1. An Overview of Healthy Start David S
An Overview of Healthy Start David S. de la Cruz, PhD, MPH Captain, US Public Health Service Deputy Director Dept. of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau (MCHB) Division of Healthy Start and Perinatal Services (DHSPS) Presentation to SACIM – July 2012

2. Vision Healthy Communities, Healthy People
Mission To improve health and achieve health equity through access to quality services, a skilled health workforce and innovative programs.
Our administrator is Dr. Mary Wakefield. HRSA, is an agency of the U.S. Department of Health and Human Services, and the primary Federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable.
It is comprised of six bureaus and 13 offices, HRSA provides leadership and financial support to health care providers in every state and U.S. territory. HRSA grantees provide health care to uninsured people, people living with HIV/AIDS, and pregnant women, mothers and children. They train health professionals and improve systems of care in rural communities.
Our agency is located in Rockville, MD. But for this presentation we will focus on the Maternal and Child Health Bureau specifically the Division of Healthy Start and Perinatal Services.

3. Maternal and Child Health Bureau
2/24/2012
Office of the Associate Administrator
Associate Administrator
Michael C. Lu, M.D., M.S., M.P.H.
Deputy Associate Administrator
Jon Nelson
(RM)
Office of Operations and
Management
Director
Michael A. Mucci
(RM1)
Office of Policy
Coordination
Director
James Resnick (Acting)
(RM10)
Division of Services for
Children with Special
Health Needs
Director
Bonnie Strickland, Ph.D.
(RM2)
Division of Child,
Adolescent and Family
Health
Director
David E. Heppel, M.D.
(RM3)
Division of Maternal and
Child Health Workforce
Development
Director
Laura Kavanagh, MPP
(RM4)
Division of Healthy
Start and Perinatal
Services
Director
Chris DeGraw, M.D.
(Acting)
(RM5)
Division of State and
Community Health
Director
Cassie Lauver, ACSW
(RM6)
Division of Home
Visiting and Early
Childhood Systems
Director
Terry Adirim (Acting)
(RM8)
Office of Epidemiology
and Research
Director
Michael Kogan, PhD.
(RM9)
Integrated Services
Branch
Chief
Diana Denboba
(RM21)
Adolescent Health
Branch
Chief
Trina Anglin, M.D.
(RM35)
Healthy Start East
Branch
Chief
Beverly Wright
(RM58)
State and Community
Partnership East
Branch
Chief
Ellen Volpe
(RM63)
Eastern Program Implementation Branch
Chief
Judith Thierry
(RM81)
Division of Research
Director
Stella Yu, Sc.D.
(Acting)
(RM91)
About Us
As the only governmental program responsible for ensuring the health and well-being of the entire population of women, infants, and children, the Title V program plays a critical role in coordination, capacity building, and quality oversight at the community and state levels.  By connecting people to services, programs to programs, and agencies to agencies, Title V programs maximize resources and increase quality and effectiveness.
MCH Mission
The mission of the Maternal and Child Health Bureau (MCHB) is to provide leadership, in partnership with key stakeholders, to improve the physical and mental health, safety and well-being of the maternal and child health (MCH) population which includes all of the nation’s women, infants, children, adolescents, and their families, Including fathers and children with special health care needs.
Genetic Services
Branch
Chief
Sara Copeland, M.D.
(Acting)
(RM22)
Injury and Emergency
Medical Services for
Children Branch
Chief
Elizabeth Edgerton, M.D.
(RM36)
Health Start West
Branch
Chief
Vacant
(RM59)
State and Community
Partnership West
Branch
Chief
Michele Lawler (Acting)
(RM64)
Western Program Implementation Branch
Chief
Angela Ablorh-Odjidja
(RM82)
Division of
Epidemiology
Director
Vacant
(RM92)
Policy, Program Planning, and Coordination Branch
Chief
Audrey Yowell
(RM83)

4. The MCH Block Grant (Title V) States’ Program 501(a)(1)(a-d)
“Title V authorizes appropriations to states to improve the health of all mothers and children”
“To provide and assure mothers and children... access to quality maternal and child health services”
“To reduce infant mortality…preventable diseases and handicapping conditions among children… and increase number of...immunized children…”

5. The MCH Block Grant (Title V) States’ Program 501(a)(1)(a-d)
“To increase [the number of] low income children receiving health assessments and…diagnosis and treatment services”
“Promote health…by providing prenatal, delivery, and postpartum care…”
“Promote health of children by providing preventive and primary care services…”

6. Healthy Start

7. HEALTHY START AND PERINATAL SERVICES
Where are we now?
39 States
District of Columbia
Puerto Rico
Indigenous Populations
Border Communities
New Immigrants

8. This reflects 105 grants operating 163 local sites in 39 states plus DC and PR. 
We counted multiple sites per grant for state health departments, tribal grantees, and consortiums. 
In some cases this reflected service areas and not an actual site.  It was difficult to distinguish these and I’m sure it’s not perfect but it does a much better job of showing actual service locations for grants that operate multiple sites. 
A total of 142 counties were served and among eligible counties, the service rate is now 31.5% (not very different from before but at least we corrected some obvious errors).

