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Strategies and Lessons from California’s MCAH Five-Year Needs Assessment and Implementation Plan Maternal, Child Strategies and Lessons from California’s MCAH Five-Year Needs Assessment and Implementation Plan Maternal, Child & Adolescent Health Program Center for Family Health California Department of Public Health Rocky Mountain Public Health Education Consortium, Albuquerque, NM; Sept. 19, 2008

California’s Story – Presentation Outline – Overview • California’s Environment & Demographics • MCAH California’s Story – Presentation Outline – Overview • California’s Environment & Demographics • MCAH Program – Title V 2005 Needs Assessment • • • Framework Guideline Development Quantitative Indicators & Qualitative Analysis Stakeholder Input & Capacity Assessment Establishing Priorities – Title V Implementation Plan • Development Process • Monitoring Progress – Lessons Learned • Recommendations • Challenges

California Demographic Characteristics: 2006 • State Projected Total Population – Hispanic – Non-Hispanic • California Demographic Characteristics: 2006 • State Projected Total Population – Hispanic – Non-Hispanic • White • Asian • Pacific Islander • African American • American Indian • Multi-Race 37. 4 million 13. 2 million (35%) 24. 2 million (65%) 16. 4 million (44%) 4. 3 million (12%) 0. 1 million (0. 4%) 2. 3 million (6%) 0. 2 million (0. 6%) 0. 8 million (2. 1%) • California Resident Women Births – 13. 3% of 2005 US Births 562, 157 • Births to Resident Hispanic Women 52% of total births • Paid by Medi-Cal – Prenatal Care – Delivery 46% of total births 47% of total births • Unintended Births to California Women 43% Data Sources: State of California, Department of Public Health, 2006 Birth Records; Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2005. Health E-Stats. Released November 21, 2006; State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, 2000– 2050. Sacramento, CA, July 2007. ; Maternal and Infant Health Assessment (MIHA) Survey, 2005.

Urban Rural counties are defined by the state Rural Health Policy Council as having Urban Rural counties are defined by the state Rural Health Policy Council as having a population of less than 250 persons per square mile and do not contain an incorporated area with a population greater than 50, 000. California Counties by Urban & Rural Designation

Live Births by County of Residence, 2006 California = 562, 157 Resident Births Source: Live Births by County of Residence, 2006 California = 562, 157 Resident Births Source: 2006 Birth Statistical Master File Prepared by: Maternal, Child and Adolescent Health Program, Center for Family Health, California Department of Public Health

LOCAL HEALTH DEPARTMENT MCAH PROGRAM GENERAL PROGRAM ACTIVITIES • All 61 Local Health Jurisdictions LOCAL HEALTH DEPARTMENT MCAH PROGRAM GENERAL PROGRAM ACTIVITIES • All 61 Local Health Jurisdictions (LHJs) have MCAH programs which serve women of reproductive age, infants, children, adolescents and their families, especially low-income families and individuals • Assess and monitor the health status, needs and services available to women and children, especially low-income populations • Provide community health programs that address a broad range of topics • Local MCAH agencies provide the CDPH MCAH Program annual documentation of progress made on SOW objectives and strategies • Four Objectives included in the SOW • Objective Four relates to development of an action plan at the local level

Organization of the MCAH Division Center for Family Health Deputy Director Catherine Camacho Maternal, Organization of the MCAH Division Center for Family Health Deputy Director Catherine Camacho Maternal, Child and Adolescent Health Division Acting Division Chief Shabbir Ahmad, DVM, MS, Ph. D Assistant Division Chief Les Newman Program Standards Chief Policy Development Chief Anita Mitchell, M. D. Karen Ramstrom, DO, MSPH Program Allocations, Integrity, & Support Chief Fred Chow Epidemiology, Assessment, and Program Development Acting Chief Mike Curtis, Ph. D Human Stem Cell Research & Cord Blood Program Chief Shabbir Ahmad Financial Management & Contract Operations Chief Jo Miglas California Birth Defect Monitoring Program Chief Marcia Ehinger, M. D.

Maternal, Child and Adolescent Health Programs (www. cdph. ca. gov/programs/MCAH/Pages/default. aspx) 1. Local Maternal Maternal, Child and Adolescent Health Programs (www. cdph. ca. gov/programs/MCAH/Pages/default. aspx) 1. Local Maternal and Child Health (MCH) Program - www. cdph. ca. gov/programs/Local. MCAH/Pages/Default. aspx 2. Birth Defects Monitoring Program – www. cbdmp. org or www. cdph. ca. gov/programs/CBDMP/Pages/default. aspx 3. Black Infant Health (BIH) - www. cdph. ca. gov/programs/BIH/Pages/default. aspx 4. Fetal Infant Mortality Review Program (FIMR) - www. cdph. ca. gov/programs/FIMR/Pages/default. aspx 5. Sudden Infant Death Syndrome (SIDS) - www. cdph. ca. gov/programs/SIDS/Pages/default. aspx 6. Comprehensive Perinatal Services Program (CPSP) - www. cdph. ca. gov/programs/CPSP/Pages/default. aspx 7. Regional Perinatal Programs of California (RPPC) - www. cdph. ca. gov/programs/RPPC/Pages/default. aspx 8. California Diabetes and Pregnancy Program (CDAPP) - www. cdph. ca. gov/programs/CDAPP/Pages/default. aspx 9. Breastfeeding Program (BFP) - www. cdph. ca. gov/programs/Breast. Feeding/Pages/default. aspx 10. California Perinatal Quality Care Collaborative (CPQCC) - http: //www. cpqcc. org 11. California Perinatal Transport System (CPe. Ts) - http: //www. perinatal. org 12. California Perinatal Profiles - http: //perinatalprofiles. berkeley. edu 13. Improved Perinatal Outcome Data Report (IPODR) – http: //ipodr. org/ccpr. html or www. cdph. ca. gov/data/indicators/Pages/Infant. Perinatal. Outcomes. Data. Report. aspx

