Introduction

Starting in fall 2018, the Department of Health (DOH) Office of Family and Community Health Improvement (OFCHI) formally began its work on the maternal and child health (MCH) five-year needs assessment to be completed in 2020. Under the guidance of the Title V MCH Director, an approach and timeline were developed and implemented.

 

Personnel from each of the OFCHI Title V sections were identified to work on a core team called the MCH Needs Assessment Workgroup. This team of eight individuals met twice monthly from fall 2018 through February 2020 to refine the approach, address emerging issues, and assure that work proceeded in a timely manner. The group formed teams and brought additional personnel into the work as needed.

 

The Title V MCH Director also convened a second group to inform the process from local perspectives, called the MCH Block Grant Needs Assessment Advisory Group. This group included nine representatives of local health jurisdictions (LHJs) and a staff person from the American Indian Health Commission’s Maternal and Infant Health program. The group’s makeup was diverse in the sizes and geographic locations of the organizations represented.

 

Together the Washington State Title V program leads and epidemiologists developed the needs assessment methods, collected data from four distinct qualitative data sources, completed qualitative and quantitative data analysis, and reviewed a number of community and DOH program documents as a part of this five-year needs assessment.

 

Qualitative data were a significant source of information for the needs assessment, and include the following: LHJ-specific needs assessment reports, notes from facilitated discussions with DOH staff and program partners, notes on key informant interviews from subject matter experts throughout Washington State, and a population-level Discovery Survey conducted online (more detail below).

 

Quantitative data used to inform the needs assessment included vital statistics data (birth, death, infant death), Pregnancy Risk Assessment Monitoring System (PRAMS), National Survey of Children’s Health, Washington State Smile Survey, and the Behavioral Risk Factor Surveillance System (BRFSS). Existing reports that informed the needs assessment include the Perinatal Indicators Report, the Home Visiting Needs Assessment, Washington State Maternal Mortality Report to the Legislature, and Infant Mortality Reduction Report. Information regarding data collection and management methods for these sources can be found at their respective program sites.

 

Primary Data Collection and Analysis Methods

 

Local Health Jurisdiction Needs Assessments

In order to provide community-level perspective on challenges and opportunities facing Title V activities, each LHJ conducted a local needs assessment in 2018-2019. These needs assessments used a combination of quantitative and qualitative methods. DOH developed a data-book with specific MCH indicators at an LHJ and state level, as well as related Healthy People 2020 goals. Each LHJ was asked to complete a brief report outlining the status of their MCH populations, including information on strengths, opportunities, and needs. The report included a narrative section as well as a list of topics to be ranked (High, Medium, Low, or Not Applicable) according to perceived priority and capacity to address at both an LHJ and community level.

 

These reports, submitted by all 35 LHJs, were reviewed independently by three DOH staff to assess regional patterns and themes in content. Final summary documents were uploaded and qualitatively analyzed in nVivo 11.0 using a coding schema that was developed using all primary data collection materials. Data was used to generate “word clouds” on various themes, and the coding schema was used to identify key quotes which most clearly represented identified patterns. In addition to integrating findings into an overall summary of needs assessment findings, an LHJ Needs Assessment Report was produced to be shared back with LHJs to help inform regional understanding and encourage continued participation in Title V partnerships and collaborative efforts. See Appendix B – MCH Local Work for additional information about the local needs assessments.

 

Facilitated Discussions

In the spring and summer of 2019, DOH conducted facilitated discussions with a range of stakeholder group to identify needs, gaps, and strengths related to the health and wellness of MCH Title V populations. Discussions were conducted separately with the following entities:

 

• American Indian Health Commission Maternal and Infant Health Workgroup
• Children and Youth with Special Health Care Needs Communication Network
• Essentials for Childhood Steering Committee
• Washington State Interagency Fatherhood Network
• Graduation, Reality, and Dual-Role Skills (GRADS) Instructors
• Home Visiting Advisory Committee
• Washington State Perinatal Collaborative
• DOH Office of Family and Community Health Improvement

 

Discussions included small group work to identify needs, strengths, and gaps on poster paper. Groups voted on top priority needs using stickers, and the results were discussed by the larger groups and collected by facilitators.

 

Notes were transcribed by DOH staff and all findings were divided into needs, strengths, and gaps. Final summary documents were uploaded and qualitatively analyzed in nVivo 11.0 using a coding schema that was developed using all primary data collection materials. Themes from these discussions were ranked based on the number of meeting groups they were mentioned in, the number of votes received, and the number of times each larger qualitative theme was coded into the summary notes.

 

Key Informant Interviews

Key informant interviews were conducted with community leaders representing a diverse array of communities around the state. Key themes of the interviews included: emerging and ongoing health needs of women, children, and families; local and regional strengths related to the ability to respond to identified needs and gaps; and gaps or improvements needed at a state level to address identified needs. DOH developed a key informant interview guide, and all interviews were conducted and documented by one of two partner staff at the University of Washington (UW) Medical Home Partnerships Project. Invitations to participate were sent from the Office Director for OFCHI, and UW staff were sent a list to follow up with each individual selected. Notes were shared back with interviewees to check for completeness and accuracy before being sent to DOH for analysis. Forty potential interviewees were selected, and twenty two interviews were completed.

 

Final summary documents were uploaded and qualitatively analyzed in nVivo 11.0 using a coding schema that was developed using all primary data collection materials.

 

Discovery Survey

In order to develop a broader understanding of emerging health needs across the state from the perspective of Washington residents, an online “Discovery Survey” was developed, modeled with permission after a Discovery Survey implemented by the state of Minnesota. Questions were intentionally open-ended in order to allow for and encourage responses that inform the needs assessment on all needs, and not limited only to those viewed as healthcare related or Title V funded. The survey included the following questions:

 

• What is the most important thing that women, children, and families need to live their fullest lives?
• What are the biggest unmet needs of women, children, and families in your community?