9. IMR (per 1,000 live births) is higher in the South and Midwest Regions of the U.S.
IMR ranged from for Mississippi to 4.88 for Washington and 4.89 for Utah.
Highest Rate in D.C. – IMR (comparable to other large cities due to high concentration of women at high risk in these areas)

10. Authorization Language
Factors that contribute to infant mortality
Include a focus on Low Birthweight
Community Based approach to delivery of services
Comprehensive approach to women’s health care to improve perinatal outcomes
Re-Authorized October 2013 to reflect Transformed Healthy Start 3.0

11. HEALTHY START AND PERINATAL SERVICES
Goals:
Improve health care access and outcomes for (high risk) women and infants
Promote healthy behaviors and reduce the causes of infant mortality
Presidential initiative in 1991

12. HEALTHY START’S ROLE IN ADDRESSING DISPARITIES
Reduce the rate of Infant Mortality
Eliminate disparities in perinatal health
Implement innovative community-based interventions to support & improve perinatal delivery systems in project communities

13. HEALTHY START’S ROLE IN ADDRESSING DISPARITIES
Assure that every participating woman & infant gains access to the health delivery system & is followed through the continuum of care
Provide strong linkages with the local & state perinatal system

14. HEALTHY START AND PERINATAL SERVICES
TARGET AUDIENCE
Families Across the Lifespan -- particularly women of reproductive age and their infants
FOCI OF PROGRAM ACTIVITIES
Risk Prevention/Reduction
Health Promotion
Infrastructure/Systems Building
Programmatic Involvement of Women, Their Families (Including Male Partners) & Communities

15. HEALTHY START AND PERINATAL SERVICES
HEALTHY START COMPONENTS
5 Core Services: Outreach, case management, health education, screening for depression, and interconceptional continuity of care
4 Core Systems Building: Consumer and consortium involvement in policy formation and implementation, local health system action plan, collaboration with Title V, and sustainability
Healthy Start

16. HEALTHY START AND PERINATAL SERVICES
Core Interventions: Outreach
Definition: Provision of case finding services that actively reach out into the community to recruit & retain Perinatal/interconceptional clients in a system of care
Purpose: To identify, enroll & retain clients most in need of Healthy Start services

17. HEALTHY START AND PERINATAL SERVICES
Core Interventions: Case Management
Definition: Provision of services in a coordinated culturally sensitive approach through client assessment, referral, monitoring, facilitation, & follow-up on utilization of needed services
Purpose: To coordinate services from multiple providers to assure that each family's individual needs are met to the extent resources are available, & the client agrees with the scope of planned services

18. HEALTHY START AND PERINATAL SERVICES
Core Interventions: Health Education & Training
Definition: Health education includes not only instructional activities & other strategies to change individual health behavior but also organizational efforts, policy directives, economic supports, environmental activities & community-level programs
Purpose: The purpose of a health education campaign is to disseminate information with the goal of improving an audience’s knowledge, attitudes, behaviors & practices regarding a particular area of health promotion

19. HEALTHY START AND PERINATAL SERVICES
Core Interventions: Screening for Perinatal Depression
A depressive disorder is defined as an illness that involves the body, mood and thoughts. It affects the way a person eats and sleeps, the way one feels about oneself and the way one thinks about things
According to the National Institute of Mental Health, about 70 – 80% of women experience some type of postpartum “blues” (usually beginning about 2-3 days after birth).
According to the National Institute of Mental Health, about 70 – 80% of women experience some type of postpartum “blues” (usually beginning about 2-3 days after birth). About 10% of these women develop a much more severe postpartum depression that disrupts the new mother’s ability to function (postpartum psychosis). Very common: 60% to 80% of new mothers About 10% of these women develop a much more severe postpartum depression that disrupts the new mother’s ability to function (postpartum psychosis).
About 10% of these women develop a much more severe postpartum depression that disrupts the new mother’s ability to function (postpartum psychosis).
Little functional impact: Short duration
Onset: 3 to 12 days after delivery.
Hormonal fluctuations common following delivery
Symptoms: Irritability, anxiety, tearfulness

20. HEALTHY START AND PERINATAL SERVICES
INTERCONCEPTION CARE FOR WOMEN
Outreach and case management (e.g., risk assessment, facilitation, monitoring) for women to assure they are enrolled in ongoing care (women’s health/medical home) and are obtaining necessary referrals
Availability of and access to a system of integrated and comprehensive services
Health education (tied to identified needs includes attention to mental health, substance abuse, smoking, domestic violence, HIV and STDs)