Maternal, Child and Adolescent Health Programs (www. cdph. ca. gov/programs/MCAH/Pages/default. aspx) 14. Local Maternal Maternal, Child and Adolescent Health Programs (www. cdph. ca. gov/programs/MCAH/Pages/default. aspx) 14. Local Maternal and Child Health (MCH) Program – www. cdph. ca. gov/programs/Local. MCAH/Pages/Default. aspx 15. Adolescent Family Life Program - www. cdph. ca. gov/programs/AFLP/Pages/default. aspx 16. Pregnancy Associated Maternal Mortality Review (PAMR) - www. cdph. ca. gov/data/statistics/Pages/California. Pregnancy-Relatedand. Pregnancy. Associated. Mortality. Review. aspx 17. California Maternal Quality Care Collaborative (CMQCC) - www. cpqcc. org 18. Advanced Practice Nurse Program - 19. Human Stem Cell Research and Cord Blood Program - www. cdph. ca. gov/programs/HSCR/Pages/default. aspx 20. Nutrition and Physical Activity – www. cdph. ca. gov/programs/Nutiritionand. Physical. Activity/Pages/default. aspx 21. Family Health Outcome Project (FHOP) - www. cdph. ca. gov/data/indicators/Pages/Family. Health. Outcomes. Project(FHOP). aspx 22. Maternal Infant Health Assessment (MIHA) - www. cdph. ca. gov/data/surveys/Pages/Maternaland. Infant. Health. Assessment(MIHA)survey. aspx

Maternal, Child and Adolescent Health Programs (www. cdph. ca. gov/programs/MCAH/Pages/default. aspx) 23. Childhood Injury Maternal, Child and Adolescent Health Programs (www. cdph. ca. gov/programs/MCAH/Pages/default. aspx) 23. Childhood Injury Prevention Program (CIPP) – www. cdph. ca. gov/programs/CIPP/Pages/default. aspx 24. Oral Health Program - www. cdph. ca. gov/programs/MCAHOral. Health/Pages/default. aspx 25. California Early Childhood Comprehensive System (CA-ECCS) - www. cdph. ca. gov/programs/ECCS/Pages/default. aspx 26. Preconception Health and Health Care (PC) – www. cdph. ca. gov/programs/Preconception/Pages/default. aspx 27. Birth and Beyond California – www. cdph. ca. gov/Health. Info/healthyliving/childfamily/Pages/Birthand. Beyond. California. Description. aspx 28. Adolescent Health Promotion 29. Perinatal Substance Use Prevention (PSU) - www. cdph. ca. gov/programs/perinatalsubstanceuse/Pages/default. aspx

MCAH Work Philosophy (http: //ww 2. cdph. ca. gov/programs/MCAH/Pages/default. aspx) Data and/or Evidence Information MCAH Work Philosophy (http: //ww 2. cdph. ca. gov/programs/MCAH/Pages/default. aspx) Data and/or Evidence Information Evaluation Plan Action Maternal, Child and Adolescent Health Program Center for Family Health, California Department of Public Health

Title V Needs Assessment & Implementation Plan Timeline Title V Needs Assessment & Implementation Plan Timeline

Compartmentalize Needs Assessment State Oversight of the Process 61 Local Jurisdictions UCSF Needs Assessment Compartmentalize Needs Assessment State Oversight of the Process 61 Local Jurisdictions UCSF Needs Assessment Quantitative Qualitative Analysis Local & State Stakeholders Program Administrators

Major MCAH Needs Assessment Components • Select Health Status Indicators by surveying local jurisdictions Major MCAH Needs Assessment Components • Select Health Status Indicators by surveying local jurisdictions • Have local jurisdictions conduct a needs assessment • State Title V Agency summarize local level needs and priorities – Provide summary to local jurisdictions and stakeholders • Analyze both local jurisdiction qualitative information and statewide quantitative epidemiologic data • Assess State Title V Agency capacity • Involve external stakeholders, state administrators, and State Title V agency staff in the prioritization of needs • Obtain public input on needs assessment report • Develop SPM to measure progress towards achievement of objectives • Provide feedback to local jurisdictions • Develop and monitor state level MCAH implementation plan

Conceptual Framework • Decentralize statewide needs assessment process by having each local jurisdiction conduct Conceptual Framework • Decentralize statewide needs assessment process by having each local jurisdiction conduct a needs assessment • 61 local health jurisdictions • Key Goals 1. Build local jurisdiction needs assessment capacity 2. Obtain extensive stakeholder input at the local level 3. Identify “needs” that may have been missed by only analyzing statewide surveillance data systems 4. Focus local MCAH efforts by having each jurisdiction identify 2 -7 priority areas they will focus on during the next five years

Needs Assessment Activity Timeline, 2003 Needs Assessment Activity Timeline, 2003

Needs Assessment Activity Timeline, 2004 Needs Assessment Activity Timeline, 2004

Needs Assessment Activity Timeline, 2005 Needs Assessment Activity Timeline, 2005

Development of Needs Assessment Guidelines to Local Health Jurisdictions Development of Needs Assessment Guidelines to Local Health Jurisdictions

