Maternal and Child Health Services
Title V Block Grant

State Narrative for
Arizona
Application for 2011
Annual Report for 2009

Document Generation Date: Thursday, September 16, 2010

Table of Contents
I. General Requirements ................................................................................................................. 4
A. Letter of Transmittal................................................................................................................. 4
B. Face Sheet .............................................................................................................................. 4
C. Assurances and Certifications................................................................................................. 4
D. Table of Contents .................................................................................................................... 4
E. Public Input .............................................................................................................................. 4
II. Needs Assessment...................................................................................................................... 6
C. Needs Assessment Summary ................................................................................................. 6
III. State Overview ........................................................................................................................... 8
A. Overview.................................................................................................................................. 8
B. Agency Capacity.................................................................................................................... 18
C. Organizational Structure........................................................................................................ 25
D. Other MCH Capacity ............................................................................................................. 27
E. State Agency Coordination.................................................................................................... 31
F. Health Systems Capacity Indicators ...................................................................................... 34
Health Systems Capacity Indicator 01: .................................................................................. 34
Health Systems Capacity Indicator 02: .................................................................................. 35
Health Systems Capacity Indicator 03: .................................................................................. 35
Health Systems Capacity Indicator 04: .................................................................................. 36
Health Systems Capacity Indicator 07A:................................................................................ 37
Health Systems Capacity Indicator 07B:................................................................................ 37
Health Systems Capacity Indicator 08: .................................................................................. 38
Health Systems Capacity Indicator 05A:................................................................................ 39
Health Systems Capacity Indicator 05B:................................................................................ 40
Health Systems Capacity Indicator 05C:................................................................................ 41
Health Systems Capacity Indicator 05D:................................................................................ 42
Health Systems Capacity Indicator 06A:................................................................................ 42
Health Systems Capacity Indicator 06B:................................................................................ 43
Health Systems Capacity Indicator 06C:................................................................................ 44
Health Systems Capacity Indicator 09A:................................................................................ 44
Health Systems Capacity Indicator 09B:................................................................................ 45
IV. Priorities, Performance and Program Activities ....................................................................... 47
A. Background and Overview .................................................................................................... 47
B. State Priorities ....................................................................................................................... 48
C. National Performance Measures........................................................................................... 51
Performance Measure 01:...................................................................................................... 51
Form 6, Number and Percentage of Newborns and Others Screened, Cases Confirmed, and
Treated ................................................................................................................................... 54
Performance Measure 02:...................................................................................................... 56
Performance Measure 03:...................................................................................................... 59
Performance Measure 04:...................................................................................................... 63
Performance Measure 05:...................................................................................................... 66
Performance Measure 06:...................................................................................................... 70
Performance Measure 07:...................................................................................................... 74
Performance Measure 08:...................................................................................................... 78
Performance Measure 09:...................................................................................................... 80
Performance Measure 10:...................................................................................................... 82
Performance Measure 11:...................................................................................................... 85
Performance Measure 12:...................................................................................................... 88
Performance Measure 13:...................................................................................................... 91
Performance Measure 14:...................................................................................................... 94
Performance Measure 15:...................................................................................................... 96
Performance Measure 16:...................................................................................................... 99

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Performance Measure 17:.................................................................................................... 101
Performance Measure 18:.................................................................................................... 103
D. State Performance Measures.............................................................................................. 106
State Performance Measure 1: ............................................................................................ 106
State Performance Measure 2: ............................................................................................ 108
State Performance Measure 3: ............................................................................................ 111
State Performance Measure 4: ............................................................................................ 114
State Performance Measure 5: ............................................................................................ 117
State Performance Measure 6: ............................................................................................ 119
State Performance Measure 8: ............................................................................................ 120
State Performance Measure 9: ............................................................................................ 123
E. Health Status Indicators ...................................................................................................... 125
Health Status Indicators 01A:............................................................................................... 126
Health Status Indicators 01B:............................................................................................... 127
Health Status Indicators 02A:............................................................................................... 128
Health Status Indicators 02B:............................................................................................... 129
Health Status Indicators 03A:............................................................................................... 130
Health Status Indicators 03B:............................................................................................... 131
Health Status Indicators 03C:............................................................................................... 133
Health Status Indicators 04A:............................................................................................... 134
Health Status Indicators 04B:............................................................................................... 135
Health Status Indicators 04C:............................................................................................... 136
Health Status Indicators 05A:............................................................................................... 137
Health Status Indicators 05B:............................................................................................... 138
Health Status Indicators 06A:............................................................................................... 139
Health Status Indicators 06B:............................................................................................... 140
Health Status Indicators 07A:............................................................................................... 141
Health Status Indicators 07B:............................................................................................... 142
Health Status Indicators 08A:............................................................................................... 142
Health Status Indicators 08B:............................................................................................... 143
Health Status Indicators 09A:............................................................................................... 144
Health Status Indicators 09B:............................................................................................... 146
Health Status Indicators 10: ................................................................................................. 147
Health Status Indicators 11: ................................................................................................. 147
Health Status Indicators 12: ................................................................................................. 148
F. Other Program Activities...................................................................................................... 148
G. Technical Assistance .......................................................................................................... 149
V. Budget Narrative ..................................................................................................................... 150
Form 3, State MCH Funding Profile ..................................................................................... 150
Form 4, Budget Details By Types of Individuals Served (I) and Sources of Other Federal
Funds.................................................................................................................................... 150
Form 5, State Title V Program Budget and Expenditures by Types of Services (II)............ 151
A. Expenditures........................................................................................................................ 152
B. Budget ................................................................................................................................. 152
VI. Reporting Forms-General Information ................................................................................... 154
VII. Performance and Outcome Measure Detail Sheets ............................................................. 154
VIII. Glossary ............................................................................................................................... 154
IX. Technical Note ....................................................................................................................... 154
X. Appendices and State Supporting documents........................................................................ 154
A. Needs Assessment.............................................................................................................. 154
B. All Reporting Forms............................................................................................................. 154
C. Organizational Charts and All Other State Supporting Documents .................................... 154
D. Annual Report Data ............................................................................................................. 154

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I. General Requirements
A. Letter of Transmittal
The Letter of Transmittal is to be provided as an attachment to this section.
An attachment is included in this section.

B. Face Sheet
The Face Sheet (Form SF424) is submitted when it is submitted electronically in HRSA EHB. No
hard copy is sent.

C. Assurances and Certifications
Certifications and assurances will be kept on file at the Arizona Department of Health Services.
An attachment is included in this section.

D. Table of Contents
This report follows the outline of the Table of Contents provided in the "GUIDANCE AND FORMS
FOR THE TITLE V APPLICATION/ANNUAL REPORT," OMB NO: 0915-0172; published March
2009; expires March 31, 2012.

E. Public Input
Several avenues were pursued to seek input from stakeholders and the public, both to help
identify and understand emerging issues and to help set priorities. Information was posted to the
Women's and Children's Health and the Children with Special Health Care Needs websites, and
other forms of electronic communications such as emails and newsletters were used to
disseminate information about the needs assessment process, issues, and findings, and to seek
input. Surveys were also used to solicit input from stakeholders, community partners, and the
public. Program managers and staff who directly work with the public, contractors, and
community also brought their perspectives to the needs assessment process.
Formal public input sessions were held around the state in Tucson, Flagstaff, Phoenix, and Mesa
in April 2010. In addition, presentations were made to the Arizona Medical Association Maternal
Child Health Committee, the March of Dimes, AHCCCS Health Plan maternal child-health
coordinators, and local public health officers. Community partners helped to extend invitations to
interested families, and two special sessions were held, one focusing on children with special
health care needs, and a tribal consultation session focusing on American Indians. Each session
was structured to present information on health trends and issues, and gather input on
community concerns, priorities, and preferred strategies.
During the public input sessions, information was presented on health issues and trends in
Arizona before attendees participated in facilitated group discussion about concerns in their
communities, priorities, and strategies. In identifying priorities, public-input participants were
asked to consider the size and seriousness of problems, as well as the availability and
effectiveness of interventions and resources to carry them out. In addition to the facilitated group
discussion, comment sheets were made available for later review. The top priorities presented in
this document reflect those needs that participants believed were most important in terms of size
and seriousness, and which the Title V maternal-child health program has the capacity to
influence.
Meetings of key stakeholders were held through an Integrated Services Grant, over a four-year
period from 2005 through 2009. Stakeholders included all of Arizona's child-serving agencies,
the state Medicaid agency, Arizona Early Intervention Program, Indian Health Services, Arizona

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Medical Association, American Academy of Pediatrics, hospitals and other health care providers,
educators, community colleges, universities, families, youth, and self advocates. Committees
focused on transportation, healthcare, education, family and youth involvement, youth to adult
transition, adolescent health, telemedicine, cultural competence, and screening for special health
care needs. The recommendations from the ISG Taskforce were an important source of public
input.
Key informant interviews were also conducted from September 2008 through March 2009 to
facilitate public input. Participants included agency leaders and physicians working with
C/YSHCN. Informants provided suggestions for improving the service delivery system and
addressing its gaps.
In 2010, OCSHCN began to solicit public input for the needs assessment through its website.
Families and providers were sent email invitations to visit the website, where they could find links
to slide presentations focusing on:
•
An overview of the needs assessment process,
•
Arizona data on MCH Bureau Core Indicators for CYSHCN at two points in time, and
•
Data showing how CSHCN compared to other children in Arizona on key indicators.
Website visitors could then respond with questions or comments to an email address, or could
call OCSHCN staff directly. In addition, two survey monkey tools were posted to the website, one
for providers, and one for families. The surveys were conducted to compare the perceived needs
of the families of C/YSHCN with those of the provider community.
The Bureau of Women's and Children's Health conducted a web-based survey of lay health
workers and community members throughout Arizona in 2010. Participants (n=878) were asked
about the health and needs of women and children living in their communities, and about the
ability of their communities to meet these needs. An additional survey was conducted of key
partner agencies that serve women and children to assess partners' perceptions of priorities,
critical health issues, service gaps, and workforce development issues. The 64 organizations
responding to the survey included county health departments, community health centers, Indian
Health Services and tribal health departments, and non-profit agencies. The surveys were used
to gather input on community perception of needs and assets and results were considered during
the priority-setting process.

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II. Needs Assessment
In application year 2011, the 2010 Needs Assessment will be attached to this Section II.

An attachment is included in this section.

