with referrals for services, care coordination, and support. Information is provided regarding the SHS diagnostic and treatment program as well as other state-wide resources (e.g., WIC, North Dakota Medicaid, Early Intervention) to assist the family in meeting their needs, and to provide them support and direction during a time that can be very stressful and overwhelming. After a diagnosis is confirmed, the baby enters the long-term follow-up program until the age of six and the family is contacted on a quarterly basis for the first year of their baby’s life and annually thereafter to ensure the baby is healthy and to see if the family is having any difficulties with things such as insurance coverage, transportation, and medication. Financial eligibility for the SHS Financial Coverage Program is legislatively mandated at 185 percent of the federal poverty level. All current NBS conditions are approved medical conditions for SHS coverage. Title V supports staff to manage the NBS Program including a program director, long-term follow-up coordinator, and an administrative assistant. In addition, Title V funds support contracts for a medical director and metabolic disorder clinic. State funds have also been provided to the program to support medical consultation and genetic counseling services.

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

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

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