2005 Needs Assessment Guideline Development • 2000 Statewide Needs Assessment criticized due to vague 2005 Needs Assessment Guideline Development • 2000 Statewide Needs Assessment criticized due to vague guidelines resulting in local needs assessments that varied greatly in structure and were difficult to summarize. • 2005 local needs assessment guidelines written very specifically and comprehensively in response to 2000 needs assessment experience. • Stakeholders involved in development of 2005 guidelines – – State MCAH Epidemiology, Program and Policy Staff Family Health Outcomes Project (FHOP) MCAH Local Jurisdictions MCAH Contractors (Adolescent Health, Injury, etc. ) • Consideration of Department of Health Services Strategic Plan (2003) • HP 2010 objectives

Local MCAH Needs Assessment Guideline Components 1. Convene a planning group 2. Stakeholder input: Local MCAH Needs Assessment Guideline Components 1. Convene a planning group 2. Stakeholder input: consumers, local MCAH programs; providers; health, social service and educational providers 3. Community Assessment – Community health profile and resources assessment – Review required and other health status indicators – Assess local MCAH program capacity 4. Identify MCAH population needs 5. Identify 2 -7 local MCAH priority areas – Take into account local capacity to address identified needs 6. Conduct a preliminary problem analysis for one priority

Support Provided for Local MCAH Needs Assessments • Provide specific needs assessment guidelines with Support Provided for Local MCAH Needs Assessments • Provide specific needs assessment guidelines with page limits in order to ensure: – Consistency of reporting format across jurisdictions – Comprehensive local needs assessment process – Prevention of extensive narrative reporting • Provide training on conducting needs assessments and ongoing technical support to local jurisdictions – Support local level capacity • Provide trend data to local jurisdictions for 27 health status indicators stratified by race/ethnicity: – Minimize local data collection/analysis burden – Ensure standardized reporting

Training and Technical Assistance Provided to Local Health Jurisdictions • FHOP provided training throughout Training and Technical Assistance Provided to Local Health Jurisdictions • FHOP provided training throughout the year to local health jurisdiction staff: – – Conducting a formal problem analysis Conducting a community assessment Developing objectives, performance measures and action plans Etc. • FHOP developed a training book: “Developing an Effective MCH Planning Process: A Guide for Local MCH Programs” • FHOP provided ongoing technical assistance to local health jurisdictions on how to complete different components of the needs assessment – – – How to do capacity assessment Data analysis and interpretation assistance Involving stakeholders Developing and implementing surveys Etc.

Quantitative Indicator Data Selection • As part of their community health assessment, each local Quantitative Indicator Data Selection • As part of their community health assessment, each local health jurisdiction was required to review data for 27 different health status indicators. • Selection of health status indicators local health jurisdictions were required to review was based upon a survey of jurisdictions. – Jurisdictions were asked to rank the indicators they thought were most important to assessing overall MCAH population health. – Over 110 indicators were reviewed, the highest ranked indicators were selected.

Examples of Quantitative Indicators • Birth – # of births / fertility rates / Examples of Quantitative Indicators • Birth – # of births / fertility rates / teen birth rates – Low, very low, and preterm births • Death – Perinatal, neonatal, post-neonatal, and infant mortality – Death rates (ages 1 -14 years and 15 -19 years) • Prenatal/Postnatal Care – 1 st trimester prenatal care initiation / Adequacy of Prenatal Care – In-hospital exclusive breastfeeding • Injuries – Hospitalization for non-fatal injuries (1 -14 years, 15 -24) – Non-Fatal injuries due to motor vehicle accidents (1 -14 years, 15 -24) • Health – Percent of children without health insurance / Percent without dental insurance – Percent of children who are overweight – Asthma hospitalization rates – Chlamydia rates for 15 -19 year old females – Hospitalization rates for mental health (5 -14 year olds, 15 -19 year olds)

Quantitative Indicator Data and Additional Optional Data • For each local health jurisdiction, FHOP Quantitative Indicator Data and Additional Optional Data • For each local health jurisdiction, FHOP computed tables and graphs for 27 health status indicators. – Data computed for the past 10 years and stratified by race/ethnicity – Compare local rate with a standard (HP 2010 and/or State rate) • Jurisdictions were encouraged to review additional data beyond the 27 indicators, including consideration of other quantitative and qualitative data sources. • Examples of additional topics include – physical activity, immunizations, vaccine preventable diseases, mental health problems, perinatal substance abuse, gestational diabetes, oral health, and youth development.

GENERAL APPROACH TO THE ANALYSIS OF QUALITATIVE DATA • Narrative results from a needs GENERAL APPROACH TO THE ANALYSIS OF QUALITATIVE DATA • Narrative results from a needs assessment must be summarized in a manner that can facilitate the discussion of problems or priorities. • Decisions should be made on: • whether to code information based on predetermined categories or based on themes developed from the dataset • whether to code the literal reading of a transcript or make inferences about what the author meant

Qualitative Data Coding • The evaluation required multiple readings of each report to reduce Qualitative Data Coding • The evaluation required multiple readings of each report to reduce the likelihood of overlooking important information. • Coding was done for five areas across health jurisdictions: - type and number of participants involved in the planning process - the types and the levels of community input, - the sources of information used for identifying problems, - the categories and subcategories of problems identified, and - the categories and subcategories of named priorities.

