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MCH 2015 STATE NEEDS ASSESSMENT Linda Kenney, MPH November 6, 2009 MCH 2015 STATE NEEDS ASSESSMENT Linda Kenney, MPH November 6, 2009

MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT PROGRAM GENERAL INTRODUCTION REQUIREMENTS 2 MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT PROGRAM GENERAL INTRODUCTION REQUIREMENTS 2

MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT PROGRAM Authorized under Title V of Social MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT PROGRAM Authorized under Title V of Social Security Act, 1935 To improve the health of ALL mothers and children in the State Consistent with Health Objectives for the Nation -- Healthy People 2010 3

KS MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT PROGRAM $4. 7 million per year KS MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT PROGRAM $4. 7 million per year down from $5 million in FFY 1994 To have the same buying power in 2009 we would need $7. 2 M (2. 46% inflation) State match requirement $3. 5 M Local agencies match another $7. 7 M 4

MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT PROGRAM Three population groups: Pregnant women and MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT PROGRAM Three population groups: Pregnant women and infants Children and adolescents Children with special health care needs 5

MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT PROGRAM Assure or provide programs for maternity, MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT PROGRAM Assure or provide programs for maternity, infant, and child care, as well as a full range of medical services for children. $ to states -- physicians, dentists, public health nurses, medical social workers, and nutritionists. 6

PUBLIC HEALTH NURSE GRADUATES, 1912 PUBLIC HEALTH NURSE GRADUATES, 1912

MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT PROGRAM OBRA 89 - Coordinate with Medicaid MATERNAL & CHILD HEALTH SERVICES BLOCK GRANT PROGRAM OBRA 89 - Coordinate with Medicaid Conduct a survey of MCH needs every 5 years. Set priorities based on needs. 8

HOME VISITING, CIRCA 1903 HOME VISITING, CIRCA 1903

PLENARY OUTLINE Introduction to Needs Assessment Involving Stakeholders Sources of Needs Assessment Data Needs PLENARY OUTLINE Introduction to Needs Assessment Involving Stakeholders Sources of Needs Assessment Data Needs as Values: Need Discrepancies Setting Priorities Selecting Solutions TIMELINE

INTRODUCTION Public health is what we do collectively as a society to create those INTRODUCTION Public health is what we do collectively as a society to create those conditions in which we can be healthy Maternal and child health (MCH) is a fundamental component of public health MCH promotes the nation’s interest in improving the health and well-being of all children and their families

INTRODUCTION Focus is on the POPULATION Emphasis is on PREVENTION Orientation is toward the INTRODUCTION Focus is on the POPULATION Emphasis is on PREVENTION Orientation is toward the COMMUNITY Efforts are directed at SYSTEMS Overarching role is one of LEADERSHIP

INTRODUCTION MCH programs engage in the core functions of public health: Assessment Policy development INTRODUCTION MCH programs engage in the core functions of public health: Assessment Policy development Assurance

INSTITUTE OF MEDICINE: “It is the responsibility of every public health agency to regularly INSTITUTE OF MEDICINE: “It is the responsibility of every public health agency to regularly and systematically collect, assemble, analyze and make available information on the health of the community, including statistics on health status, community health needs and epidemiologic and other studies of health problems” IOM 1988 The Future of Public Health

MCH ESSENTIAL SERVICES 1. Assess and monitor MCH to identify problems 2. Diagnose and MCH ESSENTIAL SERVICES 1. Assess and monitor MCH to identify problems 2. Diagnose and investigate health problems and hazards 3. Inform and educate the public and families 4. Mobilize community partnerships between policymakers, health care providers, families, the general public to identify and solve MCH problems 5. Provide leadership for priority-setting, planning and policy development to support community efforts

MCH ESSENTIAL SERVICES 6. Promote and enforce legal requirements 7. Link women, children and MCH ESSENTIAL SERVICES 6. Promote and enforce legal requirements 7. Link women, children and youth to health and other community and family services and assure access to comprehensive, quality systems of care 8. Assure the capacity and competency of the public health and personal health work force 9. Evaluate the effectiveness, accessibility and quality of personal health and population-based services 10. Support research and demonstrations