C. Needs Assessment Summary
Arizona's 2010 Needs Assessment provides an overview of the state, partnership efforts,
capacity to address MCH needs, and health status of MCH populations. Especially noteworthy at
this time in Arizona are the economic factors that impact so many areas of capacity within the
state. Arizona has experienced high rates of home foreclosures, poverty, and households on food
stamps. Unemployment rates climbed to 9.5% in February 2010, not long after achieving a
historic low of 3.7% in July of 2007.
At the same time, Arizona has experienced substantial declines in state revenue. In state fiscal
year 2009, Arizona had the largest decrease (42.5%) in income tax revenue in the nation. The
result of these economic forces is a budget deficit projection in Arizona for 2010 of $5 billion
dollars, representing 52% of the total general fund budget. This is the second largest proportional
state budget deficit in the nation. In the past three years, nearly all state funded maternal and
child health programs have been completely eliminated due to state budget cuts. The one
remaining state funded MCH program was substantially reduced.
Population trends are also of interest. While the Arizona population overall has continued to grow
since the last needs assessment, the number of births in the state began to decline in 2008. By
2009, the total number of births decreased by 10% compared to 2007, which was when the
highest number of births occurred in the state. The number and proportion of Hispanic births also
decreased in 2008 and 2009.
A brief look at the state priority needs follows.
Teen pregnancy rates in Arizona's have been declining over the past decade, but Arizona still
ranks within the top five highest teen birth rates in the nation. Community concern about teen
pregnancy was evidenced during the public input process.
Obesity and overweight has been increasing in Arizona. Arizona's percentage of children who
are overweight or obese has increased at higher rates than any other state. For youth 10 to 17
years of age, there was a 45.9 percent increase in the prevalence of obesity from 2003 to 2007,
which was the greatest increase in the nation. Nearly half of all reproductive age women in
Arizona are either overweight or obese. Public input sessions further confirmed the need to
continue to maintain addressing obesity and overweight as a priority.
Birth outcomes, such as low birth weight and infant mortality, have remained relatively stable over
the past five years. The percentage of Arizonan women accessing prenatal care in the first
trimester increased since the last needs assessment, particularly among women receiving
Medicaid. Since 2006 when the CDC issued its recommendations on how to improve the health
of women prior to pregnancy, known as preconception health, Arizona has shifted more attention
to this strategy in order to improve birth outcomes, including infant mortality. Participants of
public input sessions and stakeholders identified preconception health as a priority area.
Injuries are the leading causes of death for Arizonans ages 1-44. Homicides and suicides remain
a significant issue for teens and young adults, and dating violence among Arizona high school
students increased significantly between 2003 and 2007.
Improving preventive health services for children has been selected as a new priority by the

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group of stakeholders and ADHS staff charged with setting general MCH priorities. This new
priority ranked highest of any other priority during this session.
The oral health of children residing in Arizona is significantly worse than for their national peers.
Arizona's Healthy Smiles, Healthy Bodies survey reported that 31 percent of children ages 2-5
years in Arizona had untreated tooth delay, compared to only 16 percent of their peers nationally.
Public input sessions and the Bureau of Women's & Children's Health (BWCH) partner and
community surveys all confirmed oral health as a critical need in Arizona.
One measure of mental health is how frequently mental distress occurs. In Arizona, nearly one-infive women ages 18-44 reported problems dealing with depression, stress, and/or emotions
during the past month. Women with frequent mental distress were significantly more likely to be
obese than women without frequently mental distress. BWCH survey results and comments
provided during public input sessions indicated that mental health and substance use/abuse
(including alcohol as well as illegal drug use) are critical issues that need to be addressed.
The needs assessment data shows a relatively high proportion of unmet need related to hearing,
with one in four children with special health care needs (CSHCN) with an identified need for
hearing aids or hearing care failing to have those needs met. While every newborn in Arizona is
screened for hearing loss, approximately one third of those who fail initial screening do not
receive appropriate follow up services. Reducing unmet need for hearing services has been
selected as a new priority.
Although adolescents represent a relatively small proportion of all CSHCN, most CSHCN will
eventually become adults and will require transition services. Whether a child will grow to live
independently or require some kind of assistance, every family must address how health care
needs will be met as well as all of the requirements of everyday living. All avenues of public input
emphasized the importance of transition. Preparing CYSHCN for transition to adulthood is a new
state priority.
Inclusion of CSHCN in childcare, school, sports, work, and even in ADHS wellness activities,
such as nutrition and physical activity, and injury prevention, presented many opportunities for
improvement. During public input, families often spoke about the lack of accommodations for
CSHCN to participate in all aspects of life, and how important these were to address. Promoting
inclusion of CSHCN in all aspects of life has been selected as a new priority.

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III. State Overview
A. Overview
This overview of Arizona places the state's Title V program within the context of the overall
environment in which it operates, particularly the social determinants of health. As defined by the
World Health Organization (WHO), social determinants of health are the conditions in which
people are born, grow, live, work and age, including the health system. The conditions in which
people live and die are, in turn, shaped by political, social, and economic forces. The challenges
of a weak economy, unemployment, state budget deficits, poverty, racial and ethnic disparities,
lack of health insurance, and geography impact the state's capacity to address women's and
children health.
The challenges, as well as the assets, in the overall environment served as important
considerations in priority-setting and selection of future strategies. Arizona's selection of state
Title V priorities for 2011-2016 was grounded in review of quantitative and qualitative data, as
well as careful consideration of public input and capacity. Arizona's priority areas for the maternal
and child health population are: teen pregnancy, obesity/overweight, preconception health,
injuries, oral health, preventative health services for children, behavioral health, hearing services,
transition of children with special health care needs to adulthood, and inclusion of children with
special health care needs in all aspects of life.
This information presented in this section was extracted from the 2010 Title V Needs
Assessment. For more information and citation of reference information, please see this
document attached or online at www.azdhs.gov/phs/owch/.
Arizona is the sixth largest state in the nation, with a total area of 114,000 square miles -- about
400 miles long and 310 miles wide. Arizona is also one of the youngest states. The end of the
Mexican-American War in 1848 resulted in Mexico ceding 55 percent of its territory, including
parts of present-day Arizona to the United States. It was not until 1863 that a separate territory
was carved out for Arizona. On February 14, 1912, President Taft signed the bill making Arizona
the 48th state.
POPULATION TRENDS
Arizona has 59 people per square mile; however, 75 percent of the population lives in urban
areas, where the population density is 673 people per square mile. Twenty-three percent of
Arizona residents live in rural areas, where the density is 44 people per square mile, and 2
percent lives in areas that are considered to be frontier, in which there are only 3 people per
square mile.
From 1999 to 2009, the population of Arizona grew from 5 million to 7 million people. During that
time, Arizona had the second highest growth rate (32 percent) in the nation and came in fifth in
terms of the number of new residents.
US Census data indicates that the largest component of growth in Arizona over the last decade
has been domestic migration, or people moving to Arizona from other states (49 percent). The
next largest component of the population increase was the net natural increase, or the number of
births minus the number of deaths. The net natural increase in Arizona accounted for 32 percent
of the population growth during the last decade. The remaining growth (19 percent) was from the
net international migration, or people moving here from other countries minus the number of
people moving out.
The rapid growth seen in Arizona as a whole has not been evenly distributed throughout the
state. During the years between 1999 and 2009, growth rates in Arizona's 15 counties ranged
from a low of two percent in Greenlee County (from 8,535 residents to 8,688) to a high of 89

8

percent in Pinal County (154,335 residents to 327,699). Currently, 75 percent of the state's
population resides in either Maricopa or Pima Counties.
Three subpopulations in Arizona that had been increasing for many years, have recently
declined. The number of births to Arizona residents peaked in 2007 at 102,687 births, and
declined in both 2008 and 2009. In 2009, the number of births declined to 92,616, a 10 percent
decrease from the high point in 2007.
There was a similar pattern during this same time period in the proportion of Hispanic births,
which increased for most of the decade and declined in recent years. In 2003, Hispanic births
(n=39,101) exceeded the number of non-Hispanic, White births (n=38,842). Hispanic births
continued to outnumber non-Hispanic, White births until 2009 when there were 38,362 Hispanic
births compared to 39,781 births to non-Hispanic, Whites.
The population of immigrants without documentation of American citizenship grew for most of the
last decade, but has recently declined. After growing by 70 percent from January 2000 to
January 2008, the undocumented population declined from 560,000 in January 2008 to 460,000
in January 2009. In April 2010, Senate Bill 1070 was signed into law making it a crime to be in
the state without proper documentation. The expressed intent of the law is ". . . to discourage
and deter the unlawful entry and presence of aliens and economic activity by persons unlawfully
present in the United States." Effective July 2010, this legislation will require police officers who
are enforcing another law to determine, when practicable, the immigration status of the person
lawfully detained and verify that status with the federal government. It is likely that this law will
affect the demographic composition of Arizona in the future.
Since the last five year maternal and child health needs assessment was written, the Maternal
and Child Health (MCH) population in Arizona has increased by 14 percent from 2,797,421 in
2004 to 3,177,999 in 2009. Of these, 1,344,836 are women of childbearing age (15 through 44),
and 257,980 are estimated to be children with special health care needs. Figure 3.5 provides a
breakdown of the MCH population by age group.
RACE/ETHNICITY
The racial and ethnic makeup of the state of Arizona is different than the nation. The proportion
of the population which is Hispanic in Arizona is twice that of the nation (30 percent compared to
15 percent nationally). In addition to having a higher proportion of Hispanics, Arizona's
population also differs from the nation in that there is a smaller proportion of African Americans (5
percent compared to 14 percent nationally) and a higher proportion of Native Americans (6
percent compared to 2 percent in the nation).
The racial makeup of Arizona varies by age group. Among older age groups, the population is
predominantly white, while the proportion of the population represented by Hispanics is highest
among the younger groups. Over 40 percent of those younger than five are Hispanic compared
to eight percent of people 75 and older.
Twenty-one federally-recognized American Indian tribes are located in Arizona, each
representing a sovereign nation with its own language and culture. Tribal lands span the state
and even beyond state borders, with the Navajo Reservation crossing into New Mexico and Utah,
and the Tohono O'odham Reservation crossing international boundaries into Mexico. Some
counties have high proportions of American Indians. Eighty percent of Apache County, 48
percent of Navajo County, and 30 percent of Coconino County residents are American Indians.
LANGUAGE SPOKEN
Arizona residents are more likely to speak a language other than English at home (28 percent in
Arizona compared to 20 percent nationally), and more likely to report speaking English "less than
very well" (12 percent in Arizona compared to 9 percent nationally). Among Arizona residents

9

who spoke a language other than English, 78 percent spoke Spanish, while the other 22 percent
spoke one of many other languages.
EDUCATION
Arizona has consistently ranked lower in the nation per pupil spending compared to the U.S. The
National Center for Education Statistics reported that Arizona spent $7,727 per student compared
to the nation's average of $10,297 in fiscal year 2008.
During the 2008 -2009 school year, Arizona had 586 school districts, including 349 charter
holders. These districts housed 1,975 schools and 1,082,221 students in kindergarten through
12th grade. Over 10 percent of Arizona's K-12 students attend a charter school.
Educational attainment for adults living in Arizona is similar to the United States. Overall, 84
percent of Arizona residents age 25 and older are high school graduates compared to 85 percent
nationally. The most recent American Community Survey report shows that seven percent of
adults in Arizona did not complete ninth grade and another nine percent have not graduated from
high school.
The National Assessment of Educational Progress (NAEP) is an assessment of what America's
students know. In 2009, eighth grade students in Arizona public schools ranked 41st in NAEP
reading scores. Thirty-two percent of Arizona eighth graders tested below basic skill level for
their grade compared to 26 percent nationally. This represents an improvement over the reading
levels reported in the previous five-year needs assessment, when 46 percent of Arizona 4th
graders read below proficiency, compared to 38 percent in the rest of the nation. NAEP reading
achievement varied considerably by race and ethnicity. Higher proportions of Native American,
Hispanic, and Black public school students tested below the basic level in reading achievement,
while Asian students were more likely to test at proficient or higher.
In fiscal year 2008, 4 percent of students dropped out of public school from grade seven through
nine. This represents an improvement over the dropout rates from the 2003-2004 school- year
of 6 percent. The dropout rate for boys (4 percent) was somewhat higher than the dropout rate
for girls (3 percent). However, the dropout rate among Native America students was twice the
statewide rate.
The Arizona Department of Education also tracks cohorts of students and measures the percent
who graduate within four years. The graduation rate for the cohort that would be expected to
graduate by 2007 was 73 percent. Girls were more likely to graduate within four years (78
percent) than boys (69 percent). However, the graduation rate varied considerably by race and
ethnicity. Only 55% of Native Americans completed high school in four years, while 81% of White
students graduated in four years.
ECONOMY
Arizona incomes, as measured by average wage, earnings per employee, and per capita income,
have always tended to be lower than national averages. In 2007, the average per capita personal
income in Arizona was 85 percent of the national average. Per capita income within Arizona
varied from a high of 94 percent of the national average in Maricopa County to a low of 53
percent in Navajo County. According to US Census estimates, Arizona's median household
income in 2008 was lower than the rest of the nation ($51,009 in Arizona compared to $52,209),
ranking 29th.
Over the course of the last decade, the civilian workforce in Arizona has grown 22 percent from 3
million individuals in 2001, to more than 3 million in 2010. During this time, the composition of the
jobs has changed. The largest decrease in terms of both number and proportion of jobs lost
during this time period was in construction. In 2001, there were 173,600 construction jobs in