Coding of Local Needs and Priorities • “Problems” and “priorities” identified by local needs Coding of Local Needs and Priorities • “Problems” and “priorities” identified by local needs assessments were coded separately • Problems and priorities were coded two ways to understand the nature of the problems – General thematic areas (Substance Abuse, Mental Health, etc. ) – Specific sub-topics (perinatal substance abuse, adolescent drug use, etc. ) • Local jurisdictions identified 122 specific problems, of which 81 were identified by local jurisdictions as a priority area • “Access to Care” – 23 different specific topics • “Breastfeeding” – 3 different specific topics

Example: Subtopics Within the Access to Care Category • • • Lack of health Example: Subtopics Within the Access to Care Category • • • Lack of health insurance Lack of transportation Lack of bilingual professional staff Lack of specialty providers Access to health or dental care Lack of nurses, physicians, dietitians, & dentists Lack of providers in general Cost of health care or health insurance Complexity & bureaucracy of system Lack of information or awareness of services Language & cultural communication barriers Lack of providers who accept Medicaid

Example Summary Spreadsheet: Access to Care Sub-Topics Frequencies by Jurisdiction Example Summary Spreadsheet: Access to Care Sub-Topics Frequencies by Jurisdiction

Local Health Jurisdiction Stakeholder Participation • Over 1, 600 stakeholders participated in local needs Local Health Jurisdiction Stakeholder Participation • Over 1, 600 stakeholders participated in local needs assessment meetings – – – – City or county representatives Social service agency representatives Health care provider representatives Elementary school administrators University or college academicians Local residents in the community Other organization representatives

Supplemental Data Sources Used by Local Jurisdictions to Identify Needs • Secondary Research Data Supplemental Data Sources Used by Local Jurisdictions to Identify Needs • Secondary Research Data and Reports (500+ citations) – Academic journals, state/federal agencies, interest groups – Reports by other local health and social service groups • Local Program and Jurisdiction Data (100+ citations) – MCH program data, foster care placements, FIMR, etc. • Local Surveys – Over 5, 000 individuals surveyed, such as school administrators, clients, providers, and family members

State Level Stakeholder Input in Setting Statewide MCAH Priorities Capacity Assessment State Level Stakeholder Input in Setting Statewide MCAH Priorities Capacity Assessment

Statewide External Stakeholder Meeting • Over 50 representatives from state, local and private agencies Statewide External Stakeholder Meeting • Over 50 representatives from state, local and private agencies were invited, 37 organizations attended. – State Agencies, Local Health Jurisdictions, Provider Groups, Consumer Groups, MCAH Programs, Academic Institutions • Stakeholders were asked to review prior to the meeting – Summarized results of local MCAH jurisdiction priorities – Statewide epidemiological data

Stakeholders Invited to Statewide Needs Assessment Meeting • • • • • • • Stakeholders Invited to Statewide Needs Assessment Meeting • • • • • • • Adolescent Family Life Program American Academy of Pediatrics American College of Obstetricians and Gynecologists Birth Defects Monitoring Program Black Infant Health Program California Adolescent Health Collaborative California Conference of Local Health Officers California Dental Association California Family Health Council California Healthcare Foundation California Hospital Association California Nursing Association California Perinatal Quality Care Initiative California Public Health Association California Department of Alcohol and Drug Programs California Dept. Developmental Services California Department of Education California Department of Mental Health California Department of Rehabilitation California Department of Social Services, Children and Family Services Division Center for Healthier Children, Families and Communities, UCLA Center for Injury Prevention Policy and Practice; SDSU Charlotte Maxwell Newhart & Associates Child Death Review Team Children Now Dept. of Family & Community Medicine, UCSF Domestic Violence Programs Epidemiology and Prevention for Injury Control Branch • • • • • • • Epidemiology and Prevention for Injury Control Branch Fetal & Infant Mortality Review Program First Five Commission Genetic Diseases Branch, CDPH Immunization Branch, CDPH Indian Health Program, DHCS Institute for Health Policy Studies, UCSF Kaiser Family Foundation March of Dimes, California MCAH Action Executive Committee Medi-Cal Dental Services, DHCS Medi-Cal SCHIP, DHCS Office of AIDS, CDPH Office of Family Planning, CDPH Office of Multicultural Health, CDPH Office of Women’s Health Advisory Group Office of Oral Health, CDPH Pacific Business Group on Health Planned Parenthood Primary & Rural Health Care System, CDPH Regional Perinatal Programs of California Directors Sexually Transmitted Disease Control Branch, CDPH School of Public Health, UC Berkeley State Council on Developmental Disabilities Sudden Infant Death Syndrome Program The ARC of California Women, Infants and Children Supplemental Nutrition Branch, CDPH

Criteria Developed by Stakeholder Group to Rank Priorities • Stakeholders reviewed a list of Criteria Developed by Stakeholder Group to Rank Priorities • Stakeholders reviewed a list of possible criteria upon which to rank priorities and selected the following: – – – Problem has serious health consequences Large number of individuals affected Problem results in significant economic/social costs Problem is cross-cutting across multiple issues Problem has disparities across sub-groups • Each of the above criteria received a weight established collectively by the stakeholders

MCAH Needs Assessment Stakeholder Meeting Ranking Results MCAH Needs Assessment Stakeholder Meeting Ranking Results

State Title V Agency Capacity Assessment • State Title V Agency conducted internal capacity State Title V Agency Capacity Assessment • State Title V Agency conducted internal capacity assessment • CAST-V Tool used for assessment • Managers and senior staff participated in the process • Results listed by “strengths” and “weaknesses/areas for improvement” for each of the 10 Essential Public Health Services

