Linda Kenney, MPH November 6, 2009

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

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

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 infants  Children and adolescents  Children with special health care needs 5

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

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

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

 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

 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

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

 “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

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

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

 Required of KDHE as the State Title V agency  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

 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!

“... 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.

 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

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

 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

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

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

 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

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?

 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

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

 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

 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

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...

 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

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

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

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

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

 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

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

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

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

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

 Surveillance Systems and Survey Data  Every 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

 Program and Service Data  M&I, 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

 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

 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

 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

Public Forums and Focus Groups  Town Meetings and Public Forums  Public Hearings  Focus Groups  Anecdotal Data  Concerned citizens  Media reports  Elected officials

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

 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)

 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

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

 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

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

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

 Comparative Needs  Compare 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

 Expected, Desired or Felt Needs  We 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

 Expressed Needs  defined 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,

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

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

 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)

 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

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)

 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

 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

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)

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

 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

 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

 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 ……”

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

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

 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

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

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 1988The Future of Public Health

 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

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

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

 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

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

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

 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 –

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

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