10

Arizona compared to just 111,600 in 2010, a decrease of 36 percent. There were also decreases
in the number of jobs in manufacturing, information, and state government. The employment
sector with the largest increase in the number of jobs was trade, transportation and utilities, which
grew from 440,600 jobs in 2001 to 477,500 jobs in 2010 (an 8 percent increase). The health and
education services sector grew the most, with a 52 percent increase from 219,900 jobs in 2001 to
334,000 in 2010. This sector grew from representing 10 percent of non-farm jobs in 2001, to
representing 14 percent in 2010.
In January of 2010, Arizona ranked 8th out of 51 states and the District of Columbia in regards to
economic distress, according to a Kaiser State Health report. The report based this rank on
foreclosure rates (Arizona ranks 2nd), unemployment rates (Arizona tied for 31st), and the
proportion of the population on food stamps (Arizona tied for 10th). A closer look at the three
measures utilized in the Kaiser report shows that certain sectors of the population in Arizona are
in more distress than others. In terms of foreclosure rates, 13 of the 15 counties in Arizona had
foreclosure rates that were classified as high in March 2010 by the U. S. Bureau of Labor
Statistics. The highest foreclosure rate was found in Pinal County, with one out of every 89
households experiencing a foreclosure.
During the course of the last decade, unemployment in Arizona ranged from a historic low of 4
percent in July of 2007 to a recent high of 10 percent in February 2010. The Flagstaff
Metropolitan Statistical Area (MSA) had the lowest unemployment rate at 9 percent, while the
Yuma MSA represented the highest rate, at 30 percent in February 2010.
There is also wide variation in the proportion of households on food stamps in Arizona. The most
recent American Community Survey data shows that on average, 7 percent of households in
Arizona receive food stamps. Maricopa County (6 percent), Yavapai (6 percent), and Coconino
County (7 percent) had fewer households receiving food stamps than the state average and two
counties (Navajo, 16 percent and Apache 18 percent) had twice the state average.
Arizona also has a higher percentage of residents living in poverty compared to the nation. In
2008, 13 percent of the nation lived in poverty compared to 15 percent of those living in Arizona
(ranked 39th). The American Community Survey published average poverty rates for Arizona
residents for 2006 through 2008 by county and other demographic characteristics. During that
time period, the average poverty rate for Arizona residents was 14 percent; however, the rate
varied greatly by race, educational attainment level, gender, and geographic location. Women
(16 percent), children (20 percent), African Americans (20 percent), Indian and Alaska Natives
(32 percent), and Hispanics (23 percent) have higher poverty rates than the general population in
Arizona. Apache County has the highest poverty rate in the state (34 percent), which is more
than twice the state poverty rate. At 13%, Maricopa and Yavapai counties had the lowest poverty
rates.
THE ARIZONA STATE BUDGET
The majority of the Arizona state general fund is spent on education. Forty-two percent of the
general fund goes to elementary and secondary education and another 13 percent is used for
higher education. The next largest expenditures are Medicaid (16 percent) and corrections (11
percent).
Rankings of Arizona spending relative to other states prior to the recent recession showed that
Arizona spent more per capita on police and fire protection (rank = 11) and corrections (rank =
13), and less on highways (rank = 35), health and hospitals (rank = 37), public welfare (rank =
38), and local public schools (rank = 48). Figure 3.14 shows Arizona's state and local
government expenditures as a percent of the national average for state fiscal year 2006-2007.
Arizona's tax base depends heavily on income and sales taxes, which have been affected by the
recession. A reduction in revenues generated by income and sales taxes, together with

11

numerous tax cuts over the last 15 years, has resulted in a decline in state general fund
revenues. State tax revenues have declined 34 percent in the past three years. Since the
recession began in state fiscal year 2007, sales tax revenues have decreased 22 percent,
personal income tax revenues have decreased 38 percent, and corporate income tax revenues
have decreased 57 percent. In state fiscal year 2009, Arizona had the largest decrease (42.5
percent) in income tax in the nation.
While the general fund used to receive $50 in revenue per $1,000 of personal income in the mid
1990's, it currently receives less than $30. A structural deficit was created as taxes were
permanently reduced during years of high revenues without corresponding decreases in the
budget. Even when the economy recovers and begins to expand, revenues are projected to only
rise to $36 per $1,000 income, which is 28 percent lower than the historical norm.
The result of these economic forces is a budget deficit projection in Arizona for 2010 of $5 billion
dollars, representing 52 percent of the total general fund budget. This is the second largest
proportional state budget deficit in the nation, exceeded by California, where a $52 billion deficit
represents 57 percent of their budget. The average budget deficit nationally is 29 percent.
To balance the fiscal year 2009 budget, every state agency was given a lump sum reduction with
discretion of where to cut. Agencies used a combination of program cuts, unpaid furlough days,
and reductions in force, among other methods, to reduce their budgets. To help balance the
2011 budget, employees of each state agency will take a combination of pay reductions and
furlough days for each of the next two fiscal years, which will result in an overall annual
compensation reduction of five percent. All state employees will take the same furlough days,
according to a state-mandated schedule, which will shut down state government on those days.
In addition, Arizona state buildings including, the state capitol, the state hospital and state prisons
have been put up for sale.
Other state agencies serving children experienced significant cuts. The state budgets for both
the Arizona Department of Education and Arizona Department of Economic Security were
reduced by 20 percent between state fiscal years 2008 and 2011. Examples of program cuts that
Arizona has enacted outside of the Department of Health Services that affect the maternal-child
population include:
•

A cap on KidsCare (which is the state's CHIP program).

•
Elimination of temporary health insurance for people with disabilities who are coping with
serious medical problems.
•
Elimination of general assistance, a program designed to provide time-limited case
assistance to adults with physical or mental disabilities.
•
Elimination of independent living supports for 450 elderly residents and respite-care
funding for 130 caregivers.
•

Eliminated preschool for 4,328 children.

•

Increased in-state undergraduate tuition between 9 and 20 percent.

•

Reduction of TANF cash assistance grants for 38,500 low-income families.

•

Elimination of substance abuse services for 1,400 parents and guardians.

•

Decreased homeless shelter capacity by 1,100 individuals.

•

Stopped accepting new families in its child care assistance program in February, 2009

12

(denying assistance to more than 10,000 children.)
Over the past three years, ADHS has dramatically reduced spending and staffing levels in an
effort to bring spending in line with state revenues. Excluding the money that goes toward the
matching funds that are required for Medicaid (AHCCCS), Behavioral Health and Children's
Rehabilitative Services, the overall ADHS General Fund budget has been reduced by more than
47 percent during the past 3 years. Seventeen million dollars in operating budgets were cut
during that time period, including the entire licensure budget of $10 million.
Fiscal Year 2010 cuts include:
•
Suspended enrollment in Children's Rehabilitative Services for more than 4,000 children
who are not enrolled in AHCCCS;
•
Reduced approximately 8,800 home visits to newborns discharged from neonatal
intensive care, and enrolled in the High Risk Perinatal Program;
•
Suspended all prenatal block grants to county health departments for services to 19,000
women and children;
•

Eliminated the Hepatitis C and Valley Fever public health prevention programs;

•

Reduced county contracts for tuberculosis care by more than 50 percent;

•

Eliminated all state funding for children's vaccines;

•

Suspended remaining HIV surveillance contracts with Maricopa and Pima County;

•

Suspended remaining county grants for diabetes prevention;

•

Suspended all retinal and podiatry screenings for diabetics;

•

Suspended all grants to counties for public health personnel;

•

Reduced support for both Arizona Poison Control Centers by more than 50 percent;

•

Eliminated all birth defect call center services.

State funding for maternal and child health programs within the Bureau of Women's & Children's
Health reached a high of $10 million in state fiscal year 2007 and comprised 44 percent of the
bureau's total budget; by state fiscal year 2010, state funding had dropped by 64 percent to a
total of $3 million. State appropriated funds now comprise 18 percent of the bureau's budget.
State general funding for Health Start, Abstinence Education, County Prenatal Block Grant, and
Pregnancy Services was completely eliminated. The budget for the High Risk Perinatal Program
has been reduced by nearly 60 percent. State funding for the Children's Rehabilitative Services
Program have also been eliminated.
A one percent three-year temporary sales tax known as Proposition 100 was passed in a special
election on May 18, 2010, with 64 percent of the vote. A projected $1 billion per year will be
raised by the tax. If the initiative had failed, a legislative contingency plan would have cut another
$900 million from the 2011 state budget.
Health Insurance
The health care delivery system and its financing have dramatically changed in the last 30 years,
and managed care has played a dominant role in its evolution. Approximately 67 percent of the
population in the United States under age 65 currently has private health insurance, the majority

13

of which is managed care based and obtained through the workplace. Under the managed care
umbrella, health maintenance organizations (HMO) and preferred provider organizations (PPO)
have become major sources of health care for beneficiaries of both employer funded care and
publicly funded programs, Medicaid, and Medicare. In 2009, 66 million people had health
insurance through an HMO and 53 million people had insurance through a PPO in the United
States.
Over the past years, the percentage of employer-sponsored health insurance coverage has
gradually decreased while insurance premiums have increased. The average nationwide
premium for family health insurance increased 131 percent from 1999 to 2009. The economic
recession intensified the loss of health insurance for Arizona residents resulting in an increase in
enrollment in public insurance programs. According to 2008 United States Census data, 81
percent of Arizona residents have some type of health insurance. Many people have more than
one kind of insurance: 60 percent of people have private insurance, either employment-based
(52 percent) or direct purchase (8 percent); and 31 percent had some kind of governmentsponsored insurance such as Medicaid (18 percent), Medicare (12 percent), or military health
insurance (4 percent).
Seventy percent of all business establishments in Arizona are small businesses with less than 50
employees. There are more than 85,000 small businesses in Arizona, and each year, small
businesses add more workers to the workforce than large businesses. One of their top
challenges is to offer competitive benefits. Only 35 percent of Arizona small businesses offer
employer-sponsored health coverage with cost being cited as the primary barrier to offering
coverage. For many Arizonans, healthcare remains unaffordable.
Recognizing the importance of affordable health care, the Healthcare Group (HCG) was created
in 1985 by the Arizona State Legislature with the support of the Robert Wood Johnson
Foundation. It is a state-sponsored, guaranteed issue health insurance program for small
businesses and public servants. The Arizona Health Care Cost Containment System (AHCCCS),
Arizona's Medicaid agency, oversees and administers the program. Since inception, HCG has
undergone several substantial changes, the most notable occurring in 2004 when the Arizona
State Legislature eliminated the state subsidy that had supported the program since 1999.
Beginning in fiscal year 2005, the program has operated entirely from premiums paid by
subscribers. Enrollment has continued to grow, more than doubling between 2004 and 2006,
with March 2007 enrollment reaching 26,062 medical plan members. HCG also offers a dental
and a vision plan, bringing the total enrollment in all plans to 45,521 and making HCG one of the
largest state initiatives to provide health insurance for small businesses nationwide.
Arizona Health Care Cost Containment System
Arizona was the last state in the nation to implement a Title XIX Medicaid program. After much
debate, the legislature rejected traditional fee-for-service financing arrangements in favor of an
innovative plan for Medicaid managed care. The Arizona Health Care Cost Containment System
(AHCCCS -- pronounced "access"), is today the state's Medicaid program, representing the
single largest source of health insurance for Arizonans, providing coverage to over 1 million
people. Currently there are over 52,000 AHCCCS-registered providers throughout the State,
including approximately 80 percent of Arizona's physicians.
The acute care program accounts for the greatest percentage (97 percent) of the AHCCCS
population, and includes both Title XIX and Title XXI. The vast majority of Acute Care recipients
include children and pregnant women who qualify for the federal Medicaid program (Title XIX).
American Indians and Alaska Natives may choose to receive services through either the
contracted health plans or the American Indian Health Program. The only other population not
enrolled in a contracted health plan includes individuals who, because of immigration status,
qualify for emergency services only.