California MCAH Priority Setting Local MCAH jurisdiction input MCAH Priorities n. Quantitative analysis of California MCAH Priority Setting Local MCAH jurisdiction input MCAH Priorities n. Quantitative analysis of statewide epidemiologic data Stakeholder input State MCAH Program, Policy & Epidemiology Staff Input Administrative/Fiscal/Political Considerations u. Capacity u. Duties fulfilled by other departments and agencies

Case Study 1: Perinatal Substance Abuse • Data on perinatal substance use was very Case Study 1: Perinatal Substance Abuse • Data on perinatal substance use was very limited and no data was provided to local jurisdictions. Perinatal substance abuse, however, was one of the most common problems and priorities identified. Many jurisdictions relied on qualitative data sources. • Data Sources used by Local Jurisdictions – Provider surveys – Foster care placement information – Key informant interviews / Stakeholder input

Case Study 2: Pregnancy-Related Mortality • Pregnancy-related mortality was one of the most rare Case Study 2: Pregnancy-Related Mortality • Pregnancy-related mortality was one of the most rare events at local level. • Pregnancy-related mortality surfaced as one of the priority for state MCAH program based largely upon quantitative analysis of statewide trends. • Data Sources used by State – Death records – Linked birth - death – hospital patient discharge dataset

2006 -2010 MCAH Priorities • Enhance preconception care and work toward eliminating disparities in 2006 -2010 MCAH Priorities • Enhance preconception care and work toward eliminating disparities in infant and maternal morbidity and mortality. • Promote healthy lifestyle practices among MCAH populations and reduce the rate of overweight children and adolescents. • Promote responsible sexual behavior to decrease the rate of teenage pregnancy and sexually transmitted infections. • Improve mental health and decrease substance abuse among children, adolescents, and pregnant or parenting women. • Improve access to medical and dental services, including the reduction of disparities. • Decrease unintentional and intentional injuries and violence, including family and intimate partner violence. • Increase breastfeeding initiation and duration

Development of California’s MCAH Title V Implementation Plan (July 2005 – October 2007) Maternal, Development of California’s MCAH Title V Implementation Plan (July 2005 – October 2007) Maternal, Child & Adolescent Health Division Center for Family Health California Department of Public Health

California Title V Implementation Plan Acknowledgements: • CDPH, MCAH Division Leadership – Susann J. California Title V Implementation Plan Acknowledgements: • CDPH, MCAH Division Leadership – Susann J. Steinberg, MD (retired) – Shabbir Ahmad, DVM, MS, Ph. D • CDPH, MCAH Division IP Steering Committee: – – – – – • Kate Marie, MPA (Chair) Angela Furnari, RN, PHN, MPA Janet Hill, MS, RD Lori Llewelyn, MPP Anita Mitchell, MD Kathleen Nettesheim-Engle, MPH, RN Karen Ramstrom, DO, MSPH Leona Shields, PHN, MN, NP Eileen Yamada, MD University of California San Francisco, Family Health Outcomes Project – – Judith Belfiori, MA, MPH Brianna Gass, MPA Geraldine Oliva, MD, MPH Jennifer Rienks, Ph. D

Developing an Action Plan External Environment Should Do Organizational Values, Culture, Leadership Wants To Developing an Action Plan External Environment Should Do Organizational Values, Culture, Leadership Wants To Do Internal Environment Can Do Strategy of the Organization Focused Strategic Thinking; AC Rucks; University of Alabama Birmingham

Developing a Plan: Oral Health Example • External Environment (Should Do): – Data: • Developing a Plan: Oral Health Example • External Environment (Should Do): – Data: • By third grade, over 70% of children have a history of tooth decay • By age 2, only 1 in 10 children had any kind of preventive dental visit • Fewer than 1 in 5 pregnant women have received any dental services – Oral Health Stakeholders and Partners: • Proposed additional IP objectives and strategies – Greater use of case management with regard to maternal and children's’ oral health – Establish a Dental Health Advisory Committee to the MCAH Division, encourage local MCAH programs to do the same • Organization Values, Culture & Leadership (Want to Do): – Improve access to dental services for MCH population – Reduce disparities • Internal Environment (Can Do) – Fiscal constraints limit assistance available at state and local level – Build strong collaborations with other state and advocacy groups to address oral health issues specific to MCH population

Development of the Title V Implementation Plan Ten priority goals identified for 2006 -2010 Development of the Title V Implementation Plan Ten priority goals identified for 2006 -2010 – Seven Priority Goals – Maternal Child Adolescent Health Division – Three Priority Goals – Children’s Medical Services Implementation Plan • Focus on State MCAH Program role with regard to the identified priorities and supporting needs at the local level • Builds on existing and emerging efforts • General direction to be taken by the State MCAH Division during the Title V 2006 – 2010 grant cycle

2006 -2010 MCAH Program Priorities (biphasic process) Priorities Addressed in State Fiscal Year 2006 2006 -2010 MCAH Program Priorities (biphasic process) Priorities Addressed in State Fiscal Year 2006 -2007 • • Enhance preconception care and work toward eliminating disparities in infant and maternal morbidity and mortality. Promote healthy lifestyle practices among MCAH populations and reduce the rate of overweight children and adolescents. Improve mental health and decrease substance abuse among children, adolescents, and pregnant or parenting women. Increase breastfeeding initiation and duration (make breastfeeding the norm). Priorities Addressed in State Fiscal Year 2007 -2008 • • • Promote responsible sexual behavior to decrease the rate of teenage pregnancy and sexually transmitted infections. Improve access to medical and dental services, including the reduction of disparities. Decrease unintentional and intentional injuries and violence, including family and intimate partner violence.