21. HEALTHY START AND PERINATAL SERVICES
Core System Intervention: Community Consortium Definition: Individuals & organizations including, but not limited too, agencies responsible for administering block grant programs under Title V of the Social Security Act, consumers of project services, public health departments, hospitals, health centers under Section 330 (C/MHC, Homeless Rural) & other significant sources of health care services

22. Core System Intervention: Local Health System Action Plan
HEALTHY START AND PERINATAL SERVICES
Core System Intervention: Local Health System Action Plan
Definition: A realistic, yet comprehensive plan of achievable steps within the four-five year funding period that will improve the functioning & capacity of the local health system for pregnant and parenting women and their families.

23. SUSTAINABILITY HEALTHY START AND PERINATAL SERVICES
Essential elements:
Integrate activity into current funding sources
Maximize third-party reimbursement
Leverage other funding sources
Funding sources may include State, local, private funding; in-kind contributions
Use the consortium

24. Discretionary Grant Information System (DGIS)
Discretionary Grant Information System (DGIS)

25. Program Participants Total Women Served: 30,759
29,587 – General Population
1,172 – Border Population
African American percent
White percent
Hispanic/Latino percent
AI/AN percent
Asian percent
Source: DGIS, Calendar Year 2010 Data

26. Live Births to Participants
Total Number of Live Births: 38,075
African American percent
White percent
Hispanic/Latino percent
AI/AN percent
Asian percent
More than One Race 2.4 percent
Source: DGIS, Calendar Year 2010 Data

27. Male Participants Total Number of Males Served: 5,369
African American percent
White percent
Hispanic percent
17 Years and Under percent
18 Years and Over percent
Source: DGIS, Calendar Year 2010 Data

28. Interconceptional Care
Number of Women Receiving IC: 28,876
African American percent
Hispanic percent
White percent
Aged percent
Aged percent
Source: DGIS, Calendar Year 2010 Data

29. Major Services: Direct Health Care
Prenatal Care Visits 116,732
Well Baby Pediatric Visits 50,592
Postpartum Clinic Visits 20,725
Women’s Health 26,157
Family Planning 22,541
Adolescent Health 18,937
Source: DGIS, Calendar Year 2010 Data

30. Major Services: Enabling Services
Number of Families Served 74,938
Case Managed Families (PNC) 30,677
Case Managed Families (IC) 26,210
Outreached Families (PNC) 26,397
Outreached Families (IC) 19,271
Home Visiting (PNC) 21,369
Home Visiting (IC) 20,530
Source: DGIS, Calendar Year 2010 Data

31. Major Services: Enabling Services
Breastfeeding Education 30,026
Pregnancy/Childbirth Education 23,759
Parenting Skills 30,745
Transportation 18,182
Housing Assistance 6,814
Job Training 5,231
Translation 3,268
Source: DGIS, Calendar Year 2010 Data

32. Infrastructure Building
Consortia Training 13,517
Provider Training 10,860
Source: DGIS, Calendar Year 2010 Data

33. Healthy Start Program IMR per 1,000 Live Births
Healthy Start Program Infant Mortality Rates per 1,000 Live Births from compared to Healthy People 2020 Target
Figure 1 illustrates the trend in infant mortality rate among HS program participants compared to U.S. rate and Healthy People (HP) 2020 Target. In 2006, the infant mortality rates among HS program participants were 5.7 per 1,000, a significant decline of 2.6% from 8.3 per 1,000 live births in From , the infant mortality rate among HS program participants meet and at some point dropped below the HP 2020 infant mortality rate target of 6 per 1,000 live births. In comparison to the U.S. infant mortality rate for , Healthy Start consistently report a lower rate among their program participants.

34. Infant, Neonatal and Postneonatal Mortality Rates by Race and Hispanic Origin of Mother: United States, 2007
13.31
9.22
Two-thirds of Infant Mortality occurs during the neonatal period. AI/AN have the highest number of infant deaths that occur during the postneonatal period.
NOTE: Neonatal is less than 28 days; Postneonatal is 28 days to less than 1 year. *Includes persons of Hispanic and non-Hispanic origin.
SOURCE: CDC/NCHS, National Vital Statistics System, 2007 Linked File