 

The survey also asked about geography, age, race/ethnicity, and public health role in order to determine which populations were best represented and where additional outreach might be needed. Informed by demographics of the first half of responses, and comparing that to statewide population demographics, we placed advertisements with the survey link on Facebook and Instagram, focused in zip code areas with high Hispanic and Latinx populations, in both English and Spanish language text. We received a total of 1,114 responses to the survey, which was open for a month.

The survey was conducted in English and Spanish using SurveyMonkey, and was later analyzed qualitatively in nVivo 11.0 using a coding schema that was developed using all primary data collection materials. All identifiable information was redacted prior to analysis. All responses were coded by content theme and by question asked, and then summarized in a draft MCH Block Grant Needs Assessment Summary report. There is ongoing work to develop thematic “story sheets” which take a closer look at specific themes and patterns that emerged.

 

Summary of Five-Year Needs Assessment Findings

The qualitative findings described below are summarized from four sources: the LHJ needs assessment reports, facilitated discussions with stakeholders, key informant interviews, and the Discovery Survey responses. Each section below includes an overall summary of need, specific needs identified by one or more of the four qualitative data sources, quotes by participants, and strengths.

 

The first section is about cross-cutting topics. These were identified by participants in all four qualitative data collection methods. After cross-cutting topics are findings specific to the Title V population domains: women, infants, children, adolescents, and children with special health care needs. In addition to qualitative findings, the population domain sections include quantitative data used to describe the populations, key indicators, and disparities.

 

Appendix C includes a list of priorities and performance measures selected in the needs assessment process for the each of the population domains.

 

Cross-Cutting Topics

Cross-cutting topics include need and gaps across all MCH populations. Many of these are also considered social determinants of health.

 

Needs. Participants in the needs assessment identified six broad cross-cutting needs or gaps for women, children and families in Washington:

 

1. Families across the state are struggling with cost of living, and their health and wellness are negatively impacted. In the Discovery Survey, the impacts of the social determinants of health often came before healthcare needs. In all data sources people speak of need for economic security and the challenges of  poverty.

• Poverty and lack of economic security impact the MCH population and families’ ability to meet basic needs. This is reported across the state and in many urban counties. While lower wage jobs are available in areas such as Seattle, Tacoma, and Spokane, the income does not cover the cost of living. (LHJ summary)
• Participants reference several ways to work toward economic security and reduce poverty, including adding more jobs with living wages, job training, and better family leave policies. (Facilitated discussion summary)

 

My husband and I need fair wages and prices so we can raise our children and have time for self-care and exercise and enough money just to cover mortgage/car and basic bills. (Discovery Survey participant)

 

2. Housing, childcare, transportation, and food security top the list of essentials needed to ensure women, children and families could live their most healthy lives.

• Citing homelessness and economic concerns, participants emphasize the importance of affordable housing for low- and middle-income populations. For families in crisis, there is a need to have appropriate, accessible shelters. (Facilitated discussion summary)
• Many families have a difficult time finding and paying for childcare. When childcare is available, it is expensive. It often has restrictions on age, schedule for working families, and accommodation for children with disabilities, special needs, or behavioral challenges. (Discovery Survey summary)

 

Some families have transportation issues preventing them from completing health care not only for children but themselves. Public transportation has limitations. Also have issues with childcare, even just for an appointment and keeping appointments. (Discovery Survey participant)

 

3. Access to care and services is universally mentioned. Families need access to affordable care, and to be covered by an insurance network that has providers of needed services such as physical, behavioral, mental health, and specialty care. Participants also stress the importance of trauma informed service delivery.

 

[There is] no place to send people struggling with substance abuse or mental health; the system doesn’t have capacity. (Facilitated discussion participant)

 

Mental health needs and access [is] often dependent on your insurance. [It is] much harder to get mental health services if you have private insurance in [county in eastern Washington]. In western Washington it’s the opposite. It’s hard to tell parent of suicidal kid there is no psychiatrist available to help. (Key informant)

 

In general there is a need for expanded service capacity for all populations related to MCH health and wellbeing, such as access to medical and behavioral health care. (LHJ report)

 

Related to access to care, challenges with systems coordination and referrals are often mentioned. Participants specifically want systems to share information, and to have current referral information accessible to providers and families. Participants identified the need for telehealth or technology-based remote services, and note that it presents a possible solution to regional service provider shortages.

 

4. Cultural humility and serving marginalized populations is a prominent theme in all data sources. Participants express a need for services that respect diversity, acknowledge and train for cultural awareness, have adequate language services, are non-discriminatory, and have a culturally representative workforce.

 

[We need] access to Culturally Relevant Health Services free from structural racism, with practitioners who are supportive partners with cultural humility who have an understanding of their own implicit biases and how that bias impacts the clients that they serve. (Discovery Survey participant)

 

Recognize different kinds of families and adapt services for [them]. Don’t get locked into typical families. [Put] more focus on families that look different (same sex, generational, different cultures, blended families). (Facilitated discussion participant)

 

5. Disparities among tribal communities, women and children of color, LGBTQ community, people who are differently-abled, and rural versus urban communities are of concern for needs assessment participants.

 

[There is an] impact of racism on body, life course, and health and birth outcomes. (Facilitated discussion participant)

 

The more rural you get, the more difficult [access] is, especially if a family is experiencing any kind of transportation barriers … [in particular] rural access [creates challenges] for both farm workers and refugees and non-refugees. (LHJ report)

 

6. Community and social supports are central to the health of all members. Families need safe and caring communities with a sense of social connection and embedded programs to help provide support when they struggle.