Developing an Action Plan Understanding the Situation Planning the Strategy Planning the Implementation Planning Developing an Action Plan Understanding the Situation Planning the Strategy Planning the Implementation Planning the Control External Environmental Issues Internal Environmental Issues Vision, Mission, Values Strategy Formulation Goal Development -- Strategic Direction Implementation of the Plan Develop Specific Actions – Specify Time Priority Control of the Plan Setting Measures – Budgeting – Recycling the Plan Focused Strategic Thinking; AC Rucks; University of Alabama Birmingham

Development of Implementation Plan Process Internal Planning Meetings Statewide MCAH Stakeholder meeting MCAH Management Development of Implementation Plan Process Internal Planning Meetings Statewide MCAH Stakeholder meeting MCAH Management and Program Supervisors’ Input Review and input from recognized MCAH experts On-site meetings with local MCAH representatives Public input via webbased posting Input from MCAH County Health Directors MCAH Implementation Plan

Implementation Plan -Understanding the Situation • Input from MCAH Program Managers – Need to Implementation Plan -Understanding the Situation • Input from MCAH Program Managers – Need to know where you’ve been in order to plan where you’re going • Local Health Jurisdiction’s Input – Identified evidence based or successful program models that address TV priority area(s) – Discussed barriers to implementation; how barriers were addressed; and any problems or unresolved issues with these programs

Implementation Plan - Planning the Strategy • MCAH Action Committee Input – Review & Implementation Plan - Planning the Strategy • MCAH Action Committee Input – Review & input from local MCH Directors • Statewide Stakeholder Meeting – Representatives from 48 government, research, and community-based organizations

State of California-Health and Human Services Agency Department of Health Services January 31, 2007 State of California-Health and Human Services Agency Department of Health Services January 31, 2007 TO: TITLE V STAKEHOLDERS SUBJECT: TITLE V MATERNAL, CHILD AND ADOLESCENT HEALTH FIVE-YEAR IMPLEMENTATION PLAN (PHASE II) STAKEHOLDERS’ MEETING I invite you to participate in a meeting sponsored by the California Department of Health Services (CDHS); Maternal, Child and Adolescent Health/Office of Family Planning (MCAH/OFP) Branch to review and discuss implementation objectives and strategies for priorities identified through the 2005 -2006 Title V Needs Assessment. Your input will contribute to the five-year implementation plan that will be submitted this July as part of California’s 2007 -08 Title V Maternal and Child Health Block Grant application. The meeting will be held on Tuesday, March 20, 2007, from 10: 00 a. m. to 4: 00 p. m. , in Sacramento, and will be facilitated by the Family Health Outcomes Project of the University of California, San Francisco.

Title V Implementation Plan – Participating Stakeholders • • • • • • • Title V Implementation Plan – Participating Stakeholders • • • • • • • Adolescent Health Collaborative California Conference of Local Health Officers California Department of Alcohol and Drug Programs California Dept. Developmental Services California Department of Education California Department of Mental Health California Department of Rehabilitation California Family Health Council California Hospital Association California Perinatal Quality Care Collaborative California Public Health Association South Center for Injury Prevention Policy and Practice; SDSU Center for Positive Prevention Alternatives Child & Health Permanency, Department of Social Services Children's Medical Services Branch, DHCS Chronic Disease and Injury Control, CDPH Dept. of Family & Community Medicine, UCSF Family Health Outcomes Project, UCSF FASD Advocacy Group, The Arc of California Fetal & Infant Mortality Review Program Genetic Diseases Branch, CDPH Health Initiatives for Youth Immunization Branch, CDPH Indian Health Program, DHCS Institute for Health Policy Studies, UCSF • • • • • • LA Best Babies Network March of Dimes, California Maternal, Child and Adolescent Health Program Office of Family Planning Branch, CDPH MCAH Action Executive Committee MCH-Contra Costa County Medi-Cal Dental Services, DHCS Medi-Cal Eligibility, DHCS Medi-Cal Policy, DHCS Obstetrics, Gynecology & Reproductive Sciences: UCSF Office of AIDS, CDPH Office of Oral Health, CDPH Office of Perinatal Substance Abuse, California Department of Alcohol and Drug Programs Primary & Rural Health Care System, CDPH Refugee Health Section; CDPH Regional Perinatal Programs of California Sexually Transmitted Disease Control Branch, CDPH State & Local Injury Control Section, CDPH State Council on Developmental Disabilities Sudden Infant Death Syndrome Program Sutter Medical Center WEAVE, Inc Wellstart International Women, Infants and Children Supplemental Nutrition Branch, CDPH

Stakeholder Meeting Criteria for Evaluating Strategies The strategy/intervention … • • • is evidence-based Stakeholder Meeting Criteria for Evaluating Strategies The strategy/intervention … • • • is evidence-based and/or promising can be implemented in different size counties with modification or assistance (broadly applied); is cost effective (based on research); addresses Federal and State priorities for reducing health disparities; is supported by “political will”; provides collaboration opportunities across State and/or local agencies and programs

