1. What is Happening in State Title V Nutrition Services? Helene Kent, RD, MPH Joan Eden, RD, MS Kristin Biskeborn, RD, MPH

2. Session Objectives 1.Provide an overview of the MCH Title V Block Grant highlighting the opportunities and challenges it offers for nutrition services. 2.Describe how two states have funded state and local nutritionists through the MCH Block grant. 3.Describe different roles of nutritionists funded through MCH. 4.Identify ways to use the State MCH Needs Assessment Process and the National and State Performance Measures to address nutrition issues. 5.Discuss strategies for maximizing MCH funded nutrition services through planning and coordination with other programs.

3. Title V and Nutrition Services

4. Milestones 1921 Shepard-Towner Act Maternity and Infancy Act 1935 Title V of the Social Security Act 1946 National School Lunch Act 1953 ASTPHND 1964 Food Stamp Act 1966 Child Nutrition Act 1970 Food Stamp Act 1972 National School Lunch Act Amendments 1979 Dietary Guidelines for Americans 1980 Healthy People

5. Title V to provide and to assure mothers and children (in particular those with low income or with limited availability of health services) access to quality maternal and child health services; [and] … to reduce infant mortality and incidence of preventable diseases and handicapping conditions among children, to reduce the need for impatient and long-term care services, to increase the number of children (especially preschool children) appropriately immunized against disease and the number of low income children receiving health assessments and follow-up diagnostic and treatments services, and otherwise to promote the health of mothers and infants by providing prenatal, delivery, and postpartum care for low income, pregnant women, and to promote the health of children by providing preventive and primary care services for low income children;

6. Title V To improve the health of all mothers and children consistent with the applicable health status goals and national health objectives established by the Secretary under the Public Health Service Act for the year 2000 ….

7. Title V Is Broad Can Take a Lifespan Perspective Promotes Health Tailored to Each State or Territory

8. Opportunities and Challenges Take Leadership See the Forest and the Trees Seek the Opportunities Breakdown the Barriers Be Creative Build on what Exists Communicate

9. Topics Improve Overall Wellness of Women and Children Breastfeeding Healthy Weight Preconception/Interconception Folate https://performance.hrsa.gov/mchb/mchreports/Search/search.asp

10. Helene Kent, RD, MPH HM Kent Consulting 7543 East 6 th Place Denver, Colorado 80230 Phone: 303 364-1546 Email: HMKent@netzero.net

11. What is Happening In Colorado’s MCH Title V Nutrition Services?

12. Prevention Services Division Organizational Chart

13. Funding for Nutrition Services in the Division

14. Trends in MCH 1980s Primarily Direct Services Prenatal Medical Care Well Child Clinics Dental Care Specialty Care for CSHCN

15. Trends in MCH Prenatal Diet Counseling Breast Feeding Promotion & Counseling Child Feeding & Anticipatory Guidance Nutrition Services

16. Trends in MCH Core Public Health Functions 10 Essential Public Health Services OBRA 89 Medicaid Expansion IOM Report – Towards the Future of Public Health MCH Pyramid

17. MCH PYRAMID

18. Trends in MCH GPRA in 1993 National/ State-Defined Performance Measures 5-year Needs Assessment Focus on Priorities SCHIP

19. Trends in MCH What is missing from Medicaid/SCHIP benefits? Will providing direct care for a small number of individuals improve our performance measures? If not, what will? Use priorities and Performance Measures to engage stakeholders Result in Colorado Look at big picture Plan more strategically

20. 1. Improve healthy birth outcomes for pregnant women (Subpriorities: appropriate weight gain, smoking cessation, prematurity prevention, elimination of physical abuse, improved oral health care, no drug or alcohol use, and early prenatal care) 2. Improve access to health care for MCH populations (Subpriorities: primary care, specialty care, mental health, oral health) 3. Improve immunization rates for all children 4. Reduce the adolescent fertility rate (Subpriority: Latina Population) 5. Reduce the rates of child and adolescents motor vehicle injury and death 6. Improve preconceptual health among women (Subpriority: pregnancy intendedness) 7. Reduce the incidence of overweight and obesity among children and adolescents 8. Improve the mental health of MCH populations (Subpriorities: depression, suicide) 9. Improve the health of children (Subpriority: health and safety in child care, breastfeeding, abuse and neglect) 10. Reduce the use of tobacco, alcohol, and other drugs among MCH populations The following is a list of the ten priorities selected through the MCH prioritization process. They are listed in rank order from the priority determined the most important. FY 2006 Priorities Chosen