 

[We need] a village … especially [as] a single mom. Direct involvement and support of others with a vested interest in the welfare of our children and the physical and emotional health of the entire family unit. Families need to feel less isolated and secure in knowing that there is a community there to help when needed. (Discovery Survey participant)

 

Community based programs addressing substance use, gang activity and other forms of community violence, including sexual violence are among some of the top unmet needs.... (Discovery Survey participant)

 

Strengths. During the facilitated discussions and for the LHJ needs assessment, we asked about existing strengths in Washington.

 

Strengths identified by participants in the facilitated discussions include:

• The MCH population is a priority in Washington.
• Washington is a compassionate, innovative place with progressive policies.
• The governor and state legislature typically champion MCH initiatives.
• Strong partnerships exist within communities and between local organizations and state agencies.
• State-led or state-run initiatives and programs, such as the Maternal Mortality Review Panel and Breastfeeding Friendly Washington, are strong.
• Wide health care coverage exists in the state, particularly as a result of Medicaid expansion.
• Public health work is data-informed.

 

Strengths identified by LHJs include:

• LHJs ability to partner with other governmental, private, non-profit, and faith based groups; and to leverage resources to serve the MCH population in their communities.
• There is strong community involvement in local MCH initiatives, including parents as advocates and partners. Community commitment to supporting families is prevalent.
• Many LHJs reported developing their workforce with continuing education opportunities and specialized trainings to stay abreast of issues and concerns relating to the MCH population in their communities. Adverse Childhood Experiences training is mentioned as a useful tool that is shifting the care paradigm.
• Vaccination coverage is seen as a success for some LHJs. Adequate and appropriate immunization of the children and youth with special health care needs (CYSHCN) population is identified by LHJs as a priority issue that is being addressed.

 

Additional strengths were identified through assessing quantitative data. Washington ranks favorably in comparison to other states on many MCH indicators such as low birth weight, premature birth, teen/adolescent pregnancy, and infant mortality. It also has met many Healthy People 2020 goals including premature birth, low birth weight and very low birth weight deliveries, teen pregnancy, and high risk deliveries in appropriate care settings. It is close to achieving the goal on others, such as Nulliparous, Term, Singleton, Vertex C-sections.

 

Women

Population. In 2019, there were 1,472,279 women of reproductive age (ages 15-44) in Washington. In 2009 non-Hispanic White women made up 69 percent of this population, while in 2019 it had dropped to 61 percent, an 11 percent decline. Non-Hispanic Native American/Alaska Native women’s population also declined by 9 percent from 2009 to 2019. The population of non-Hispanic Asian and non-Hispanic multi-racial women is increasing the fastest, 33 percent and 29 percent respectively. Women under 30 years of age saw marked decreases in pregnancy rates over the past decade. Women 30-34 years of age did not see a statistically significant decrease, but over the last three years their rates began to drop as well. Pregnancy rates for women over 35 increased over this same time period.

 

Needs. Mothers and women of childbearing age need comprehensive care throughout their lifetime, including preconception, OB/GYN, family planning, early prenatal and post-partum care. For example:

• Access to health care for women is identified by most LHJs as a priority. Many of the least populous counties report having no or only one provider to meet these needs. Likewise, in more rural areas, access to both general practice services and obstetric care are scarce. (LHJ summary)
• Racial and ethnically diverse counties note that women of color have less access to services that meet their needs than non-Hispanic White women. In addition, women with more financial resources have less difficulty in obtaining services than those without. (LHJ summary)
• Postpartum care and support during the “fourth trimester” is lacking or absent. More postpartum care will allow providers to check in with mothers about their mental health and other medical issues. (Facilitated discussion summary)

 

With pregnant women carrying future generations, I think that it is really important we do more about taking care of women. They are setting the life course of future generations. (Facilitated discussion participant)

 

In rural communities, we are seeing real challenges in rural hospitals opting out of delivering babies except in emergencies. Moms may now have to drive long distances for OB care. (Key informant)

 

Cuidado de salud garantizado antes, durante y despues del embarazo.  (Guaranteed health care before, during and after pregnancy.) (Discovery Survey participant)

 

Key Indicators. In 2018, 11 percent of pregnant women had diabetes, which represents a 75 percent increase since 2008. Pre-existing diabetes was up 43 percent, and gestational diabetes was up 79 percent. Hypertension increased as well, up 53 percent overall since 2008. Gestational hypertension and pre-existing hypertension increased at approximately the same rate, 53 percent and 54 percent respectively.

 

Pre-pregnancy obesity and morbid obesity were up 12 percent and 16 percent respectively since 2008. Obese and overweight categories made up a little less than 50 percent of pregnancies in Washington.

 

Disparities. While the overall rates of obesity are up for pregnant women in Washington, the impact is greater in some racial/ethnic groups. Among Native Hawaiian or Pacific Islander women, 55 percent were obese and 16 percent were morbidly obese. Among American Indian/Alaska Native women, the rates were 41 percent and 7 percent respectively. Black/African American, Hispanic and multi-racial women all had higher rates of obesity than White and Asian women.

 

Native Hawaiian or Pacific Islander women were also the least likely to have received pre-natal care (PNC) in the first trimester, 45 percent, and more likely to have started PNC in the third trimester or to have received no PNC at all (20 percent). Black/African American and American Indian/Alaska Native women, while having higher rates of first trimester PNC than Native Hawaiian or Pacific Islanders, lagged behind women of other racial/ethnic groups.

 

Singleton low birth weight was higher for Black/African American infants (8.0 percent) than for any others. White infants had the lowest rate (4.3 percent), followed by Hispanic (5.5 percent) American Indian/Alaska Native (6.7 percent), Asian (6.8.percent) multi-racial (6.9 percent) and Pacific Islander (7.3 percent) infants.

 

White mothers had the lowest rate of preterm birth (7.6 percent), significantly lower than all other groups. American Indian/Alaska Native women had a preterm birth rate of 13.1 percent, significantly higher than all other groups. Native Hawaiian and Pacific Islander, Black/African American and multi-racial women had similar rates (9.7 percent, 10.1 percent, and 10.2 percent), followed by Hispanic (8.7 percent) and Asian (8.0 percent) women. These data are from all births.