14

In 1998, KidsCare became Arizona's Title XXI Children's Health Insurance Program (CHIP).
Eligibility for KidsCare includes children under age 19 whose families' incomes are higher than
that allowed for Medicaid eligibility under Title XIX, but lower than 200% of the Federal Poverty
Level (FPL). With the exception of American Indians, who are exempt in accordance with federal
law, parents pay a monthly premium based on income.
In November 2000, Arizona voters approved Proposition 204, which increased the income limit
for Medicaid to 100% of the Federal Poverty Level (FPL) and permitted childless adults and
parents to enroll in the Medicaid program. In 2002, the KidsCare program was expanded to
cover the parents of children enrolled in KidsCare. The expansion, called KidsCare Parents, was
a low-cost health insurance program for working parents whose income is below 200% of the
federal poverty level. Parents paid a monthly premium of up to $100 depending on their income.
By July 2009, AHCCCS was providing health care coverage to approximately 19 percent of
Arizona's population. At the same time, Arizona's budget deficit was deepening, which
necessitated changes to AHCCCS eligibility requirements. On September 30, 2009, the
KidsCare Parents program was eliminated, which had served approximately 10,000 adults. On
January 1, 2010, Kidscare enrollment was frozen, which meant that no new applications are
being processed, but applicants are put on a waiting list. The state budget passed in March of
2010 directed AHCCCS to eliminate the KidsCare program beginning June 15, 2010. Partial
funding was also to be cut beginning January 1, 2011 for the population covered by the
Proposition 204 expansion.
The law to repeal KidsCare had not taken full effect when the Patient Protection and Affordable
Care Act (also known as Health Care Reform) was passed and signed by President Obama on
March 23, 2010. This law contained a provision that required a maintenance of effort, which
effectively required the State to restore, at a minimum, the KidsCare program with a freeze on
new enrollment, and maintain the Medicaid program at the level that was in effect at the time that
the Patient Protection and Affordable Care Act was signed. On April 29, 2010, the Arizona
Legislature restored the matching funds for KidsCare with a freeze on new enrollment.
Children's Rehabilitative Services
Children's Rehabilitative Services (CRS) Program is administered by the Office for Children with
Special Health Care Needs at the Arizona Department of Health Services. CRS provides multispecialty interdisciplinary care to children under age 21 with qualifying chronic and disabling
health conditions. There are over 350 conditions covered by CRS, including diagnoses such as
cerebral palsy, cleft lip/cleft palate and other cranial-facial disorders, tracheal-esophageal fistula,
scoliosis, juvenile arthritis, muscular dystrophy, osteogenesis imperfecta, spina bifida, cystic
fibrosis, sickle cell anemia, metabolic and endocrine disorders, neurofibromatosis, heart
conditions, Hirschsprungs disease, hydrocephalus, glaucoma, neurosensory disorders, broncho
pulmonary dysplasia, and many congenital anomalies.
Members typically have more than one diagnostic condition, and are involved in multiple systems
of care across child-serving programs and agencies. CRS members often require multiple
specialists and a high level of care coordination. A team approach allows for interdisciplinary,
family-centered, culturally-competent care to address the multiple medical needs of members, as
well as transition and family-support.
Covered services include surgeries and other inpatient hospital services; pediatric physician
specialty care; physical, speech, and occupational therapies, laboratory, radiology and pharmacy
services; vision services; durable medical equipment, such as orthotics and wheel chairs; and
social services. CRS does not cover basic primary care that is not related to the CRS diagnosis.
The ultimate aim of the CRS program is to enhance members' quality of life through the
appropriate utilization of services, optimizing their functionality and minimizing their need for
emergency care.

15

The relative scarcity of some specialists poses a challenge for delivering timely services,
especially to members who live in remote areas of the state. The CRS program offers statewide
management of these specialists and innovative strategies to ensure that services are
coordinated and delivered timely throughout the state. In addition to members and providers
traveling to clinics, members also receive services through the use of telemedicine and in
field/outreach clinics.
Before March of 2009, CRS covered the cost of medical services for children that did not qualify
for AHCCCS, but were below certain family income limits. These members were called StateOnly members. However in March 2009, due to budget cuts, all State-Only members assumed
all responsibility for payment for medical services, regardless of income, but were able to cap
their fees at rates no higher than AHCCCS provider scheduled rates. In December of 2009,
further cuts resulted in the suspension of all State-Only services, and approximately 4,000
members were disenrolled from CRS. Consequently, only members who are enrolled in an
AHCCCS Health Plan remain enrolled.
General and Special Hospitals
According to the Arizona Department of Health Services Division of Licensing Services, there
were 64 general acute care hospitals in the State of Arizona in 2009, with 13,245 beds and 34
specialty hospitals with 2,433 beds. There are two children's hospitals, both of which are located
in the Phoenix metropolitan area. In 2007, the state overall had 2 hospital beds per 1,000
population compared to the national average of 3 per 1,000. Arizona ranks 46 in the number of
hospital beds per 100,000 population.
Neonatal intensive care units and continuing care units are classified by the level of care they are
capable of providing. In Arizona, while hospitals are licensed by the ADHS Office of Licensing,
perinatal care facilities are certified by the Arizona Perinatal Trust, a nonprofit organization
established in 1980 and dedicated to improving the health of Arizona's mothers and babies. The
levels of neonatal care are built on the classification system of the American Academy of
Pediatrics with some Arizona specific differences. The Level III facilities are the highest level and
are capable of caring for all neonates, while Level I provides services for low-risk obstetrical
patients and newborns, including cesarean section at 36 weeks gestation and greater, and In
Hospital Birthing Centers, only found within Indian Health Service. In Arizona, there are currently
nine Level III, six Level II EQ, fourteen Level II, nine Level I hospitals and two In-Hospital Birthing
Centers.
Disproportionate share hospitals (DSH) are hospitals that serve large numbers of Medicaid, lowincome, and uninsured patients. In the DSH program, a state makes a separate payment to a
hospital in addition to its standard Medicaid reimbursement which is reimbursed by the federal
government based upon the state's Medicaid matching rate. The American Recovery and
Reinvestment Act of 2009 (ARRA) provided a temporary increase of about $3 million in Arizona's
DSH allotment for Fiscal Years 2009 and 2010. However, due to state budget cuts, DSH
payments were reduced by over $25 million in Arizona during Fiscal Year 2010.
Professional Health Care Providers
Arizona has 12,436 physicians, 58,441 registered nurses, and 3,633 dentists. The majority of
physicians (87 percent), nurses (80 percent), and dentists (82 percent) practice in either Maricopa
or Pima County. Federal regulations establish health professional shortage areas (HPSA) based
on three criteria: the area must be rational for the delivery of health services, more than 3,500
people per physician or 3,000 people per physician if the area has high need, and healthcare
resources in surrounding areas must be unavailable because of distance, over-utilization, or
access barriers. As of May 2010, 63 areas in Arizona are federally designated as Primary Care
HPSAs, 51 areas are designated as Dental HPSAs, and 6 areas are designated as Mental
HPSAs. According to the Arizona Department of Health Services Bureau of Health Systems

16

Development, Arizona has a shortage of 242 FTE primary care physicians.
Federal regulations also establish medically underserved areas/populations (MUA/MUP) based
upon four criteria: ratio of primary medical care physicians per 1,000 population, infant mortality
rate, percentage of population below the federal poverty level, and percentage of population 65
years and older. As of May 2010, 49 areas in Arizona have federal MUA/MUP designations.
Additionally, Arizona has developed its own designation system for identifying under-served
areas. All federally designated HPSAs are automatically designated as Arizona shortage areas.
In addition, Arizona's system involves the application of an index which weights 14 indicators
such as providers to population ratios, travel time, percent of population below poverty, and
adequacy of prenatal care. As of May 2010, there are five state designated Arizona Medically
Under-Served Areas.
According to the American Medical Association Masterfile, there were 57,698 general
pediatricians in the United States in 2007, representing about 8 pediatricians per 10,000 children
age 0-17. Arizona has 914 general pediatricians, representing 5 pediatricians per 10,000 children
age 0-17. The majority of pediatricians practice in Maricopa (68 percent) and Pima (22 percent)
Counties. A recent survey of primary care pediatricians raised significant concerns about the
adequacy of children's access to pediatric subspecialists, especially in rural communities.
CYSHCN often require services provided by pediatric specialists and sub-specialists. An analysis
of data on pediatric subspecialty practices nationwide estimated the size of the pediatric
population that would be necessary to sustain a subspecialty practice. Depending upon the kind
of subspecialty, estimates ranged from a low of 100,000 children per specialist to 200,000
children per specialist. By this estimate, there are only two areas in Arizona with pediatric
populations large enough to support pediatric subspecialty practices: Maricopa and Pima
Counties, which is where Phoenix and Tucson are located. There is also a shortage of pediatric
physical, speech, and occupational therapists, which results in approximately one in four children
with special health care needs in Arizona having an unmet need for these services, according to
the 2005/2006 NS-CSHCN.
Community Health Centers
Community health centers were established in the 1960s by federal law to treat and provide
primary care to all patients regardless of their ability to pay. The Arizona Association of
Community Health Centers represents health centers statewide and provides advocacy,
professional education programs, financial services, and programs designed to improve the
health status of the medically underserved and uninsured. The Association reports that their
membership included 37 community health centers with more than 150 locations statewide in
2009.
Community health centers were affected by Arizona state budget reductions in 2009. Cuts were
made to the Primary Care Program which distributed funds to community health centers to assist
in supporting the provision of services on a sliding fee scale. Funding for community health
centers through the Primary Care Program was reduced from $12 million to $2 million. A onetime appropriation from Arizona's American Recovery and Reinvestment Act funding restored
sliding fee scale services in Fiscal Year 2010 for patients between 100 and 200 percent of the
federal poverty level. However, the Fiscal Year 2011 state budget will not restore the cuts to
community health centers' sliding fee scale program, as the ARRA funds will no longer be
available.
As a result of the loss of state funds and ARRA funding ending in June 2010, the Arizona Primary
Care Program terminated 19 contracts with 138 service sites throughout the state. Some of the
sites are expected to close or scale back the availability of services to Arizona's uninsured
population. However, significant increases in funding to Federally Qualified Community Health
Centers are expected through the passage of the Patient Protection and Affordable Health Care

17

Act. The legislation authorizes a total of $14 billion over a five year period, and is expected to
result in 7,000 -- 10,000 new and expanded community health center sites nationwide.