Priority Goal 3: Promote responsible sexual behavior in order to decrease the rate of Priority Goal 3: Promote responsible sexual behavior in order to decrease the rate of teenage pregnancy and sexually transmitted infections. Objective 3. 2 – Increase the sexual health knowledge and counseling skill level of providers and professionals providing family planning and reproductive health services to teens. Evidencebased 3. 2. 1 Create a comprehensive outline of knowledge, abilities and skills necessary to be an effective and highly qualified educator, counselor, or case manager in the area of adolescent sexual health. 3. 2. 2 Disseminate core competencies applicable to a wide range of professionals for providing sexual health education and counseling services to adolescents and young adults consistent with best practices for effective interventions and appropriate to age and ethnicity. 3. 2. 3 Develop a comprehensive and appropriate training based on the core competencies. Explore the need for the development of a certification program for defined categories of counselors Broadly Cost Addresses Political Applied Effective Disparities Will Collaborative Opportunities

Stakeholder Identified Cross Cutting Objectives • MCAH key program components integrated throughout all programs Stakeholder Identified Cross Cutting Objectives • MCAH key program components integrated throughout all programs – Preconception Health – Breastfeeding – Nutrition & Healthy Lifestyles – Oral Health • Eliminate health disparities • Promote cultural and linguistic competence in MCAH programs and staff

Implementation Plan – Planning the Strategy • Review and input by recognized leaders/experts in Implementation Plan – Planning the Strategy • Review and input by recognized leaders/experts in MCAH – Is the information accurate? – Are there additional activities that are feasible given limited resources? – Are there any glaring omissions? • Web-based posting for public input – Notice sent to MCAH stakeholders, directors and program coordinators

Implementation Plan – Overview Maternal Health Implementation Plan – Overview Maternal Health

Implementation Plan – Case Study Maternal Health • Maternal Quality Indicator Workgroup (2001) – Implementation Plan – Case Study Maternal Health • Maternal Quality Indicator Workgroup (2001) – Assess current levels of maternal morbidity in California and – Develop valid indicators in order to measure trends in maternal outcomes where local and statewide projects have been initiated to improve maternal health. • CA-Pregnancy-Associated Mortality Review (2004) – Identify and review deaths of women during pregnancy and childbirth – Deaths of African American women are over-sampled in order to gain insight into maternal health disparities. • CA Maternal Quality Care Collaborative (2006) – Improving maternal health through data driven quality improvement – Determine possible opportunities for prevention • Hemorrhage Task Force • Maternal Quality Improvement Panel – Provide recommendations to reduce future morbidity and mortality • Local Assistance for Maternal Health (2008) – Improve prevention of, recognition of, and response to maternal morbidities and obstetrical emergencies – Improve accuracy and usefulness of administrative data – Reduce fragmentation of maternity care – Inform and educate the public and families about maternal issues related to reducing morbidity and mortality

Post Implementation Plan - Programmatic Changes • Preconception Care Council of California (Priority Goal Post Implementation Plan - Programmatic Changes • Preconception Care Council of California (Priority Goal 1) – Forum for statewide planning and decision-making on issues and programs related to preconception health and health care. – Convener of the Second National Preconception Care Summit, October 2007 • Perinatal Substance Abuse Prevention Efforts (Priority Goal 4) – California Fetal Alcohol Spectrum Disorders Task Force – State Interagency Team Workgroup on Alcohol and Other Drugs – Perinatal Substance Use Screening Data Report by Dr. Ira Chasnoff • Projected publication release: Summer 2008 • Breastfeeding Promotion (Priority Goal 10) – Encourage Baby Friendly Hospitals

Title V Implementation Plan: Monitoring Progress Are we there yet? Title V Implementation Plan: Monitoring Progress Are we there yet?

Implementation Plan – Planning the Control • National and State Title V performance and Implementation Plan – Planning the Control • National and State Title V performance and outcome measures monitor progress on state priorities – Intermediary measures of change needed • Documentation of progress made on objectives and strategies following the Phase I Stakeholder Meeting – Inform stakeholders about progress in preparation for Phase II Stakeholder Meeting – First step for developing means to monitor progress • Ongoing monitoring of Title V implementation plan – Developing a process – Build into how we do day-to-day business

State Performance Measures To measure progress toward achievement of objectives SPM #3. Percent of State Performance Measures To measure progress toward achievement of objectives SPM #3. Percent of women (18 -44 years) who reported 14 or more “not good” mental health days in the past 30 days. SPM #4. Percent of women who reported drinking any alcohol in the 1 st or 3 rd trimester of pregnancy. SPM #5. Rate of deaths per 100, 000 adolescents (15 -19 years) caused by motor vehicle accidents. SPM #6. Incidence of neural tube defects (NTDs) per 10, 000 live births plus fetal deaths among counties participating in the California Birth Defects Monitoring System. SPM #8. Percent of births resulting from an unintended pregnancy. SPM #9. Percent of 9 th grade students who are not within the Healthy Fitness Zone for Body Composition. SPM #10. Percent of women reporting intimate partner physical, sexual, or psychological abuse in the past 12 months. SOM #1. The pregnancy-related mortality rate per 100, 000 live births.