 

While smoking has decreased among new mothers in Washington, there is a large disparity by Medicaid status. Rates of smoking three months before pregnancy, during pregnancy, and postpartum for women with Medicaid were higher at all three points of time in comparison with women who do not have Medicaid.

 

Women who receive Medicaid had high rates of breastfeeding initiation, but by two months postpartum they lag behind non-Medicaid women by a significant amount, 73 percent to 91 percent respectively.

 

Strengths. Many LHJs report a good working relationship with their Women, Infants, and Children Supplemental Nutrition Program (WIC). In some of the smaller LHJs, WIC is the primary way they interact with the MCH population. Breastfeeding is strongly promoted in WIC. High breastfeeding initiation rates is mentioned by many LHJs as a strength.

 

Rates for cesarean section and vaginal birth after cesarean (VBAC) have improved over the past decade with overall C-section rates down by 3 percent and VBAC rates increasing from 12.0/1,000 live births in 2009 to 19.9 in 2018. Over the same time period vaginal deliveries increased by 4 percent. Smoking among women of childbearing age is down significantly since 2008.

 

Infants, Children and Adolescents

Population. In 2018 there were 86,407 births in Washington. The racial/ethnic makeup of the newborn cohort is becoming more diverse. The number of births had decreased over the past few years. The population of children age 1-11 was 1,023,000 in 2018 and is undergoing the same demographic changes seen in infants, with the state’s percentage of non-Hispanic White children decreasing, making up 62 percent in 2008 but only 53 percent in 2018. In 2018 there were 553,000 adolescents, ages 12-17, accounting for 7.4 percent of Washington’s population. The racial/ethnic percentages of this population were 58 percent White, 20 percent Hispanic, 8 percent multi-racial and Asian each, 4 percent Black/African American and 1 percent both American Indian/Alaska Native and Pacific Islander.

 

Needs. Infants, children, and adolescents need care by providers in their communities who specialize in their unique developmental opportunities and challenges. They need providers who can administer developmental screenings and make referrals to needed care. Mental and behavioral health services from infancy to adulthood should be integrated and easy to access.

• Children and adolescents need specialized care in addition to a stable medical home. (Key informant summary)
• Access to oral and mental health are concerns throughout the state. (Key informant summary)
• Bullying is identified as an issue among teens and older children, especially among the LGBTQ population. (LHJ summary)
• Many LHJs report increasing rates of vaping among adolescents. This is a major set-back given the recent success in reducing tobacco use in this age group. Marijuana use is also reported as a topic of concern in this age group. (LHJ summary)

 

[There is a] growing substance use disorder with big impact on children and infants, and moms using. [There is an] increasing rate of Neonatal Abstinence Syndrome … [we] need targeted education to moms who are substance using – in treatment or not – for healthy deliveries. (Key informant)

 

There are challenges across many parts of the state to [access] medical homes for kids, especially those on Medicaid ... there are areas where because Medicaid reimbursement is so much lower than Medicare, practices won’t take kids on Medicaid which reduces pediatric access to medical home. (Key informant)

 

We have an epidemic of depression and anxiety in youth at the middle and high school level. We do not have enough psychiatric professionals that serve youth, need social workers in our K-12 public schools, and greater awareness of the impact of mental health on students’ ability to be successful academically in school. (Discovery Survey participant)

 

Key Indicators

Infants. In 2018 there were 400 deaths in Washington State resident infants, higher than the 373 per year average from the past five years. Low birth weight among singleton deliveries is up after many years of remaining constant, increasing 13 percent in the past decade. About half of all deliveries were paid for by Medicaid, indicating a high rate of infant/child poverty.

 

Children. Compared with other populations, we have little quantitative data about health needs of pre-adolescent children in Washington, especially by sub-populations and geography. Some information is available in the National Survey of Children’s Health (NSCH), with limitations; one particular disparity in 2017-2018 NSCH data shows that children, aged 4 months to 17 years, have disparate differences in sleeping the recommended age appropriate hours on weeknights. Hispanic children have a lower percentage of sleeping the recommended hours (49 percent), compared with non-Hispanic White children (74 percent). Another data source is the Washington Oral Health Basic Screening (Smile) Survey. Based on the Smile Survey, the 2015/16 rate of caries experienced among third graders was 53 percent, making it the most prevalent communicable and chronic condition in the state. Among low income preschool aged children, 45 percent of children had caries, which does not meet the Healthy People 2020 goal of 30 percent.

 

Adolescents. In 2018, 78 percent of tenth graders in Washington did not meet the recommended daily amount of physical activity. Vaping has increased from 18 percent to 21 percent between 2014 and 2018. Fifty-six percent of tenth graders reported vaping a product with nicotine, 21 percent with tetrahydrocannabinol (THC), and 33 percent vaping with only flavor. While the prevalence of marijuana use among tenth graders has not changed since 2008, remaining around 20 percent, perceptions of how problematic occasional or regular use of marijuana is have changed, with significantly more youth expressing there is no or a low risk from using marijuana. Seventy-three percent of tenth graders reported consuming sugar-sweetened beverages in the past week, and 61 percent reported eating chips or other snack foods at school. Eighty-three percent reported eating fewer than five servings of fruits/vegetables per day.

 

Disparities

Infants. Historically, infants born to Black/African American and American Indian/Alaska Native women have had the highest mortality rates in Washington. However, when compared to infants born to multi-racial women and Pacific Islander women, there is no statistically significant differences among them. From 2016-2018, the rate of infant mortality among Black/African American infants was 8.6 per 1,000 births, 7.9 for American Indian/Alaska Native infants, 7.0 for multi-racial infants , and 5.6 for Native Hawaiian or Pacific Islander infants. In comparison, the rate of infant mortality was 4.2 for Hispanic infants, 3.9 for White infants, and 3.2 for Asian infants. Although disparities in infant mortality are well documented, the rate can vary considerably between years for these groups.