INTRODUCTION Required agency of KDHE as the State Title V Comprehensive N. A. every INTRODUCTION Required agency of KDHE as the State Title V Comprehensive N. A. every 5 years ID State MCH priorities Use priorities to set program and policy activities Use state performance measures to monitor the success of these efforts Population-based and community-focused

NURSE AND MOTHER, 1909 NURSE AND MOTHER, 1909

INTRODUCTION Assessment is not new to MCH 1912 charter establishing the Children’s Bureau states INTRODUCTION Assessment is not new to MCH 1912 charter establishing the Children’s Bureau states as its mission: “. . . to investigate and report upon matters pertaining to the welfare of children and child life among all classes of people. . . ” “investigate and report” = assessment!

MCH MISSION “. . . to assure the health of all mothers and children. MCH MISSION “. . . to assure the health of all mothers and children. . . ” requires ongoing monitoring and assessment of trends in population characteristics, health status indicators, risk factors, health system attributes, and the availability and accessibility of quality services for mothers and children.

SCHOOL NURSE, 1909 SCHOOL NURSE, 1909

TARGETING OUR ENERGY & RESOURCES Use of the most appropriate programs and policies to TARGETING OUR ENERGY & RESOURCES Use of the most appropriate programs and policies to promote the health of women, children, adolescents, and children with special health care needs, and their families – budget constraints A fundamental element of any program planning activity So, needs assessment is about change

INTRODUCTION Ongoing planning cycle that enables us to 1. assess problems, needs, assets and INTRODUCTION Ongoing planning cycle that enables us to 1. assess problems, needs, assets and strengths 2. develop and implement solutions 3. allocate resources 4. evaluate activities 5. monitor performance 6. begin anew, back to #1

INTRODUCTION Basically, data-driven But, involves politics of policy-making, program development and resource allocation So, INTRODUCTION Basically, data-driven But, involves politics of policy-making, program development and resource allocation So, important to engage and involve the community of interest, the stakeholders

INTRODUCTION Ideally N. A. bridges: Science and politics Data and community values Needs and INTRODUCTION Ideally N. A. bridges: Science and politics Data and community values Needs and strategies for their solution All within a comprehensive planning process

INTRODUCTION N. A. ongoing process; process is revisited & formalized every 5 years INTERVENING INTRODUCTION N. A. ongoing process; process is revisited & formalized every 5 years INTERVENING YEARS – implement strategies and focused assessment

NATIONAL BABY WEEK, 1918 NATIONAL BABY WEEK, 1918

INTRODUCTION NOT BECAUSE “We have to” We need to justify our current efforts Forget INTRODUCTION NOT BECAUSE “We have to” We need to justify our current efforts Forget it, if we do not intend to act on the results BECAUSE recognize the dynamic nature of MCH good stewards of the public’s trust must set priorities within limited resources

INTRODUCTION Parameters vary Statewide or in specific community? Entire population or certain population group? INTRODUCTION Parameters vary Statewide or in specific community? Entire population or certain population group? All of MCH or just certain aspects? Any health issue or focused topic? Independent or in collaboration with other groups?

AAP FOUNDED, 1930 S AAP FOUNDED, 1930 S

MCH 5 -YEAR NEEDS ASSESSMENT Keep as broad and comprehensive as possible Do focused MCH 5 -YEAR NEEDS ASSESSMENT Keep as broad and comprehensive as possible Do focused assessment in the intervening years, while the ongoing broad-based monitoring continues Examples of focused assessment - adolescents, farm injuries, needs of recent immigrants, frontier counties, specific urban neighborhoods, etc

MCH NEEDS ASSESSMENT To begin. . . Where do we start? with the data? MCH NEEDS ASSESSMENT To begin. . . Where do we start? with the data? or with the community?