B. Agency Capacity
The Arizona Department of Health Services (ADHS) houses the Title V program. The State
Maternal & Child Health (MCH) program resides within the Bureau of Women's & Children's
Health, and the Children with Special Health Care Needs program resides within the Office for
Children with Special Health Care Needs. This section will highlight statutes relevant to the Title
V program; the general capacity of ADHS to promote and protect the health of all mothers and
children, including children with special health care needs; and culturally competent approaches.
State Statutes Relevant to Title V Program
Arizona Revised Statute (A.R.S.SS36-691) formally accepts Title V and designates ADHS as the
Title V agency:
A. This state accepts the conditions of title V of the social security act, entitled "grants to states
for maternal and child welfare", enacted August 14, 1935, and as amended.
B. The department of health services is designated as the state agency to cooperate with the
department of health, education and welfare for the administration of part 1 and part 4 of title V, of
the social security act.
Additional state statutes authorize some maternal and child health programs or functions but are
not specific to Title V. The statutory list of functions (A.R.S. 36-132) of ADHS includes:
encourage and aide in coordinating local programs concerning maternal and child health,
including midwifery, antepartum and postpartum care, infant and preschool health and the health
of school children, including special fields such as the prevention of blindness and conservation
of sight and hearing; encourage, administer and provide dental health care services and aid in
coordinating local programs concerning dental public health, in cooperation with the Arizona
dental association. Subject to the availability of monies, develop and administer programs in
perinatal health care.
State statute (A.R.S. 36-697) authorized the Health Start program, administered by Bureau of
Women's & Children's Health; the program is required to serve pregnant women, children and
their families. The program is required to be statewide, based in identified neighborhoods and
delivered by lay health workers through prescheduled home visits or prescheduled group classes
that begin before the child's birth or during the postnatal period and that may continue until the
child is two years of age. Statute also requires the program to develop and distribute an Arizona
Family Resource Directory to enable parents to obtain information that is critical to the
development of their young children.
State statute (A.R.S. 36-899.01) also requires ADHS to administer a program of hearing
evaluation services administered to all children as early as possible, but in no event later than the
first year of attendance in any public or private education program, or residential facility for
handicapped children, and thereafter as circumstances permit until the child has attained the age
of sixteen years or is no longer enrolled in a public or private education program. Bureau of
Women's & Children's Health administers this program and provides administrative rules and
technical assistance to schools to implement required hearing screening.
The Child Fatality Review Program is authorized by state statute (A.R.S. 36-3501). The State
Child Fatality Review Team is required to conduct an annual statistical report on the incidence
and causes of child fatalities and submit a copy of this report, including its recommendations for
action, to the Governor and legislative leadership on or before November 15 of each year. The
Team is also required to develop protocols for child fatality investigations including protocols for
law enforcement agencies, prosecutors, medical examiners, health care facilities and social

18

service agencies. The team is required to educate the public regarding the incidence and causes
of child fatalities as well as the public's role in preventing these deaths.
State Statute (A.R.S. 36-2291) established the Unexplained Infant Death Council, which is staffed
by the Bureau of Women's & Children's Health. The unexplained infant death advisory council is
charged with assisting ADHS in developing unexplained infant death training and educational
programs, and periodically review and approving the infant death investigation checklist
developed by ADHS. The statute also mandates that ADHS submit an annual report of the
incidences of stillborn infants and the reported causes of death for the previous year to the
Governor and legislative leadership.
In FY07, ADHS was given new statutory responsibility (A.R.S. 36-112) to develop and distribute
an umbilical cord blood pamphlet. The pamphlet is available on the Bureau of Women's &
Children's Health website.
Children's Rehabilitative Services, administered by the Office for Children with Special Health
Care Needs, is authorized in state statute (A.R.S. 36-261). Statute mandates that the program
shall provide for:
(a) Development, extension and improvement of services for locating such children.
(b) Furnishing of medical, surgical, corrective and other services and care.
(c) Furnishing of facilities for diagnosis, hospitalization and aftercare.
(d) Supervision of the administration of services in the program which are not administered
directly by the department.
(e) The extension and improvement of any services included in the program of services for
chronically ill or physically disabled children as required by this section.
(f) Cooperation with medical, health, nursing and welfare groups and organizations and with any
agency of the state charged with administration of laws providing for vocational rehabilitation of
physically handicapped children.
ADHS is required to issue a request for proposal at least once every four years to contract for the
care and treatment of chronically ill or physically disabled children. The scope of the contracted
services shall include inpatient treatment services, physician services and other care and
treatment services and outpatient treatment services which shall not be mandated at a single
location.
Statute also mandates a central statewide information and referral service for chronically ill or
physically disabled children. The purposes of the information and referral service for chronically
ill or physically disabled children are to:
1. Establish a roster of agencies providing medical, educational, financial, social and
transportation services to chronically ill or physically disabled children.
2. Develop or use an existing statewide, computerized information and referral service that
provides information on services for chronically ill or physically disabled children.
Capacity of Arizona's Title V Program to Provide Preventive and Primary Care Services for
Pregnant Women, Mothers and Infants
Reproductive Health Services
A nation-wide comparison of reproductive health services and family planning indicated that the
number of women in need of contraceptive services and supplies grew by 6 percent nationally
between 2000 and 2008, and over 28 percent in Arizona.
The Bureau of Women's and Children's Health (BWCH) dedicates Title V funds to support family
planning services through twelve county health departments and Maricopa Integrated Health
Services, which operates several clinic sites in Maricopa County. About 4,300 low-income people
are served each year through Title V funding. BWCH works closely with the Arizona Family
Planning Council, the statewide organization that administers federal Title X funds, to coordinate

19

family planning services and address gaps in the state. Title X funding provides services to over
42,000 women, teens and men through 33 family planning health centers throughout the state.
In 2009, the Title X network provided care to 16 percent more unduplicated clients from the
previous year.
Pregnancy & Breastfeeding/Baby Arizona Hotline
Bureau of Women's & Children's Health operates the Pregnancy & Breastfeeding and Baby
Arizona Hotline with two bilingual Certified Lactation Consultants. Baby Arizona is a program to
help pregnant women begin the important prenatal care they need while waiting for the AHCCCS
eligibility process. The hotline also has an International Board Certified Lactation Counselor
available to answer all breastfeeding questions after normal business hours and to answer
technical questions 24 hours a day, seven days a week.
High Risk Perinatal /Newborn Intensive Care Program
For nearly 40 years, the BWCH High Risk Perinatal Program/Newborn Intensive Care program
has provided maternal and neonatal transports, hospital and inpatient physician services, and
community health nursing to families, and served over 5,000 families in FY09. The program
provides emergency maternal and neonatal transports, hospital and inpatient physician services,
and community health nursing. Follow-up services support the family during transition from the
hospital to home; conduct developmental, physical, and environmental assessments; provide
education and guidance; and direct families to programs and services. During home visits,
community nurses also assess other children in the home to identify children at risk and screen
mothers for postpartum wellness. Budget cuts during fiscal year 2010 eliminated approximately
8,800 home visits to newborns who had previously been in newborn intensive care. Eligibility
criteria were also changed to require a minimum five day stay (previously three days) in the NICU
to be enrolled in the program. Because the program suffered a budget reduction of about 60%,
Title V funds are being used to help offset some of the reduction while the program continues to
operate at reduced capacity.
Health Start
Health Start applies a community based model that utilizes Community Health Workers or
promotoras to identify, screen and enroll at risk pregnant or postpartum women and their families
and assists them with obtaining early and consistent prenatal care, provides prenatal and
postpartum education, information and referral services, advocacy and emphasizes timely
immunizations and developmental assessments for their children. In 2009, the Health Start
Program was provided in 100 targeted high risk communities in ten counties and provided
services to 2,300 women and their families. Health Start is funded with state lottery dollars.
Domestic Violence and Sexual Violence Services
In state fiscal 2008, Arizona state agencies administered over $26 million in federal and state
funding dedicated to domestic violence. In contrast, state agencies administered just over $2
million in the same year for sexual assault. All state agencies involved in domestic and sexual
violence services, including Arizona Department of Health Services, meet regularly as the State
Agency Coordination Team, to address common issues and ensure services are coordinated
throughout the state.
The BWCH administers the federal Family Violence Prevention and Services Act Grant. These
funds are used primarily to support shelter and services in rural Arizona, known as the Rural Safe
Home Network. Funds also support infrastructure-building activities of the Arizona Coalition
Against Domestic Violence. Between October 1, 2008 and September 30, 2009 the Rural Safe
Home Network programs provided 14,567 shelter nights to 466 women, 515 children and three
men. Programs provided 1,825 hours of batterers' intervention services to 572 people, as well as
766 domestic violence training and prevention services to 24,741 participants.
BWCH also administers the only funding source dedicated solely to primary prevention of sexual
violence. The Arizona's federally funded Sexual Violence Prevention and Education Program

20

reached 25,719 Arizonans with primary prevention education in the last fiscal year. The program
worked with multiple stakeholders to develop the first state plan specific to the prevention of
sexual violence. In 2009, BWCH accepted its first federal funding for direct services for victims of
sexual assault.
Capacity of Arizona's Title V Program to Provide Preventive and Primary Care Services for
Children
Medical Services Project
To help improve access to care for children, BWCH provides Title V funding to the Medical
Services Project. Administered through the Arizona chapter of the American Academy of
Pediatrics, the Medical Services Project increases access to and utilization of primary care
services for Arizona's uninsured children from low-income families. The Medical Services Project
provides delivery of medical services in participating physicians' offices to children without health
insurance and to those who do not qualify (or are in the process of qualifying) for public
assistance. School nurses identify children who are eligible to participate in the Medical Services
Project and facilitate their enrollment. To be eligible for the Medical Services Project a child must
have no health insurance, must not be eligible for AHCCCS, KidsCare, or Indian Health Services;
and must have a household income less than 185 percent of the federal poverty level.
A network of physicians (pediatricians, family practice physicians, and specialists) provides care
to children qualifying for the Medical Services Project for a fee of either $5 or $10 as payment-infull for an office visit. The health care providers agree to provide a certain number of appointment
slots to Medical Services Project children each month. In addition, prescription medications,
diagnostic laboratory services and eyeglasses are provided as necessary to qualifying children.
In 2009, the Medical Services Project served 242 individual children.
Hearing and Vision Screening
While the requirement to providing hearing screening is an unfunded state mandate for the
schools and ADHS, the Bureau of Women's and Children's Health uses Title V dollars at the state
level to support the infrastructure necessary to carry out the statutory duties of ADHS. The
Bureau of Women's and Children's Health contracts with the University of Arizona to develop
hearing screening curriculum and to train hearing screening trainers. Arizona currently has 128
hearing screening trainers throughout the state that provide the infrastructure to train enough
hearing screeners to screen Arizona's school age children. In the school year 2008-2009,
535,001 students were screened and 1,259 were identified for the first time with a hearing
disorder. To help support the schools, ADHS makes hearing screening equipment available by
loan to Arizona's schools.
Unlike hearing screening, vision screening is not mandated in the state of Arizona. However,
many schools voluntarily provide vision screening to school age children. The ADHS Bureau of
Women's and Children's Health supports vision screening with Title V dollars by contracting with
the University of Arizona to develop vision screening curriculum and to train vision screening
trainers. In addition, ADHS has worked with many partner organizations to update Vision
Screening Guidelines to serve as a tool for schools and others who provide vision screening to
children.
Oral Health
State public health capacity is enhanced through the Office of Oral Health (OOH) in the Arizona
Department of Health Services. While the requirement to have an oral health program is an
unfunded state mandate, BWCH dedicates Title V dollars to support the program. The Office of
Oral Health contracts with county health departments to provide school-based dental sealants
and screenings to over 10,000 children per year. OOH manages the Arizona Fluoride Mouthrinse
program, providing approximately 20,000 children in participating schools with fluoride mouthrinse
annually. OOH supports the efforts of communities to fluoridate their water systems through
providing technical assistance, training, and workshops for community fluoridation campaigns.