 

Singleton low birth weight has increased among Native Hawaiian or Pacific Islander women by 74 percent over the past decade. Hispanic women and Asian women saw increases of 15 percent and 10 percent respectively. Black/African American and White low weight births saw slight increases of 1 percent to 2 percent, and American Indian/Alaska Native women saw a decrease of 6 percent over the same time period. Infants whose mothers had Medicaid-paid birth are less likely to be placed on their back to sleep compared with those who did not have a Medicaid-paid birth. This disparity has increased by 4 percent over the past 10 years.

 

Children. Third grade students of color, especially Hispanic (71 percent), Pacific Islander (75 percent) and American Indian/Alaska Native (67 percent) experienced a far higher burden of dental caries than did their White classmates (45 percent). However, when it came to dental sealant placement on molar teeth, Hispanic children had higher rates (61 percent) than did White children (48 percent) and the combined state average of 50 percent among all children.

 

Adolescents. Among tenth graders surveyed, students who identified as gay, lesbian or bisexual were more likely to have been bullied in the prior month than their straight peers. They were also more than twice as likely to have attempted suicide in the previous year. Smoking did not vary by race/ethnicity in tenth graders surveyed.

 

Strengths

Infants. The sudden unexpected infant death (SUID) rate significantly decreased from 2008 to 2018, from 1.0 deaths per 1,000 live births to 0.6 deaths. Compared to other states, Washington’s infant mortality rate is among the lowest, including among non-White infants.

 

Children. According to the NSCH, over 90 percent of young children in Washington had their health status reported as excellent or very good, comparable with the national rate. Due to Washington State’s Medicaid expansion program, Apple Health, insurance coverage among children is near universal in the state. Between 2005 and 2015/16, the rate of untreated decay in third graders decreased in Washington, meeting the Healthy People 2020 goal. The caries rate among low-income preschoolers also declined since 2005 from 26 percent to 17 percent.

 

Adolescents. Birth and pregnancy rates among adolescents continue to decline, reaching the lowest ever recorded. Among 15-17-year-olds the pregnancy rate went from 27 per 1,000 in 2008 to 9 per 1,000 in 2018. This meets the Healthy People 2020 goal of 36.2 per 1,000 population. Use of cigarette and smokeless tobacco products by tenth graders has decreased since 2008, from 14 percent and 7 percent, to 5 percent and 2 percent respectively.

 

Children and Youth with Special Health Care Needs

Population. According to the NSCH (2017-19), 19 percent of children in Washington ages 0-17 have a special health care need. This represents has an estimated 311,000 children and youth in Washington with a special health care need. Of these, an estimated 195,000 are non-Hispanic White children, 57,000 Hispanic children and 52,000 children classified as other non-Hispanic.

 

Needs. Children and youth with special health care needs and their families need adequate screenings and services that are accessible across the state. CYSHCN need all the services that children their age need, with providers that are competent in the care of CYSHCN. This includes access to childcare, recreation and other services.

• CYSHCN and their families experience significant barriers to accessing services. Screening, therapeutic treatments and support are significantly impacted by provider shortages, especially in remote areas. For some CYSHCN and their families, financial eligibility is a barrier to accessing health care and other support services. Additionally, there can be long waitlists to access care for this population. (Facilitated discussion summary)
• Transitioning of care from CYSHCN pediatric to adult specialty services can be disruptive to the person with special health care needs and their support system. (Facilitated discussion summary)
• Inadequate numbers of providers are trained on needs specific to the CYSHCN population. (Facilitated discussion summary)
• CYSHCN and their caregivers can usually receive needed screenings, but the distance to those and other services can be prohibitive. Specialized services, regular therapeutic treatments, access to respite care, and mental/behavioral health services for the population are harder to access for those living in remote areas. Those in more urban areas struggle with transportation and long waiting lists. (Key informant summary)

 

[There is a definite] growing need for mental and behavioral health services for children with behavioral disabilities including [autism spectrum disorder] … [as well as a] need for [applied behavior analysis] providers in rural areas. (Key informant)

 

Childcare that’s available, affordable, and high quality. This includes supporting children with special needs who need diapering far past age three and need supported care past age 12. (Discovery Survey participant)

 

[We need] multiple supports for families of kids with disabilities, especially kids with challenging behaviors, including those who don’t reach eligibility for special services. (Facilitated discussion participant)

 

Key Indicators. Based on the NSCH only 45 percent of children with special needs had a medical home.

 

Disparities. Language and cultural barriers make it more difficult for non-English speakers and those from other cultures to access appropriate services, information, and resources for their CYSHCN. This is especially true among recent immigrant and refugee populations. More severely affected children were found to have more difficulty in obtaining necessary services as well. In some cases, families may have had to move to obtain the needed services, potentially disrupting the lives of all the members of the family.

 

Strengths. Since 2010, universal developmental screening (UDS) has been a DOH priority. DOH is currently in the process of developing a UDS data system in order to facilitate increased screening and referral. In 2018, Washington’s Early Hearing-loss Detection, Diagnosis and Intervention Program successfully screened 83,343 infants’ hearing. In spring 2020, a new Child Health Intake Form data system was developed, which will make care coordination for CYSHCN easier across the state.

 

The Department of Health is led by Secretary of Health John Wiesman, who reports directly to Governor Jay Inslee. Title V programs are located in the Prevention and Community Health (PCH) division. Acting Assistant Secretary of Prevention and Community Health Michele Roberts reports to DOH Chief of Staff Jessica Todorovich. Organizational charts in front of the appendix show these reporting relationships.