MCH NEEDS ASSESSMENT This is NOT a trivial question! How much do we want MCH NEEDS ASSESSMENT This is NOT a trivial question! How much do we want to shape (or control) the process? By presenting data first, we potentially limit the universe of possibilities, but we also clarify the parameters of our capacity By seeking input from the community first, we potentially open ourselves up to unrealistic expectations but we gain a wealth of insight that limited data cannot possibly give us

INVOLVING STAKEHOLDERS Regardless of where we begin, it is absolutely essential to the entire INVOLVING STAKEHOLDERS Regardless of where we begin, it is absolutely essential to the entire needs assessment process that we involve and engage our stakeholders early on and throughout the process Ultimately what we do in public health is about the public, and if the public doesn’t buy that a problem exists or doesn’t buy your solution to the problem, we’ve got an uphill battle on our hands

INVOLVING STAKEHOLDERS Who are “stakeholders”? Represent a group with an interest in the process INVOLVING STAKEHOLDERS Who are “stakeholders”? Represent a group with an interest in the process & outcomes Has a “stake” in the process & outcomes, with a vested interest (beware of the conflicts of interest that will arise. . . ) N. A. is about change, so lots of folks will have something to say about the process & outcomes. . .

INVOLVING STAKEHOLDERS For MCH these typically include: Other state agencies/programs Local health departments Providers INVOLVING STAKEHOLDERS For MCH these typically include: Other state agencies/programs Local health departments Providers and facilities serving MCH populations Professional organizations Funders and/or elected officials Clients of service programs, persons served The media The public at large Community-based and advocacy organizations

INVOLVING STAKEHOLDERS How do they help? Identify the full scope of needs Interpret available INVOLVING STAKEHOLDERS How do they help? Identify the full scope of needs Interpret available data or collect new Sort out priorities Identify and select solutions Build awareness of your program Build consensus Advocate for needed changes Support your overall efforts

INVOLVING STAKEHOLDERS Ways to involve stakeholders: Can be a source of data Serve on INVOLVING STAKEHOLDERS Ways to involve stakeholders: Can be a source of data Serve on formal advisory committees Informally review proposals in N. A. process Assemble into coalitions to support the N. A. recommendations

INVOLVING STAKEHOLDERS Advisory Committees (EXPERT PANELS) Possibly a significant amount of work, assembling various INVOLVING STAKEHOLDERS Advisory Committees (EXPERT PANELS) Possibly a significant amount of work, assembling various stakeholders into groups: 1. engages people in the process 2. elicits rapport and good will 3. addresses opposition 4. legitimizes the NA process

INVOLVING STAKEHOLDERS Various ways to do this: Convene chairs of multiple advisory committees Assemble INVOLVING STAKEHOLDERS Various ways to do this: Convene chairs of multiple advisory committees Assemble multiple ad hoc advisory committees to focus on specific issues Assemble one large advisory committee with subcommittees to see you through the whole process

INVOLVING STAKEHOLDERS Possible types of committees Data committee State agency partners committee Local health INVOLVING STAKEHOLDERS Possible types of committees Data committee State agency partners committee Local health agency partners committee Community partners committee Population subgroup committees Pregnant Women & Infants Children & Adolescents Children & Youth with Special Health Care Needs

INVOLVING STAKEHOLDERS Population Review Subgroup Committee: data and ID needs Set priorities and recommend INVOLVING STAKEHOLDERS Population Review Subgroup Committee: data and ID needs Set priorities and recommend strategies Set an advocacy agenda Develop evaluation plan with performance measures

INVOLVING STAKEHOLDERS Any comments at this point? Ways expert panels are helpful? Ways expert INVOLVING STAKEHOLDERS Any comments at this point? Ways expert panels are helpful? Ways expert panels are not helpful? Ideas to improve process?

SOURCES OF DATA Essentially 4 sources Population-based data (vital records, census) Surveillance systems and SOURCES OF DATA Essentially 4 sources Population-based data (vital records, census) Surveillance systems and survey data Program or service data Public forums or focus groups

SOURCES OF DATA Population-based Data Census Vital Records Births Deaths Fetal Deaths Abortions (not SOURCES OF DATA Population-based Data Census Vital Records Births Deaths Fetal Deaths Abortions (not all states have individual records) Marriages, divorces, adoptions

SOURCES OF DATA Surveillance Every Systems and Survey Data state has access to SLAITS SOURCES OF DATA Surveillance Every Systems and Survey Data state has access to SLAITS data Every state has BRFSS data Most states have YRBS data Some states have PRAMS data Every state has communicable disease incidence data Many states have registry data Some states conduct their own surveys routinely or as needed to answer a particular question