MCAH Priority Areas and Corresponding Performance Measures Priority National Performance Measure State Performance Measure MCAH Priority Areas and Corresponding Performance Measures Priority National Performance Measure State Performance Measure Enhance preconception care and work toward eliminating disparities in infant and maternal morbidity and mortality. 01, 15, 17, 18 06 (and SOM 01) Promote healthy lifestyle practices among MCAH populations and reduce the rate of overweight children and adolescents. 14 09 Promote responsible sexual behavior to decrease the rate of teenage pregnancy and sexually transmitted infections. 08 08 Improve mental health and decrease substance abuse among children, adolescents, and pregnant or parenting women. 16 03, 04 Improve access to medical and dental services, including the reduction of disparities. 01, 04, 07, 09, 12, 13, 17, 18 Decrease unintentional and intentional injuries and violence, including family and intimate partner violence. 10, 16 Increase breastfeeding initiation and duration. 11 Health Status Indicator 05, 10 01, 02 05 03, 04

Monitoring Title V Implementation Plan Progress • Local Health Jurisdiction Activities – Capture how Monitoring Title V Implementation Plan Progress • Local Health Jurisdiction Activities – Capture how local activities support our state level objectives and strategies • MCAH Division Internal Monitoring

Monitoring Title V Implementation Plan Progress – Local Health Jurisdictions • Track local health Monitoring Title V Implementation Plan Progress – Local Health Jurisdictions • Track local health jurisdictions activities in a uniform way – Identify activities through LHJ annual reports – Utilize MCH pyramid of services to capture information • Utilize information to integrate evaluation and program planning – Identify best or promising practices – Identify challenges/barriers faced – Provide technical assistance back to LHJs • Capture anecdotes about MCAH programs (infrastructure challenges, accomplishments) – Inform Legislators; guide policy discussions

Monitoring Title V Implementation Plan Progress 2008 INDEX- Local Annual Report Instructions: Type Monitoring Title V Implementation Plan Progress 2008 INDEX- Local Annual Report Instructions: Type "1" if the health topic is covered in their report and "0" if not covered in the report. DO NOT type "Yes" or "No" in the box; typing "1" automatically converts to "Yes" and "0" converts to a "No" response in the grid. COUNTY/ Health Topic D H C Infant Morbidity/ Mortality Preconception Care P B S Alpine Amador Berkeley D H C Alameda I B E S Mental Health D H C Alameda Alpine Amador Berkeley TOTAL 0 I B D H C E S P B S I B Breastfeeding Teen Pregnancy 0 0 0 E S P B S I B D H C P B S E S P B S I B D H C E S P B S I B E S P B S Oral Health Injury/ Violence 0 0 0 0 I B E S P B S D H C E S D H C I B Access to Medical Care P B S D H C Childhood Injury Prevention Smoking/ Substance Use I B E S STD D H C I B P B S I B E S D H C E S P B S D H C Obesity/ Nutrition/ Physical Activity Obesity I B E S P B S Maternal Morbidity/ Mortality I B D H C E S P B S I B DHC=Direct Health Care Services; ES=Enabling Services; PBS=Population-Based Services; IB=Infrastructure Building Services

Monitoring Title V Implementation Plan Progress Monitoring Title V Implementation Plan Progress

Monitoring Title V Implementation Plan Progress – MCAH Division Internal Monitoring • Monitor Internal Monitoring Title V Implementation Plan Progress – MCAH Division Internal Monitoring • Monitor Internal Progress on Title V Implementation Plan Activities – Develop tool to document Title V Priority area activities – Draft format includes: priority goal, objective, strategies, team, activities, resources, process measures and short and intermediate outcomes • Next Steps: – Pilot test the tool – Finalize the format and process for use – Assess indicator data for each priority area – Revisit objectives/strategies and identify revisions needed

Recommendations for 2010 Needs Assessment Recommendations • Needs assessment efforts in large states need Recommendations for 2010 Needs Assessment Recommendations • Needs assessment efforts in large states need to be decentralized. • Clear, concise guidelines need to be provided to local jurisdictions • Emphasize the need for local jurisdictions to obtain stakeholder input. • Technical assistance, training, and data need to be provided to local jurisdictions. • Qualitative analysis of local needs assessment data should organize the needs/priorities by both general subject areas as well as specific sub-topics. Both levels of information are important. • Most priority areas are inter-related. Use the needs assessment process to bring together other state departments. Areas of common interest will be identified among all stakeholders and collaborative efforts will be strengthened. Lessons Learned • Small jurisdictions may find the needs assessment hard to complete. We will be assessing our guidelines to identify areas to delete while still ensuring the needs assessment is comprehensive. • Enhance analysis of local level MCAH capacity and report findings back to jurisdictions.

2010 Five Year Needs Assessment Capacity Assessment • Discussion started in September 2007 – 2010 Five Year Needs Assessment Capacity Assessment • Discussion started in September 2007 – Modified CAST-V – Assess Local Health Jurisdiction Capacity • Guidelines released in May 2008 – For 2010 Five-year Needs Assessment – Available online at: http: //www. cdph. ca. gov/programs/MCAH/Documents/ MO-Title. VGuidelines. For. Local. Needs. Assessment 11 a. pdf

Title V Five Year Needs Assessment and Implementation Plan are indeed CONTINUOUS PROCESSES (The Title V Five Year Needs Assessment and Implementation Plan are indeed CONTINUOUS PROCESSES (The cycle started in Jan 2003 and ended in Oct 2007)

Challenges… • Staff Turnover • Fiscal Constraints • Department Reorganization (planning started in Jan Challenges… • Staff Turnover • Fiscal Constraints • Department Reorganization (planning started in Jan 2006) • Development of efficient process – Takes into account existing process – Feeds into Implementation Plan progress • Keeping Stakeholders informed on the progress made

Must Haves… • Support of Management/Leadership • Right people at the table – Engage Must Haves… • Support of Management/Leadership • Right people at the table – Engage staff in the process • Structured but flexible process – Open lines of communication – Ongoing evaluation – Subsequent revision/adjustment of activities • Stakeholder’s buy-in on common priorities – Local Health Jurisdictions

“And you better start swimming or you’ll sink like a stone. For the Times, “And you better start swimming or you’ll sink like a stone. For the Times, they are a-changin” Bob Dylan

Thank you Thank you