 

Approximately 68 percent of Maternal and Child Health Block Grant (MCHBG) funds are distributed to partners, including 59 percent to local health jurisdictions. The remaining funds support DOH activities, mostly within PCH’s Office of Family and Community Health Improvement. OFCHI Director Katie Eilers is designated the Title V Maternal and Child Health Director and is the primary administrator of programs with allotments under Title V. The second page of the organizational chart shows programs supported by federal MCHBG funds highlighted in yellow.

 

OFCHI includes the following:

 

• Thriving Children and Youth includes the adolescent health, child health and development, children and youth with special health care needs, and Essentials for Childhood programs.
• Community Healthcare Improvement Linkages includes the breast, cervical and colon health; community health worker training; family planning; and perinatal health programs.
• Surveillance and Evaluation oversees data collection and assessment activities that inform OFCHI programs and policy decisions, including the Healthy Youth Survey, PRAMS, home visiting evaluation, maternal and child health epidemiology and evaluation, Birth Defects Surveillance System, and State Systems Development Initiative.
• Healthy Systems and Operations coordinates contracts and activities with the local health jurisdictions’ maternal and child health programs, oversees the MCHBG, and works on health systems improvement and population health initiatives.
• Screening and Genetics includes the Early Hearing-loss Detection, Diagnosis and Intervention; cancer genomics; and genetic counseling programs.
• Equity and Community Engagement focuses on development of the community based workforce and advancing equity in our funding, program development, and processes.

 

MCHBG funds also support the Injury and Violence Prevention program and the Oral Health program in the Office of Healthy and Safe Communities.

 

The Department of Health plays an important role in helping to build healthier communities, including supporting the health of the populations addressed in the MCHBG. We work to assure the quality of our health system and provide the data and information necessary for research and resource planning. We also provide funding and technical assistance to and collaborate with partner organizations working on key prevention issues. This includes providing preventive health information and educational messages to the public and to health care providers about early identification of health issues, referral and linkage to services, and coordination of services.

 

OFCHI generally does not fund direct services, but can support a "last-stop safety net" when there is a major gap in services for the maternal and child health population, especially for children and youth with special health care needs.

 

Preventive and primary care services for pregnant women, mothers and infants up to age one

The DOH Perinatal Health unit focuses on women’s health, infant health and the mother/infant dyad. The program offers educational materials and links to resources on a wide range of topics that affect women. Following culturally and linguistically appropriate service (CLAS) recommendations, publications are available in multiple languages. The unit manages specific programs to improve birth equity in communities where disparities exist.

 

The Screening and Genetics program works to improve the health of people with, or at risk of, genetic disease. The program identifies babies who have hearing loss and works to assist in getting them enrolled in early intervention by six months of age. It provides information on genetic conditions for parents and health professionals, promotes educational opportunities for health and social service providers, and evaluates quality, trends, and access to services.

 

PRAMS is a survey of new mothers conducted by DOH and the Centers for Disease Control and Prevention (CDC). PRAMS gathers information from mothers about their experiences before, during, and after their most recent pregnancy. PRAMS survey answers give us information about access to health care, quality of health care, and other circumstances that may affect the health of the mother and her new baby. PRAMS informs program needs throughout the state.

 

DOH offers resources and technical assistance to parents, child care, foster care, group care, juvenile and correctional institutions, community action groups and others on how to prepare and keep children safe, healthy and in developmentally appropriate learning environments. Topics include developmental screening and milestones, infant safe sleep practices, and feeding infants.

 

Preventive and primary care services for children

The Thriving Children and Youth (TCY) section promotes integrated systems that improve access, linkages and coordination directed toward health and well-being, health equity, early and ongoing learning and development, and safe environments and relationships for children, youth, and their families.

The Essentials for Childhood unit within TCY is part of a comprehensive child abuse and neglect prevention effort across several states supported by the CDC and other funders. The focus is coordination and collaboration to align systems, strategies, and policies to improve how families experience supports, reduce stress, and increase resilience.

 

The Adolescent Health program in TCY works to ensure equitable opportunities for improved social, emotional, and physical health and wellbeing for adolescents and young adults. Program goals include providing access to quality health services that are age-appropriate, ensuring safe and supportive environments at home, school, and in the community, and increasing reproductive health services and information.

 

The Injury and Violence Prevention Program coordinates Safe Kids Coalitions throughout the state to prevent unintentional injuries to children. The statewide network involves hospitals, local agencies, advocacy organizations, and private sector partners. They educate adults and children, conduct research and collect data, and strengthen laws to help families and communities protect children. They also provide safety devices to families in need.

 

DOH’s Oral Health program promotes prevention and access to oral health care. They coordinate the Smile Survey, a report on the oral health of Washington’s children, in partnership with the Office of the Superintendent of Public Instruction (OSPI), the Department of Children, Youth, and Families (DCYF), school districts, early learning programs and dental professionals. They provide information on finding dental care and resources through a number of organizations in the state.

 

The Healthy Youth Survey is a collaborative effort of DOH, OSPI, the Department of Social and Health Services (DSHS) Division of Behavioral Health and Recovery, and the Liquor and Cannabis Board. The survey provides information about youth in Washington, including safety and violence; physical activity; diet, alcohol, tobacco and other drug use; and related risk and protective factors. County prevention coordinators, community mobilization coalitions, community public health and safety networks, and others use this information to guide policy and programs that serve youth.

 

The Child Profile Health Promotion System sends child health and safety information to all families with young children in Washington State by mail and e-mail. Each mailing has age-specific reminders about well-child checkups and immunizations. They also give up-to-date information on growth and development, nutrition, safety, and many other health topics. This work is conducted in the Office of Immunization and Child Profile, also part of the PCH division.