SOURCES OF DATA Program M&I, and Service Data Healthy Start, WIC, CYSHCN and so SOURCES OF DATA Program M&I, and Service Data Healthy Start, WIC, CYSHCN and so forth for program management purposes Local agency service data that may be of interest, e. g. , immunization data Sister programs and agencies have data, e. g. , Medicaid

SOURCES OF DATA Program and Service Data Newborn Screening WIC Family Planning Prenatal Clinics SOURCES OF DATA Program and Service Data Newborn Screening WIC Family Planning Prenatal Clinics Well-baby Clinics, Immunization Programs Lead Poisoning Prevention Programs Children & Youth with Special Health Care Needs

SOURCES OF DATA Program and Service Data Disease Control Chronic Disease Prevention State Laboratory SOURCES OF DATA Program and Service Data Disease Control Chronic Disease Prevention State Laboratory Primary Care Minority Health Environmental Health Facilities and Professional Licensure Injury Prevention & SAFE Kids

SOURCES OF DATA Program and Service Data Medicaid SCHIP Education (special ed, lunch and SOURCES OF DATA Program and Service Data Medicaid SCHIP Education (special ed, lunch and breakfast programs, graduation rates, enrollment, etc) Social Services (child abuse and neglect, adoption, foster care, child care, etc) Mental Health and Substance Abuse Justice System (adult and juvenile) Hospital discharge data

SOURCES OF DATA Public Forums and Focus Groups Town Meetings and Public Forums Public SOURCES OF DATA Public Forums and Focus Groups Town Meetings and Public Forums Public Hearings Focus Groups Anecdotal Data Concerned citizens Media reports Elected officials

SOURCES OF DATA Stakeholder Focus involvement provides public input groups are a qualitative source SOURCES OF DATA Stakeholder Focus involvement provides public input groups are a qualitative source of data and can be used at multiple points in the process

SOURCES OF DATA Public Forums: open sessions where people can share their ideas, concerns, SOURCES OF DATA Public Forums: open sessions where people can share their ideas, concerns, etc Have to be well-managed to avoid pandemonium Conference Model: invited sessions where input is solicited through structured conversations Carousel Model – people move from issue table to issue table Circuit Riding: MCH program officials attend other meetings and ask for input on the subject relevant to the meeting (piggy-back on the existing forum)

SOURCES OF DATA Street Interceptions A form of ethnographic research Designed to elicit opinions SOURCES OF DATA Street Interceptions A form of ethnographic research Designed to elicit opinions on a few key questions quickly; often leads to focus groups or other data collection strategies Web Sites, the Internet Permanent request for input, e. g. , web posting Specific web-based survey, e. g. , survey monkey

SOURCES OF DATA Resource Inventories Important in Capacity Assessment Help identify services available from SOURCES OF DATA Resource Inventories Important in Capacity Assessment Help identify services available from a variety of providers Help reveal gaps in services (service elements, geography, accessibility, continuity, etc) Help identify under-utilized capacity (missed opportunities) Help optimize capacity given needs identified

SOURCES OF DATA State Level: resource inventories more about overall capacity State-level programs in SOURCES OF DATA State Level: resource inventories more about overall capacity State-level programs in operation Eligibility for these programs Local-level access Distribution of providers and facilities Local Level: resource inventories more specific Within communities, specific services available Type and nature, hours, accessibility, etc

SOURCES OF DATA Resource inventories do not Indicate need Evaluate quality Assess effectiveness of SOURCES OF DATA Resource inventories do not Indicate need Evaluate quality Assess effectiveness of the service within the larger system

KEEPING THE TRAIN ON THE TRACK NEEDS AS VALUES KEEPING THE TRAIN ON THE TRACK NEEDS AS VALUES

NEEDS AS VALUES Patterns emerge from data How to sort? Look for discrepancy (desired NEEDS AS VALUES Patterns emerge from data How to sort? Look for discrepancy (desired vs. actual) Needs show what we value; needs are values

NEEDS AS VALUES Needs are value judgments Needs suggest that problems exist for specific NEEDS AS VALUES Needs are value judgments Needs suggest that problems exist for specific population groups or in specific communities Needs are subject to disagreement and debate For needs to be useful in policy and program planning, there has to be agreement that they reflect real and important problems