21

Office of Oral Health was awarded a HRSA Grant to States to Support Oral Health Workforce
Activities in 2006 and a subsequent grant which continues through 2012. These grants funded a
program to promote and develop enhanced dental teams utilizing teledentistry practice to improve
workforce capacity, diversity and flexibility for providing oral health services to underserved
populations. As of June 2010, five dental service delivery sites in Arizona are using teledentistry
technology.
The passage of health care reform is expected to bring additional federal funds for oral health.
These funds represent a comprehensive systems change approach to oral health with funding
specific for building state infrastructure and school-based sealant programs.
Injury Prevention
Arizona is one of 30 states that are funded by the Centers for Disease Control and Prevention
(CDC) to enhance the injury prevention infrastructure in the state. This infrastructure at the state
level includes an injury epidemiologist, a program manager, an Injury Prevention Advisory
Council, and a state injury prevention plan. Arizona's Injury Prevention Program resides within
the ADHS Bureau of Women's & Children's Health, providing easy integration with maternal and
child health programs. The injury prevention network is vast, and includes trauma/children
hospitals, county health departments, tribal governments, fire and EMS services, and community
based organizations. ADHS provides technical assistance and support upon request, and
produces annual county injury reports.
Arizona Safe Kids is a statewide program dedicated to the prevention of unintentional injury for
Arizona's children less than 15 years of age. Arizona Safe Kids is a member of Safe Kids
Worldwide. Local Safe Kids Coalitions throughout Arizona receive leadership and technical
assistance from Arizona Safe Kids. There are five local Safe Kids Coalitions, one local chapter,
and the Arizona State Coalition.
Emergency Medical Services for Children (EMSC) program works to expand and improve
capacity to reduce and ameliorate pediatric emergencies. In 2008, the program utilized its
Pediatric Advisory Committee for Emergency Services, along with additional stakeholders, to
begin working on establishing a voluntary pediatric designation system for hospital emergency
departments. This system will identify minimum training and equipment a hospital should have to
care for a pediatric patient. The system is scheduled to begin in fall of 2010.
Teen Pregnancy Prevention Services
Arizona currently receives more than $3 million per year in lottery funds to address teen
pregnancy prevention. Arizona funds multiple approaches, including abstinence education and
comprehensive teen pregnancy prevention. County health departments, tribal agencies, and
non-profit organizations implement these approaches across the state. Strategies focus on youth
development and parent education. Growing capacity is expected in this area as federal funding
becomes available through the Affordable Care Act.
Capacity of Arizona's Title V Program to Provide Preventive and Primary Care Services for
Children with Special Health Care Needs
In Arizona, all SSI recipients are eligible for comprehensive services under Medicaid.
Consequently, OCSHCN's main function is to make sure they are aware of their eligibility for
Medicaid as well as other services. Letters are sent to all families of SSI applicants to inform
them of services, including Medicaid, for which they may be eligible, and provides assistance with
the application process. A similar process is followed for infants identified through the Newborn
Screening Program, as well as the Birth Defects Registry. OCSHCN Information and Referral
services assist families in navigating the system of care, helping them to understand eligibility
requirements for different programs, application processes, and rights. OCSHCN offers training
to health plans, school nurses, educators, and other child-serving agencies on strategies to
support CYSHCN to participate in school, recreational, and child care settings in the least

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restrictive and most inclusive environment.
Children's Rehabilitative Services
Children's Rehabilitative Services (CRS) Program is administered by OCSHCN. CRS provides
multi-specialty interdisciplinary care to children under age 21 with qualifying chronic and disabling
health conditions. There are over 350 conditions covered by CRS, including diagnoses such as
cerebral palsy, cleft lip/cleft palate and other cranial-facial disorders, tracheal-esophageal fistula,
scoliosis, juvenile arthritis, muscular dystrophy, osteogenesis imperfecta, spina bifida, cystic
fibrosis, sickle cell anemia, metabolic and endocrine disorders, neurofibromatosis, heart
conditions, Hirschsprungs disease, hydrocephalus, glaucoma, neurosensory disorders, broncho
pulmonary dysplasia, and many congenital anomalies.
Members typically have more than one diagnostic condition, and are involved in multiple systems
of care across child-serving programs and agencies. CRS members often require multiple
specialists and a high level of care coordination. A team approach allows for interdisciplinary,
family-centered, culturally-competent care to address the multiple medical needs of members, as
well as transition and family-support.
Covered services include surgeries and other inpatient hospital services; pediatric physician
specialty care; physical, speech, and occupational therapies, laboratory, radiology and pharmacy
services; vision services; durable medical equipment, such as orthotics and wheel chairs; and
social services. CRS does not cover basic primary care that is not related to the CRS diagnosis.
The ultimate aim of the CRS program is to enhance members' quality of life through the
appropriate utilization of services, optimizing their functionality and minimizing their need for
emergency care.
The relative scarcity of some specialists poses a challenge for delivering timely services,
especially to members who live in remote areas of the state. The CRS program offers statewide
management of these specialists and innovative strategies to ensure that services are
coordinated and delivered timely throughout the state. In addition to members and providers
traveling to clinics, members also receive services through the use of telemedicine and in
field/outreach clinics.
Before March of 2009, CRS covered the cost of medical services for children that did not qualify
for AHCCCS, but were below certain family income limits. These members were called StateOnly members. However in March 2009, due to budget cuts, all State-Only members assumed
all responsibility for payment for medical services, regardless of income, but were able to cap
their fees at rates no higher than AHCCCS provider scheduled rates. In December of 2009,
further cuts resulted in the suspension of all State-Only services, and approximately 4,000
members were disenrolled from CRS. Consequently, only members who are enrolled in an
AHCCCS Health Plan remain enrolled.
Cultural Competent Approaches
Culture is defined as a shared, learned, symbolic system of values, beliefs and attitudes that
shapes and influences perception and behavior. People typically think of culture as the foods,
music, folk costumes, holidays, and religious beliefs associated with different countries and ethnic
groups. But culture influences all aspects of everyday life. It is learned and maintained through
social interaction.
One's own culture seems natural and normal, and is taken for granted. John Culkin (as quoted in
Edmund Carpenter's "They Became What They Beheld") said "We don't know who discovered
water, but we're certain it wasn't a fish." In fact, people often believe that their own culture is
superior to that of others. Other's views can be experienced as wrong, or as a distortion. It can
be difficult to realize that what works so well for you, may not work in another's cultural context.

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OCSHCN has a strong focus on cultural competence. There are many competing definitions of
culture. OCSHCN's working definition of culture goes beyond a focus on language and
interpretation, and embraces the idea of special health care needs and how it requires a
reinterpretation of one's traditional culture.
Culture is frequently only observable when there is a clash in expectations. Identifying that a
child has a special health care need can represent a challenge to one's cultural expectations.
Every family has expectations about what life will be like when their baby is born. Assumptions
are made about parents' job participation, daycare, healthcare, school, and the child's integration
into everyday family life and ultimately transition to adult life and independence. Different cultures
have different ideas about what the special healthcare means and what a family should do or not
do. But families also must now renegotiate their every day expectations in ways that their culture
did not prepare them.
Institutions, such as healthcare, education, and work, are all designed with certain assumptions
and rules for what is acceptable and how to participate. These assumptions and rules may
present barriers to a person with special healthcare needs, who must constantly find ways to
negotiate expectations. Sometimes personal adaptations are needed, but often full participation
requires institutional change in terms of policies and practices.
In order to ameliorate the harmful effects of failing to appreciate another's everyday reality,
OCSHCN promotes cultural relativism. Activities are designed to promote an understanding that
your experience of the world is only one of many possibilities, and you cannot judge a culture
using the standards of your own culture. Activities are not so much oriented towards trying to
understand the intricacies of every other potential cultural belief system, which can have the
unintended consequence of stereotyping (which is an over-generalization about a group) but to
sensitize staff towards listening for what others may be thinking and remaining open to hearing
their points of view and adapting to it.
Nowhere is it more critical to appreciate one's taken for granted assumptions than when a health
care provider and a family must together decide on an appropriate course of treatment. The
provider brings his or her own assumptions of what is necessary and good, which are influenced
by their cultural expectations and training. They may have their own feelings about the child, and
may be oriented towards a cure or amelioration of disability. The family's priorities could be
different, but they are dependent upon the provider to help them to understand risks and
possibilities of different treatment options.
OCSHCN embeds cultural competence concepts into contract language and training, which go
beyond requirements for reading level, interpretation, translation, and alternative formats, and
include best practices for family-centered care, including people-first language and disability
etiquette. Satisfaction surveys are conducted and analyzed to identify areas of strengths and
opportunities for improvement. OCSHCN involves families and youth with special health care
needs in policy and resource development, and makes translation and interpretation services
available to other community partners. OCSHCN's cultural competence committee brings in
regular speakers to address the unique perspectives of culturally diverse groups.
The following are just a few examples of how services are linguistically and culturally appropriate,
and family centered in Arizona.
Arizona Department of Health Services houses the Arizona Health Disparities Center within the
Bureau of Health Systems Development. The Arizona Health Disparities Center organizes
frequent brown bag speakers that highlight the many cultures present in Arizona. The Arizona
Health Disparities Center provides regular updates through email and through its website on
news, funding opportunities, publications and events related to health disparities. Subscribers
receive links/attachments to the latest resources identified by AHDC on their selected topic by
email.

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The Arizona Health Disparities Center worked closely with the Arizona WIC program to produce
online courses and CD-ROMs on orientation to Culturally and Linguistically Appropriate Services
(CLAS) standards. Additional courses on CLAS standards are in the process of development.
ADHS is working on integrating CLAS standards into the orientation process required of all new
employees.
Health Start is designed on the principle that workers reflecting the neighborhoods in which they
serve will be effective in identifying women in their community who need services. Health Start
hires and trains lay health workers from targeted neighborhoods to provide outreach and services
to pregnant women and new moms in their community.
Project LAUNCH, provides evidence-based services for children ages 0-8 years and their families
in neighborhoods in South Phoenix, which has a significant minority population. The program has
as one of its guiding principles investing in the community to ensure cultural competence and
sustainability by encouraging hiring staff and contracting with organizations from within those
neighborhoods.
The Office of Women's Health has implemented a social marketing campaign targeting African
Americans around a message of preconception health. The campaign consists of radio spots,
billboards, brochures, mood piece, website and E-blasts, and educational presentations in African
American churches and other appropriate venues in Maricopa County and other areas of the
state. The Phoenix Chapter of the Black Nurses Association conducts presentations and trains
barbers and beauticians on preconception health so they can educate their clients. The graduate
chapters of Black fraternities and sororities at Arizona State University staff exhibit tables and
provide education at large gatherings.
In the Bureau of Women's & Children's Health, the many Title V funded contracts with
community-based organizations include in the scope of work language requiring services to be
culturally competent.
An attachment is included in this section.