 

The Office of Nutrition Services in PCH manages the WIC program. The Office of Healthy and Safe Communities (OHSC) manages the Injury and Violence Prevention and Oral Health programs mentioned above, as well as the Healthy Eating Active Living program, the Tobacco/Vapor Product Prevention and Control program, and the Marijuana Product Prevention program. Title V staff coordinate with each of these programs that has close ties to and influences our work and priorities to protect and improve children’s health.

 

Services for children with special health care needs

The Children and Youth with Special Health Care Needs (CYSHCN) program within TCY promotes an integrated system of services for infants, children and youth who have or are at risk for chronic physical, developmental, behavioral, or emotional conditions and require health and related services of a type or amount beyond what is generally needed. At the state level, the program collaborates with families, policy makers, health care providers, agencies, and other public-private leaders to identify and improve health system issues that impact this population. At the local level, the program supports public health staffing and contractors to help families with resources and linkages to community services including family support, care coordination, and health information.

 

This work is carried out through partnerships with other state-level agencies and contractual relationships with LHJs, the University of Washington (UW), and family service organizations. These contracts and partnerships significantly extend CYSHCN program capacity in the areas of assessment, provider education and technical assistance, improvement of care coordination, and family leadership development. Our work is guided by and aligned with the national Standards for Systems of Care for CYSHCN.

 

Cross-Cutting and Systems Building

Supporting work in all domains, the Surveillance and Evaluation section oversees assessment activities (including HYS, PRAMS, and the five-year MCH needs assessment) required for effective planning, monitoring, and action to improve health outcomes in many program areas.

 

DOH promotes a patient-centered medical home approach to meeting consumers’ physical and mental health care needs. To that end, DOH offers, promotes, and participates in collaborative learning opportunities, such as in-person trainings, webinars, primary care practice coaching, community asset mapping, and other technical assistance.

 

Community Health Workers (CHWs) provide services such as health education, informal counseling, social support, care coordination, and health services enrollment, navigation, and advocacy. To support the system of CHWs in Washington, DOH offers a free online training curriculum that strengthens common skills, knowledge and abilities. The core competency training is a free ten-week program. It was formerly held as a combination of online and in-person training held regionally throughout the state, and in response to the COVID-19 pandemic, the curriculum has transitioned to fully online. Free Continuing Education Health Specific Modules are available for additional learning for CHWs after the core curriculum has been completed.

 

The DOH agency capacity has been significantly affected by the COVID-19 public health emergency, as has that of LHJs. Staff have been reassigned to incident management teams and also to backfill positions to ensure continuity of operations of core functions. Agency and program priorities have been reassessed and revised. As has occurred world-wide, staff transitioned to primarily working from home for an unknown duration, and many must balance family care and education needs with work. Due to economic impacts of COVID-19, the Governor has imposed mandatory furlough days for most state employees, including Title V program staff.

 

Many elements of our regular program work have been set aside or slowed significantly as we address the public health emergency and current and emerging needs. We are also in the early stages of shifting how we manage our COVID-19 response. Initially it was organized as an agency-wide incident management team structure. Now we are integrating COVID-19 planning and response into the agency’s divisions for long-term response and recovery.

 

For federal fiscal year 2021, the total number of full-time equivalent (FTE) positions in DOH to be funded by federal MCHBG dollars is 17.55 FTE (down 0.45 FTE from 2020). This represents 35 individuals; most positions are funded using multiple sources. Title V activities are the predominant focus of OFCHI, as highlighted in the attached organization charts.

 

In the Perinatal and Women’s Health programs, MCHBG funds contribute toward 0.95 FTE (portions of two positions) of the total staffing of eight FTEs.

 

In the Child Health and Development and Adolescent Health programs, federal MCHBG funds contribute toward 4.0 FTEs (portions of five positions) of the total staffing of eight FTEs.

 

The CYSHCN unit includes 1.6 FTEs funded by federal MCHBG (one full position and portions of three others), of the total of four FTEs. One of these positions is a paid Family Engagement Coordinator. This position provides leadership for inclusion of family and community perspectives in policy and program development, oversees parent leadership development programs, and serves as a statewide resource for promoting quality, culturally appropriate, integrated systems of care for children and youth, including those with special health care needs and their families. This position is consulted for assistance in family engagement in the other population domains as well. The person currently in this position has a family member with special health care needs, providing lived experience in this area.

 

The Screening and Genetics program includes 1.2 FTEs (portions of three positions) funded by federal MCHBG. Their total staffing is six FTEs.

 

Surveillance and Evaluation includes 6.31 FTEs funded by federal MCHBG (portions of 12 positions), of the total 19 staff.

 

The Healthy Systems and Operations budget includes 3.1 FTEs funded by federal MCHBG (one full position and portions of six others). This includes the MCHBG coordinator, the two community consultants who provide liaison and contract management with the LHJs, and fiscal and policy support.

 

In the separate Office of Healthy and Safe Communities, we use MCHBG funding to supplement two positions (0.39 FTE) that focus on child injury prevention and oral health.

 

Each of the 35 LHJ contracts funds at least part of an FTE to focus on maternal and child health. In some of the larger LHJs, several MCH staff are funded in part or entirely by MCHBG. In very small LHJs, MCHBG funds a portion of time for one staff.

 

Katie Eilers, RN, MSN, MPH, is the state Title V MCH Director. Katie is the Director of the Office of Family and Community Health Improvement in the Prevention and Community Health division of DOH. Katie has been with DOH since February 2019. She has 20 years of experience working on family and community health in a variety of positions in Washington, California and in Africa. Her experience in family and community health includes direct care, coalition work, program management, program evaluation, planning and policy work and leadership.