NEED DISCREPANCIES Comparative Compare Needs our actual state to a desired state defined by NEED DISCREPANCIES Comparative Compare Needs our actual state to a desired state defined by experts IDEAL: no infant deaths NORM: state rate versus national rate MINIMAL: 1995 rate OPTIMAL: Healthy People 2010 rate COMPARATIVE: Iowa’s or Oregon’s rate

NEED DISCREPANCIES Expected, We Desired or Felt Needs compare our actual state to a NEED DISCREPANCIES Expected, We Desired or Felt Needs compare our actual state to a desired state defined by the target population EXPECTED: similar to the norm or minimal DESIRED: similar to the optimal or the ideal

NEED DISCREPANCIES Expressed defined Needs in terms of supply and demand assumes that demand NEED DISCREPANCIES Expressed defined Needs in terms of supply and demand assumes that demand for services reflects need Problem: demand might not reflect the sum total of the need or might not reflect actual needs Demand might be more a reflection of the supply,

SETTING PRIORITIES Understand Set where people are coming from parameters, or provide a starting SETTING PRIORITIES Understand Set where people are coming from parameters, or provide a starting point, to bring some method to the madness of so many potential needs (use of tools)

SETTING PRIORITIES Consider the work of others! Healthy People 2020 National MCH Strategic Plan SETTING PRIORITIES Consider the work of others! Healthy People 2020 National MCH Strategic Plan MCH National Performance Measures MCH Health Status Indicators Title V MCH Grant Statutory Requirements Kansas’ state health objectives

SETTING PRIORITIES We will segment needs into natural categories as in the MCH Block SETTING PRIORITIES We will segment needs into natural categories as in the MCH Block Grant Women and infants Children and adolescents Children and youth with special health care needs We will not pit the needs of one population group, locality or emphasis area against another (3 priorities per group)

SETTING PRIORITIES Within each of these the panels will use group process to rank SETTING PRIORITIES Within each of these the panels will use group process to rank order the needs May take several tries to get to a manageable list Use the “parking lot” for issues that people are passionate about but that don’t seem to fit – then revisit later

SETTING PRIORITIES CRITERIA for the selection of priorities from among the many needs identified SETTING PRIORITIES CRITERIA for the selection of priorities from among the many needs identified Size and Seriousness of the problem Size: extent of the problem, numbers affected directly, numbers affected indirectly Seriousness: urgency, severity, economic loss, potential impact on the population (SARS) or on family groups (homicide)

SETTING PRIORITIES: CDC/ASTHO Size of the problem Seriousness of the problem Availability of interventions SETTING PRIORITIES: CDC/ASTHO Size of the problem Seriousness of the problem Availability of interventions Effectiveness of interventions Economic feasibility Community perception of the problem Acceptability of the intervention to the public Legality of the intervention Political issues related to the problem Propriety/scope of responsibilities Adequacy of funding/existing sources of funding

SETTING PRIORITIES Group Process - to winnow the initial list down to a set SETTING PRIORITIES Group Process - to winnow the initial list down to a set of needs that are both linked to the population of interest, and are of sufficient impact in terms of size and severity to warrant inclusion in the final group Ordering needs

FACILITATORS Keeping lists: List of needs being discussed and debated by stakeholders and that FACILITATORS Keeping lists: List of needs being discussed and debated by stakeholders and that will ultimately reflect the values of a broad constituency Lists of things that will be done regardless of NA outcome (e. g. programs mandated by statute)

FACILITATORS Lists of things that emerge but we just don’t know enough about the FACILITATORS Lists of things that emerge but we just don’t know enough about the issue yet view as developmental needs

FACILITATORS Use different techniques to force people to order needs from most important to FACILITATORS Use different techniques to force people to order needs from most important to least important Remember, everyone will come to the table with his or her own agenda Methods for sifting through many competing priorities to reach consensus on a manageable list

SELECTING SOLUTIONS Not enough to identify something as a problem or a high priority SELECTING SOLUTIONS Not enough to identify something as a problem or a high priority need Can we do anything about it? and what precisely? Only then can a need achieve State Priority status

MORE OF THE SAME? Do not limit discussion to what we already do Do MORE OF THE SAME? Do not limit discussion to what we already do Do not assume that the only possible solution is more of the same Even stakeholders need reminders about this: “if only we had more ……”