C. Organizational Structure
Janice K. Brewer became the 22nd person to take the oath of office as Governor of Arizona on
January 21, 2009. She is Arizona's fifth Secretary of State to succeed to Governor in mid-term.
Jan Brewer has lived in Arizona for 39 years, and she has spent the past 27 of them serving the
people and upholding the public trust. There are few, if any, elected officials in Arizona with a
broader range of productive experience in public service. Prior to her succession to Governor,
she served as Arizona Secretary of State, as Maricopa County Supervisor, and as a highly
respected member of both houses of the Arizona Legislature, where she rose to leadership of the
State Senate.
The Arizona Department of Health Services (ADHS) is one of the executive agencies that report
to the Governor. ADHS was established as the state public health agency in 1973 under A.R.S.
Title 36 and is designated as Arizona's Title V MCH Block Grant administrator. The agency has
four divisions: Public Health Services, Behavioral Health Services, Licensing Services, and
Operations. The Office of Director includes a Native American Liaison, Local Health Liaison,
Border Health, Public Information Office, and Legislative Services. An ADHS organization chart
can be viewed at www.azdhs.gov/diro/documents/w_orgchart.pdf
The Division of Public Health Services is organized into two primary service lines; Public Health
Preparedness Services and Public Health Prevention Services (PHPS). Public Health Prevention
Services includes four bureaus: Women's & Children's Health, Nutrition & Physical Activity
(includes WIC), Tobacco & Chronic Disease, and Health Systems Development (includes Center

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for Health Disparities). Bureau of Health Statistics is also part of the Division of Public Health
Services. The Division of Behavioral Health Services includes the Office for Children with Special
Health Care Needs, as well as the State Hospital.
Arizona Department of Health Services administrative offices are located in the capitol mall area
in the city of Phoenix. This location enhances collaboration between ADHS divisions as well as
other state agencies.
Structure of Bureau of Women's & Children's Health
The organizational structure of the Bureau of Women's & Children's Health is comprised of four
offices and two sections: Office of Women's Health, Office of Children's Health, Office of Oral
Health, Office of Assessment & Evaluation, Injury Prevention & Child Fatality Section, and
Business & Finance Section. An organization chart is attached.
The Office of Women's Health provides leadership for planning, program development, and
program management of initiatives and programs related to women. Programs include: teen
pregnancy prevention, reproductive health services, sexual violence prevention and education,
sexual assault services, family violence prevention and services/Rural Safe Home Network,
Health Start, and First Time Motherhood. The office lead's the bureau's preconception health
initiative and the Department's Women's Health Week activities.
The Office of Children's Health provides leadership for planning, program development, and
management of initiatives and programs related to children. Programs administered by this office
include the Title V Community Health Grants, Pregnancy & Breastfeeding/Baby Arizona/WIC
Hotline, Children's Information Center, High Risk Perinatal Program, Sensory Program, Medical
Services Project for uninsured children, Project LAUNCH, and early childhood initiatives.
The Office of Oral Health (OOH) provides leadership for planning, program development, and
management of oral health initiatives. The office administers the school-based sealant program,
fluoride mouthrinse program, and first dental visit by age one campaign. OOH provides technical
assistance, training, and workshops for community fluoridation campaigns, and works to develop
the current dental workforce by creating linkages with the Bureau of Health Systems
Development scholarship and loan forgiveness programs. OOH administers a HRSA Oral Health
Workforce grant which is developing teledentristry sites to provide oral health services to
underserved populations.
Injury Prevention & Child Fatality Review Section leads the Department's assessment of injuries
and child fatality, as well as planning and program development for injury prevention. This
section includes overseeing the state injury prevention plan, injury prevention advisory council,
injury epidemiology, Child Fatality Review Program, Unexplained Infant Death Council,
Emergency Medical Services for Children Program, and the Pediatric Advisory Council for
Emergency Services.
The Office of Assessment and Evaluation Section leads the Bureau's research, evaluation,
epidemiology, and data management functions. The office provides technical assistance to
Bureau programs on evaluation, data analysis, and outcomes measures. The office supports
data collection, management, and reporting for BWCH programs. Current Assessment and
Evaluation programs/projects include Title V MCH Block Grant Application and Five-Year
Maternal-Child Health Needs Assessment, State Systems Development Initiative, home visiting
assessment, and program evaluation for Project LAUNCH, Fetal Alcohol Spectrum Disorders
grant, and First Time Motherhood grant.
Structure of Office for Children with Special Health Care Need
The Office for Children with Special Health Care Needs has five divisions, plus a medical director

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and chief financial officer. The medical director is responsible for medical direction of the quality
and utilization management functions of the Office, and gives expert opinions on medical
necessity determinations. The chief financial officer oversees all financial functions, including
encounter submissions, financial statement reporting and reinsurance, and capitation rate
development for Children's Rehabilitative Services.
The Division of Member and Provider Services, Advocacy and Education assists families in
accessing appropriate care and services for children and youth with special health care needs,
and provides information and referral services. The Division oversees the telemedicine program,
e-learning, social service funds, family involvement, member materials and correspondence,
websites and compliance with Americans with Disabilities Act. They also lead the office in the
development of best practices for CSHCN among providers, school nurses, community partners
and other child serving agencies through training and education. Best practices are focused on
family-centered care, cultural competence, medical home, and pediatric to adult transition.
The Division of Consumer Rights is responsible for the development, monitoring and oversight of
the Notice, Appeal, Claims Dispute and Administrative Hearing processes for CRS members,
providers, and applicants for CRS eligibility and enrollment to ensure compliance with all state
and federal requirements related to these processes.
The Division of Quality, Utilization, and Medical Management assures appropriate utilization of
services through monitoring authorization and denial processes, and overseeing compliance with
service plans. Timeliness and quality of services is improved through investigating member
complaints, auditing credentialing and medical records, monitoring of performance improvement
projects and compliance with clinical practice guidelines.
The Compliance and Policy Division's responsibilities include developing contracts and
overseeing performance audits for contracted providers, tracking AHCCCS deliverables, policy
development and the HIPAA Compliance Program. The Compliance Division notifies contractors
of areas of non-compliance and evaluates corrective action responses.
The Assessment and Evaluation Division is responsible for analysis and reporting that support
every other function in the Office, including development of management reports, statistical
analysis, data validation, study design and interpretation, performance measure development,
surveys, predictive modeling, and needs assessment.
An attachment is included in this section.

D. Other MCH Capacity
Executive leadership for maternal and child health is provided by Director of ADHS and Assistant
Director for Public Health Prevention Services and Dr. Laura Nelson, ADHS Chief Medical Officer
and Deputy Director for Behavioral Health Services.
Will Humble was named Interim Director of the Arizona Department of Health Services on
January 21, 2009, and was formally confirmed as Director in February 2010. Mr. Humble was
most recently the Deputy Director of the Division of Public Health Services, and has been with
ADHS since 1992. Mr. Humble holds a Masters Degree in Public Health with an emphasis in
environmental science. He has served as chief of the Office of Environmental Health and was the
Assistant Director of Public Health Preparedness in ADHS.
Jeanette Shea is the Assistant Director of Public Health Prevention Services in the Division of
Public Health. Ms. Shea has served in many public health leadership positions, and was formerly
the Title V and MCH Director. A Master's Degree in Social Work with specialization in planning,
administration, and community development, combined with professional experience in case
management and as a Medicaid policy specialist brought Ms. Shea to public health in 1990 as
manager of the Teen Prenatal Express Program.

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Laura Nelson, MD, joined ADHS in September 2005 and currently serves as the Deputy Director
for Behavioral Health Services. She was also recently appointed as ADHS Chief Medical Officer,
and will be leading the agency in developing and implementing medical policy. Dr. Nelson
previously served as the Associate Medical Director at the Arizona Department of Economic
Security/Division of Developmental Disabilities.
The state MCH workforce is primarily housed within the Bureau of Women's and Children's
Health and Office for Children with Special Health Care Needs. While most of the staff is funded
by sources other than Title V, all contribute to the Title V mission and MCH priorities. For
example, a substantial number of MCH staff work within the Bureau of Nutrition & Physical
Activity carrying out the implementation of the state's WIC program.
The state MCH workforce has been challenged and capacity lessened as a result of severe
budget deficits. A hiring freeze has been in place since February 2008. Exceptions for hiring can
be made by the Department of Administration if the position is considered "mission-critical." In
many cases, when a position becomes vacant, it will remain vacant and the work will be divided
up among existing staff. As a result, most current staff and managers are doing two or more jobs.
Starting in July 2010, state mandated furlough days will shut down nearly all state services on
designated furlough days. A pay cut also goes into effect in July 2010.
Bureau of Women's and Children's Health
The Bureau of Women's and Children's Health has approximately 40 fulltime staff . All staff are
located together in Phoenix. The following are brief biographies of senior level management and
key staff involved in the Title V needs assessment and application processes.
Sheila Sjolander has been the MCH Director and Bureau Chief of Women's & Children's Health
since October 2005. She began her service with the Bureau of Women's & Children Health in
2001 as a manager overseeing several programs and leading the bureau's planning functions.
Ms. Sjolander previously held strategic planning positions with the Wisconsin Department of
Health Services and a workforce development agency in Oregon. She holds a Master's Degree in
Social Work with an emphasis on planning and policy.
Syed (Khaleel) Hussaini has led the Office of Assessment and Evaluation since January 2009.
Dr. Hussaini has been an international consultant previously and has conducted several research
and evaluation studies, including a 2007 evaluation of the Health Start Program which was
published in a peer-reviewed journal. He received his Ph.D. in Sociology from Arizona State
University.
Doug Ritenour has served as the Bureau's MCH epidemiologist since January 2008. Mr. Ritenour
has taken a lead role in producing data for the five-year needs assessment and Title V
application, and presented data to the public at public input sessions. He holds a Masters in
Public Health from Oregon State University.
Toni Means serves as the Office Chief of Women's Health. Ms. Means has 18 years of
progressively responsible program management experience, and has served in the Bureau of
Women's & Children's Health since 1991. Ms. Means received a Masters in Business
Administration in Health Care Management from the University of Phoenix.
Mary Ellen Cunningham is the Chief of the Office of Children's Health. Ms. Cunningham has led
the Bureau's High Risk Perinatal Program since 2005. Formerly with the U.S. Navy, Ms.
Cunningham is a registered nurse with a Masters in Public Administration.
Julia Wacloff joined the Office of Oral Health as Office Chief on July 6, 2009. Ms. Wacloff
previously worked with Office of Oral Health as a consultant for 13 years. She holds a Master's
degree in Dental Public Health and is a registered dental hygienist. She most recently served as