 

Rose Quinby, MSW, is the state Title V CSHCN Director. As Section Manager of the Thriving Children and Youth section in OFCHI, Rose provides leadership and strategic direction for the child, adolescent, and CSHCN activities of the MCHBG. She manages the CYSHCN Unit Supervisor position and the Essentials for Childhood and Adolescent Health Program Manager. Rose has been with DOH since February 2020. Prior to her position at DOH, Rose held leadership positions with significant responsibility for management, public health systems change, and research focused on children with special health care needs and their families.

 

The MCHBG has provided a relatively stable amount of funding over the past several years. The costs of doing business, however, have continuously increased over time. We have committed to maintain a consistent level of pass-through funding to distribute to the LHJs. But the increases in operating costs have resulted in decreases in the DOH MCH workforce (staffing level) over the years due to funding availability. Most often this takes place as not filling vacant positions, or combining and shifting positions to better align with current needs. This causes us to focus more precisely on core public health functions and our identified priority needs.

 

Maternal and child health work at the state-wide level requires strong partnerships with other organizations. We asked program leads of our MCH programs to provide suggestions about which organizations, work groups, and committees we should reach out to as we conduct the needs assessment and establish priorities.

 

The list included:

• 38 multi-agency work groups our program staff were involved with on specific issues of maternal and child health
• 8 key partner organizations that could reach out to their networks to share and receive information to inform the needs assessment
• 6 large email distribution groups focused on MCH information sharing

 

The list of partner groups included work teams with focus on specific projects or programs, committees, and coalitions. It included healthcare providers, community service providers, community and cultural groups, advocacy groups, individual consumers, interagency and local health partners, educational partners, and private and corporate partners.

 

As discussed in the Process Description section above, from this large list we selected groups to meet with for facilitated discussions, representing all the population domains. We used this list and suggestions from the program leads to identify potential key informants. We sent the Discovery Survey to members of these work groups as well.

 

The list represents the many organizations and partnerships we work with day-to-day. In the population domain narratives we describe specific examples of our work with various key partners. In a variety of ways, these partners have shaped our priority needs, our work programs, and MCH policy and funding decisions in Washington. These partnerships also allow us to reduce duplication of efforts and connect the work of related programs and initiatives.

 

Data from each of the four primary data collection methods described above (LHJ Needs Assessments, facilitated discussions, key informant interviews, and population-level Discovery Survey) were analyzed qualitatively in nVivo and compiled by topic into a summary report by a team of four epidemiologists and qualitative analysts. This summary report was shared with the MCH Needs Assessment Workgroup, the MCHBG Needs Assessment Advisory Group, and LHJ contacts for feedback on identified themes and content. The workgroup then developed a document organizing themes across data collection sources ranked by total number of coding references to guide further discussion.

 

DOH contracted with Cardea Services to facilitate a series of regional community dialogues with LHJ representatives (held October 22, 23, 29, and 30, 2019) and DOH staff (held November 6, 2019). The workgroup compiled notes from Cardea’s facilitated discussions into a single cohesive list of 34 distinct topics, ranked by number of total references from small group discussion. In addition to number of unique references, key considerations when discussing potential state-level priorities included the role of public health in addressing the issue, the severity of or potential harm caused by each issue, known disparities among vulnerable populations, and consistency or agreement across LHJs. Topics were then classified by population domain, and related topics were combined where appropriate. Cardea encouraged participants to focus on available data and intended outcomes, and work back towards viable evidence-based strategies and best practices to prioritize. Equity and addressing known disparities emerged as a key theme throughout LHJ engagement.

 

The products from these discussions were presented and discussed at three online prioritization discussion webinars, which were promoted to individuals who had contributed to the needs assessment data collection and on the DOH website for anyone interested in participating. These webinars were held November 15, 18, and 21, 2019.

 

The workgroup then used feedback from all these discussions to compile a list of eight priority need statements which incorporated as much feedback from all sources as possible. This was shared with LHJs with the notes from the Cardea-facilitated meetings.

 

The workgroup and MCHBG Needs Assessment Advisory Group held a joint performance measures work session on February 12, 2020. The intent of the meeting was to finalize the draft priority need statements, determine the performance measures to focus on, and identify potential strategies and activities.

 

At this meeting, two core principles were added to be incorporated across all priorities. Then, after continued discussion among the workgroup, these were expanded to four core principles to shape our work.

 

Core Principles Informing the State Action Plan:

 

• All people deserve the opportunity to thrive and achieve their highest level of health and well-being. Improving systems that serve families and children to be more equitable is a core responsibility of public health practitioners. We embrace this responsibility in our maternal and child health work. We are committed to being anti-racist in our programs and policies.
• We value both evidence-based and community-developed promising practices to ensure all populations, especially those who have been historically marginalized, are served by health systems that embrace cultural humility and appropriateness.
• We are working to ensure trauma informed approaches are incorporated in all our programs and services.
• We must continue to assess the effects of COVID-19 on all programs and make adjustments as needed in light of the pandemic, with particular focus on our values and goals associated with racial and ethnic equity.

 

Two priority needs were added by the workgroup and leadership after the February meeting, making a current total of ten. A priority related to strategic planning emerged as the need for a cohesive public health strategy across localities was identified. And as the COVID-19 pandemic occurred and evolved, it became clear there will be long-term impacts to our workload and capacity. State and public health agencies will need to take on new roles and new work to respond to and recover from the pandemic, and prepare for new and emerging public health threats.

 

The final ten priorities were then refined and developed in collaboration with population domain leads (i.e. adolescent health, perinatal health, and children and youth with special healthcare needs team leads) to refine definitions, integrate agency and partner strategic plans and goals, and finalize development of state performance measures. See Appendix C for a list of these priorities and performance measures.

 

As the list and language were being finalized, Washington State was identified as an early potential U.S. epicenter of the COVID-19 pandemic, impacting staff roles and public health infrastructure across the state at all levels. The workgroup has not yet created a final summary report on the full needs assessment and prioritization process, or developed thematic “story sheets” which take a closer look at specific themes and patterns which emerged.