SELECTING SOLUTIONS Avoid the narrow vision of what we already know, look to our SELECTING SOLUTIONS Avoid the narrow vision of what we already know, look to our other core functions to think more broadly: policy development assurance

SELECTING SOLUTIONS Policy Development: “every public health agency should exercise its responsibility to serve SELECTING SOLUTIONS Policy Development: “every public health agency should exercise its responsibility to serve the public interest in the development of comprehensive public health policies by promoting use of the scientific knowledge base in decision-making about public health and by leading in developing public health policy” IOM 1988

SELECTING SOLUTIONS Needs will be identified that are not within MCH’s purview Do not SELECTING SOLUTIONS Needs will be identified that are not within MCH’s purview Do not dismiss even if not our responsibility. (We may need to alert someone else to the problem Leading in policy development includes informing responsible parties and advocating for necessaryary change

SELECTING SOLUTIONS Examples: Crime Education quality Industrial pollutants Environmental concerns Jobs, transportation, other Refer SELECTING SOLUTIONS Examples: Crime Education quality Industrial pollutants Environmental concerns Jobs, transportation, other Refer to?

SELECTING SOLUTIONS Assurance: “Public health agencies should assure their constituents that services necessary to SELECTING SOLUTIONS Assurance: “Public health agencies should assure their constituents that services necessary to achieve agreed upon goals are provided, either by encouraging actions by other entities, by requiring such action through regulation, or by providing services directly” IOM 1988 The Future of Public Health

SELECTING SOLUTIONS How to ASSURE health by: Directly providing services or through local agencies SELECTING SOLUTIONS How to ASSURE health by: Directly providing services or through local agencies -- possible major changes with HC reform Contracting with other entities to provide direct services Regulating the services or regulating the problem or promoting quality improvement Educating professionals, providers or the public Collaborating with others in systems development efforts Gathering data to inform efforts in key areas

FINISH The needs assessment is not finished until : Priorities Strategies Objectives Resources State FINISH The needs assessment is not finished until : Priorities Strategies Objectives Resources State performance measures

FINISH It is NOT sufficient to “complete” a N. A. Stick You it up FINISH It is NOT sufficient to “complete” a N. A. Stick You it up on a shelf might as well have not done it at all Remember, change needs assessment is all about

SET PERFORMANCE MEASURES N. A. data helps you select measurable program objectives State Performance SET PERFORMANCE MEASURES N. A. data helps you select measurable program objectives State Performance Measures are one important tool to document our intent and ultimately evaluate our success

ALLOCATE RESOURCES From data To priorities To resource allocation Through grants or contract mechanisms ALLOCATE RESOURCES From data To priorities To resource allocation Through grants or contract mechanisms Per county? per capita? Based on level of need or on capacity?

ALLOCATE RESOURCES SHRINKING BUDGETS / INCREASED NEED Creativity Look for low- or no-cost strategies ALLOCATE RESOURCES SHRINKING BUDGETS / INCREASED NEED Creativity Look for low- or no-cost strategies Opportunities

TIMELINE BFH Start-up Planning – Spring of 2009 Stakeholder Operational Planning – Summer 2009 TIMELINE BFH Start-up Planning – Spring of 2009 Stakeholder Operational Planning – Summer 2009 Data Gathering – Fall of 2009 Needs Analysis – Nov 2009, Jan 2010 Capacity Assessment – Mar 2010 Public Comment on Draft– Apr-June 2010 Submit Final Version to Feds – July 2010 Performance Measurement & Evaluation – 20102015

TIMELINE Meeting #1 – Nov 6 - Organizational Meeting #2 – Jan 29 – TIMELINE Meeting #1 – Nov 6 - Organizational Meeting #2 – Jan 29 – Select Initial Priorities Capacity Assessment and Logic Models Spring 2010 -Draft Avail. for Public Comment

THANK YOU N. A. is a critical process for MCH in Kansas GOOD N. THANK YOU N. A. is a critical process for MCH in Kansas GOOD N. A. : informs decision-making processes engages partners and constituents helps foster accountability supports systems development and leadership

MOTHER AND CHILD, 1930 S MOTHER AND CHILD, 1930 S