21. Nutrition Services in the Health Care Program for Children with Special Needs (HCP) Started as a 3 year MCHB SPRANS grant Purpose: to develop screening/ assessment tools and a process to identify CSHCN at nutritional risk Screening tool used statewide in child health clinics and in rural specialty clinics

22. ·  Assessment and counseling done in 10 pilot communities · Data showed half the children screened were at nutrition risk and that counseling decreased risks · Project discontinued when SPRANS grant was over Nutrition Services in the Health Care Program for Children with Special Needs (HCP)

23. New Challenges and Opportunities Mandate to new HCP Director: Move money out of the State Office into the community Interests: Begin to build community capacity and to encourage collaboration and cooperation Add new benefits including nutrition

24. New RD Positions in HCP Shared positions with hospitals, Community Center Boards, Community Health Centers, schools, Part C.5 FTE position at the state Ten.2 -.5 FTE positions in the community Counseling, feeding equipment and therapy, supplemental feeding products Provided TA in community, needs assessment

26. For more information about the HCP Nutrition Program contact: Shirley Babler, R.D. HCP Nutrition Services Manager Health Care Program for Children with Special Needs (HCP) Prevention Services Division Colorado Department of Public Health and Environment PSD-HCP-A4 4300 Cherry Creek Drive South Denver, Colorado 80246-1530 303-692-2455 Shirley.Babler@state.co.us

27. Nutrition Services in the Women’s Health Program Prenatal Plus Program –Case management program for pregnant women to reduce low birth weight –Focusing on inadequate weight, smoking and psycho- social risks

28. Low Birth Weight Project Began with a SPRANS grant to look at the risk factors involved in Colorado ’ s high low birth weight rate Funded 3 local projects; collected data After funding ended, used MCH Block Grant funding to expand the project to more sites

29. Low Birth Weight Project In 2000 published Tipping the Scales: Weighing in on Solutions to the Low Birth Weight Problem in Colorado Report available in PDF format at: http://www.cdphe.state.co.us/fc/lbwreport.pdf

30. Medicaid Funding Report provided data to convince Medicaid that for every dollar spent on interventions to resolve the risks of smoking and inadequate weight gain, $2.48 could be saved on illness and conditions associated with having a low birth weight baby. Medicaid agreed to fund the program for at-risk pregnant women

31. LBW Project Becomes Prenatal Plus Multi-disciplinary case management program Model care package – 8 office visits + 2 home visits 27 projects statewide 24 mostly part-time RDs Other team members are MSWs and RNs Low birth weight rate for women at nutrition risk was 8.8% for those who gained adequately in the program vs. 14.6% for those who didn ’ t

32. For More Information on Prenatal Plus contact: Mandy McCulloch, RD Women ’ s Health Section Colorado Department of Public Health and Environment PSD-WH-A5 4300 Cherry Creek Drive South Denver, Colorado 80246-1530 Phone: 303-692-2495 FAX: 303-691-7900 E-mail: Mandy.McCulloch@state.co.usMandy.McCulloch@state.co.us Website: http://www.cdphe.state.co.us/pp/womens/PrenatalPlus.asp

33. Health Baby is Worth the Weight A social marketing campaign to decrease low birth weigh and increase the number of pregnant women who gain adequately Geared towards educating providers Primary message is that inadequate weight gain is modifiable

34. Practice Recommendations 1990-Institute of Medicine outlined specific weight gain recommendations for pregnancy based on four body mass index categories (underweight, normal, high, obese) Recommendations allow for the most optimal outcomes for both infant and mother Campaign provides several tools (i.e. combined BMI/gestational wheel) to allow for quick and easy assessment/counseling on prenatal weight gain.