35. Division of Healthy Start and Perinatal Services

36. Other Programs & Activities
National Fetal & Infant Mortality Review Program
Women’s Health Initiatives
Fetal Alcohol Spectrum Disorders Initiative
First Time Motherhood/New Parents Initiative
Community-Based Doula Program
National Fetal Infant Mortality Review (NFIMR) Program:
Eighty-eight (88) out of the 104 of the Healthy Start sites are located in communities that also support a Fetal Infant Mortality Review (FIMR) program
The Women’s and Children’s Health Policy Center at the Johns Hopkins University (JHU) FIMR national evaluation found that local health departments are two times more likely to achieve their public health goals and objectives if they had a FIMR or another perinatal initiative, such as Healthy Start (HS). In addition, if the community had both FIMR and a perinatal initiative, such as HS, they were nine times more likely to report progress.
Today, many HS Programs are integrating their activities with FIMR, in such ways as: 1) Sponsoring a FIMR program - in whole or part; 2) Sponsoring a community action recommended by FIMR; 3) Receiving requests from FIMR for the HS Coalition to act as their community action team (CAT); and 4) Having HS members serve on FIMR case reviews or CATs.
Women’s Health Initiatives:
Association for Maternal and Child Health Programs (AMCHP) adopted the Women’s Health Collaborative Framework as a theoretical foundation for their women’s health agenda to promote a life course approach to women’s health. It was a collaborative initiative with AMCHP, CityMatCH, Association for State and Territorial Health Officials (ASTHO), and the Massachusetts Department of Public Health to facilitate partnerships in States across multiple sectors to improve women’s health across the lifespan.
The Innovative Approaches to Promoting a Healthy Weight in Women (also called “Healthy Weight”) grant program was developed and implemented to address the overweight and obesity epidemic. The grant was expanded in 2009 to focus on post-partum women with overweight and obesity issues while also integrating mental health, specifically post-partum depression. In 2012, a synthesis report of the goals, methods and findings from the original 14 “Healthy Weight” grantees will be developed to highlight and eventually disseminate the lessons learned for possible future replication.
A “Healthy Weight” grantee, Michigan (Spectrum Health System), program was highlighted by the Agency for Healthcare Research and Quality (AHRQ) as an innovative model that links clinical practices and public health/community-based organizations in order to support healthy behaviors, such as physical activity and healthy diet.
Fetal Alcohol Spectrum Disorders (FASD) Initiative:
This initiative developed a screening instrument called the 4 P’s (Parent, Partner, Past, Pregnancy). It is a four-question screen tool designed to quickly identify obstetrical patients at risk for alcohol or illicit drug use. As a result, some of the HS grantees have adopted it for their drug/alcohol screenings. 
First Time Motherhood/New Parents Initiative (FTMNPI) - Highlights of two innovative approaches used to increase awareness of existing preconception/interconception, prenatal care, and parenting services:
The Massachusetts New Parents Initiative (MNPI) used emotion-based messaging and digital storytelling to promote three main themes for parents and providers - Care, Share, and Bond.
The Wisconsin ABCs for Healthy Families initiative (“ABCs” is an acronym for applied behavior change) was created to raise awareness of disparities in birth outcomes (i.e., infant mortality) between various ethnic groups and the importance of the life-course perspective.
The Community-based Doula Program (Doula):
Since funded in 2008, twelve (12) communities have been awarded funding to support community-based doulas, six (6) in urban communities and six (6) in rural communities.
The doula programs focused on engaging first-time mothers as early in pregnancy as possible, and continued services through at least 6 months (approximately 26 weeks) postpartum (optimally one year postpartum). The program also provided training to community-based outreach workers/promotoras to become doulas. The trainings were provided to grantee organizations in conjunction with the technical assistance center.

37. TAKING CARE OF MOM: BRIGHT FUTURES FOR WOMEN’S HEALTH & WELLNESS
Newest publication Available now!!! Very well received and utilized.
Bright Futures are a series of health promotion and education tools developed for consumers, providers and communities. This particular module is on maternal emotional well-being and adaptation.
The tools include anticipatory education on factors associated wit increased maternal stress and poor adaptation during the perinatal and parenting periods. 37

38. The Business Case for Breastfeeding
HRSA resource kit developed to improve lactation support in the workplace
Steps for creating a breastfeeding friendly workplace
The business case for breastfeeding was developed in collaboration with the HHS OWH; it
approaches worksite lactation support from a business perspective and is designed for use by:
Employers
Human resource managers
Employees, and
Lactation consultants and advocates
MCHB and HHS Office on Women’s Health have also funded the development of a curriculum for training on the use of the resource kit. The curriculum was designed to train state breastfeeding coalitions in selected states on how to conduct outreach with local businesses. 38

39. HEALTHY START AND PERINATAL SERVICES
Healthy Women (Men)
Healthy Infants
Healthy Families
Healthy Communities
Healthy Nation

40. David S. de la Cruz, PhD, MPH
Captain, US Public Health Service
Deputy Director
Division of Healthy Start and Perinatal Services
Maternal and Child Health Bureau
Health Resources and Service Administration
Department of Health and Human Services
5600 Fishers Lane
Room 13-91
Rockville, MD 20857
(301)