35. Campaign Roll Out Train-the-trainer model for 6 local health dept. and Kaiser with goal of training 100 providers each. Training at various professional conferences and MCH statewide video-conference. Website developed (separate sites for providers and consumers; “ Ask a Dietitian Site ” )

36. 2005-2006 Expansion Developing new materials for campaign aimed at consumers Expansion of train-the-trainer model to all local health departments and Rocky Mountain HMO

37. For more information about the Healthy Baby is Worth the Weight Campaign contact: Stephanie Beaudette, M.Ed. RD Women ’ s Health Section Colorado Department of Public Health and Environment PSD-WH-A5 4300 Cherry Creek Drive South Denver, Colorado 80246-1530 Phone: 303-692-2487 FAX: 303-691-7900 E-mail: Stephanie.Beaudette@state.co.usStephanie.Beaudette@state.co.us Web Site: www.healthy-baby.org

38. Summary MCH provides broad, flexible funding The use of SPRANS funding can help get programs going Involvement in the MCH NA and the Strategic Planning processes provide opportunities to look at state nutrition needs and issues Sometimes moving outside of nutrition positions into other leadership positions creates opportunities to expand nutrition

39. What is Happening in South Dakota’s MCH Nutrition Services?

40. South Dakota Department of Health Division of Health and Medical Services Family HealthHealth Promotion Community Health Services MCH/CSHS WIC Nutrition/PA Oral Health CSH CHNs RD Nutr Educators

41. Nutrition Services Contract RDs all CSHS clinics Field staff direct service — time study –Challenge demands of WIC and other programs Infrastructure/Population-based services — state office — time study –Nutrition/PA –School Health

42. SD Nutrition Performance Measures SD Nutrition Performance Measures Breastfeeding Initiation Obesity School Aged Child and Adolescent Obesity Preschool Child Breastfeeding Duration Past Performance Measure –Eating Disorders

43. HOW? Demonstrate Need Method of Measurement/Evaluation

44. South Dakota Department of Health School Height & Weight Report For South Dakota Students Started 1998-1999

45. Optional Participation 1998-1999: 110 schools; 16,723 1999-2000: 95 schools; 15,062 2000-2001: 86 schools; 12,493 2001-2002: 130 schools; 16,781 2002-2003: 145 schools; 20, 449 2003-2004: 196 schools; 28,699 2004-2005: ???

46. Win-Win State State data Opportunities to build support for individual and environmental change Build case for funding School (person submitting data, bldg principal, support) State Report Analyzed school data District data Trends Height Weight Equipment

47. South Dakota School Height and Weight 2003-2004 School Year At Risk For Overweight and Overweight Body Mass Index By Age AgeNumber Of Students At Risk For Overweight OverweightAt Risk For Overweight and Overweight Combined 5-8 years8,95215.1%13.0%28.1% 9-11 years9,76716.7%17.7%34.4% 12-14 years6,34716.5%17.0%33.5% 15-19 years2,17916.6%14.9%31.5% Total27,24516.1%15.8%31.9% HP2010 Goal Overweight 5%

48. Data Sources Preschool Obesity –WIC PedNSS –Head Start (planning) Breastfeeding Initiation –WIC (used initially) –Newborn Screening Initiative (now) –Birth Certificate (planned) Breastfeeding Duration –WIC (used initially) –Perinatal Health Risk Assessment Survey and/or –NIS

49. Activities

50. Breastfeeding All DOH programs same standards/training Gap-filling counseling MCH breastpumps to loan Resource materials

51. Pediatric Obesity School Height Weight Data Trainings Resources — Bright Futures CSH and DOE –“ Minds in Motion” –“SD Schools Walk ” Team Nutrition — USDA Wellness Policy

52. The state’s largest wellness centers State Parks 11 Disk Golf Courses Croquet Sets Volleyball Bocce Family Fun Opportunities

54. Plan to Promote Nutrition and Physical Activity to Prevent Obesity and Other Chronic Disease MCH Director on main team Pediatric campaign Mini-grants to School Health Councils

55. Contact Kristin Biskeborn, MPH, RD, LN State Nutritionist South Dakota Department of Health 300 S Courtland, Ste. 109 Chamberlain, SD 57325 Phone: 605/734-4551 Fax: 605/734-4552 Email: Kristin.Biskeborn@state.sd.usKristin.Biskeborn@state.sd.us