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an epidemiologist with the Centers for Disease Control and Prevention.
Tomi St. Mars serves as the manager of the Injury Prevention & Child Fatality Section, and has
lead the Department's injury prevention initiatives since August 2005. Ms. St. Mars is Arizona's
representative to the State and Territorial Injury Prevention Directors Association, an active
member of the Emergency Nurses Association (ENA) at the national and state level and is a
Certified Emergency Nurse. Ms. St. Mars holds a degree in Master of Science in Nursing.
Debi Morlan has served as the Bureau's Finance Manager since 2001. Ms. Morlan provides
financial and contractual oversight to Title V funded programs, as well as the other federal and
state programs with the Bureau.
Office for Children with Special Health Care Needs
The Office for Children with Special Health Care Needs has approximately 30 full time staff, and
also shares resources with BHS. Some positions are dedicated to the administration of the CRS
Program, and are funded by Title XIX; however, all contribute to the Title V mission of serving
children with special health care needs.
Joan Agostinelli joined ADHS in 2004, and became the administrator of the Office for Children
with Special Health Care Needs in 2006. Ms. Agostinelli has over twenty-five years experience in
health care, including ten years as the principal in a consulting practice, which provided services
to both public and private organizations related to program evaluation, strategic planning, needs
assessment, reimbursement design, and community outreach. In addition to serving as the
CSHCN director for title V, she is the administrator of the Children's Rehabilitative Services
Program.
Michael S. Clement, MD, serves as the medical director for Children's Rehabilitative Services. Dr.
Clement received his medical degree from the University of Utah in 1963. He holds a current
medical license in Arizona, and is a board certified pediatrician. Dr. Clement has previously
served as an assistant director at ADHS, the director of a county health department, the director
of Ambulatory Services at Phoenix Children's Hospital, and as a consultant to the Arizona
Perinatal Trust. He is a fellow of the American Academy of Pediatrics
Cynthia Layne has served as the chief financial officer for OCSHCN since 2002. She is a certified
public accountant, and has held positions as a financial consultant at AHCCCS and in the Auditor
General's Office and in private industry before coming to ADHS.
Jennifer Vehonsky is the division chief for policy and contract compliance. She has extensive
experience with Medicaid program administration and policy development, and was formerly the
Bureau Chief of Policy at ADHS/BHS and assistant to the legislative liaison at AHCCCS before
joining OCSHCN.
Stephen Burroughs is the division chief for Medical, Utilization, and Quality Management. Mr.
Burroughs is a registered nurse with a Bachelor of Science in Nursing. He formerly held positions
as quality director, quality manager, and risk manager for hospitals and managed care
organizations.
Margery Ault is the division chief of Consumer Rights for both OCSHCN and BHS. Ms. Ault holds
a Juris Doctor, and has been the division chief of Consumer Rights since October of 2000. Ms.
Ault brings to OCSHCN over 15 years of experience in managed health care operations for
persons who have special health care needs.
Judith Walker joined OCSHCN in 2002, and leads the Division of Member and Provider Services,
Education and Advocacy. She has over 24 years as an educator on best practices regarding
including children and youth with special needs in all aspects of life throughout the lifespan, and
is a recognized leader in medical home, transition to adulthood, and community development.
Ms. Walker led nationwide technical assistance on early intervention to parent training and

29

information centers. She has testified on behalf of CSHCN at state and federal hearings on health
care, early intervention, special education, and inclusion. She is also the parent of an adult with
special health care needs.
Lisa Anne Schamus leads the Division of Assessment and Evaluation. She holds a Master of
Public Health with an emphasis in Epidemiology, and a B. A. in Spanish Literature. Ms. Schamus
formerly served as the office chief for Assessment and Evaluation for the Bureau of Women's and
Children's Health, and as a manager at the Arizona Family Planning Council. Ms. Schamus has
over 15 years experience guiding program development and improvement through in research
and survey design, data analysis, needs assessment and program evaluation.
Jennifer Jung is the Research Manager in OCSHCN. She has worked at ADHS for five years and
has a Master of Science degree in Public Health. She has experience in epidemiological and
health services research related to Women's and Children's Health as well as Children with
Special Health Care Needs. She is skilled in designing reports and conducting data analyses
using SAS. She maintains databases, performs data validation to ensure data quality, and
establishes methodologies for analysis.
Thara Maclaren manages special projects for OCSHCN, including overseeing survey activities.
She holds a Bachelor of Science in Mathematics and a Master of Science in Economic Systems
and Operations Research. Ms. Maclaren has worked in several industries including defense,
utilities, education, and public health. She joined OCSHCN in June 2006, and her expertise in
mathematical modeling, decision analysis, and experimental design supports program decisions
and operations within OCSHCN. She contributed statistical support for the needs assessment
process.
Role of parents of CSHCN on staff:
OCSHCN has a long history of involving parents of CSHCN and youth with special health care
needs in program development and decision making. This is accomplished primarily by using
families of CSHCN and YSHCN in paid consultant roles. There are several full time staff who are
parents of CSHCN, including two of the division chiefs described above, and a few others, who
did not choose to share their family information in this application. However, the following two
people who play key professional roles in OCSHCN shared the following information.
Marta Urbina serves as the Clinical Programs Executive Coordinator, chairs the cultural
competency committee, and is responsible for information and referral. Ms. Urbina first learned
the importance of understanding the multiple, complex systems of care when she became a
parent in 1982. Her experience began with the neonatal intensive care unit and continued to
community based supports and services that included early intervention, transition to preschool,
navigating the special education system and transitioning to adult life. She immersed herself in
her daughter's medical and educational needs and sought out training, workshops and
conferences to learn to better advocate on her daughter's behalf until she could do so for herself.
Ms. Urbina has worked at Raising Special Kids and the Division of Developmental Disabilities,
with families of CYSHCN, adults living independently in their community, and with professionals
that support them.
Rita Aitken serves as a Title V outreach coordinator for OCSHCN. Ms. Aitken has two adult
children with special health care needs, and has many years experience working with families
and providers, including trainings on best practices for healthcare professionals. Rita is a board
member of Canine Companions for Independence, an organization that provides service dogs to
people with disabilities, and is a member of the Consumer Advisory Workgroup with Mountain
States Genetics Regional Collaborative Council and co-founder of Lactic Acidosis Family
Resource Group in Denver, CO.

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E. State Agency Coordination
The Arizona Department of Health Services Maternal and Child Health Program, consisting of
Bureau of Women's and Children's Health and Office for Children with Special Health Care
Needs (OCSHCN), has many partnerships with a variety of public, private, and government
agencies. Partnerships are built and enhanced through multiple formal and informal methods. A
summary of key collaborations follow, and is not intended to cover the full spectrum of
partnerships occurring.
Maternal and Child Health staff and leadership participate on committees or groups of many
partner agencies, including March of Dimes, Arizona Family Planning Council, Arizona Coalition
Against Domestic Violence, South Phoenix Healthy Start, the Early Childhood Development and
Health Board (First Things First), Arizona Perinatal Trust, School Based Health Care Council, and
Children's Action Alliance. Staff participates on committees or workgroups and collaborate on
projects with many child-serving community organizations including, Raising Special Kids -Arizona's Family to Family Health Information Center, Special Olympics Arizona, United Cerebral
Palsy of Central Arizona, Arizona Chapter of Academy of Pediatrics, and Ronald McDonald
House among others.
Participation in coalitions, networks, and associations has been a critical strategy in partnership
development. Staff actively participates in groups such as the Arizona Public Health Association,
Arizona Rural Women's Health Network, Arizona Asthma Coalition, Taskforce on Alcohol and
Drug-Exposed Infants, Arizona School Nurse Consortium, Rocky Mountain Public Health
Education Consortium, the Arizona Association of Community Health Centers, the Arizona
Developmental Disabilities Network (consisting of the Institute for Human Development University
Center of Excellence for Developmental Disabilities (UCEDD), Sonoran UCEDD, Arizona
Developmental Disabilities Planning Council, Arizona Center for Disability Law, local oral health
coalitions, and the Arizona chapters of the Dental Association and Dental Hygiene Association.
ADHS also leads collaborative efforts to address specific public health issues. For example,
ADHS coordinates an Injury Prevention Advisory Council that works on development and
implementation of the state injury prevention plan. ADHS also coordinates the Pediatric Advisory
Committee for Emergency Services, which helps facilitate accomplishment of performance
objectives of the HRSA Emergency Medical Services for Children Program. The Unexplained
Infant Death Council and State Child Fatality Review Teams address deaths of children and
strategize around areas of preventability. The Office of Oral Health has established regional oral
health workgroups to facilitate strategic planning for the state oral health workforce plan.
Staff works with University of Arizona to develop services for children with neuro-developmental
and related disabilities. In addition, ADHS has multiple partnerships in place with higher institutes
of learning that provide education for the health professions. For example, staff participates on
advisory boards, provide technical assistance and consultation on public health curricula, and
mentor students.
Most ADHS maternal child health programs contract with local organizations to carry out the
mission of the programs. These organizations are primarily county health departments, non-profit
human services agencies, and community health centers. Programs coordinate regular
contractor meetings to provide educational opportunities, technical assistance, and opportunities
for networking.
Collaboration with other state agencies occurs on a regular basis. The Governor's Office for
Children, Youth, and Families facilitates monthly meetings of the State Agency Coordination
Team, which is comprised of all state agencies providing any kind of services related to domestic
violence and sexual violence. The State Interagency Coordinating Council for Infants and
Toddlers, which includes Department of Economic Security(DES)/Arizona Early Intervention
Program (AzEIP), AHCCCS, Division of Developmental Disabilities (DDD), Arizona Schools for

31

the Deaf and Blind, families of young children and ADHS, meets regularly to advise and assist
with the development and implementation of the statewide system of early intervention services.
Maternal and child health staff also participate in meetings of Governor's commissions or
councils, such as Council on Spinal and Head Injuries, the Arizona Traumatic Brain Injury Project,
Council on Aging, and the Commission to Prevent Violence Against Women.
BWCH and OCSHCN collaborate with the Division of Behavioral Health Services (BHS) on the
Arizona Children's Executive Committee which includes partners from Department of Economic
Security, Department of Juvenile Corrections, Department of Education and the Administration of
the Courts to ensure that behavioral health services are being provided to children and families.
Staff collaborates on the Building Partnerships for Quality Care contract that funds two
community organizations to involve family and youth partners in agency decision-making.
ADHS works particularly closely with the state's Medicaid agency, AHCCCS, participating in
many AHCCCS Health Plan meetings. Health Start, Community Nursing, and Hotline staff all
facilitate families enrollment in both Medicaid and SCHIP programs. OCSHCN staff assists
families in understanding eligibility requirements and help with application processes for various
programs that serve CSHCN. Baby Arizona is a program to help pregnant women begin prenatal
care while waiting for AHCCCS eligibility. Baby Arizona providers help women apply for
AHCCCS and pre-enroll her into a health plan, and women begin prenatal care at no cost while
their eligibility is processed. If a woman is determined to be ineligible for AHCCCS, she and her
Baby Arizona doctor work out a reasonable payment plan and continue care. The Bureau of
Women's & Children operates the Baby Arizona hotline and assists callers in how to apply for
AHCCCS and helps them locate a prenatal care provider.
ADHS works with the Social Security Administration to review Social Security Income
applications, and informing families of potential services. Interagency Services Agreements are in
place with AHCCCS to operate the Baby Arizona Hotline, and the Children's Rehabilitative
Services Program as a carve out for Medicaid-eligible children with special health care needs.
BWCH and OCSHCN staff work closely with Newborn Screening, Genetics Services Advisory
Committee, the Arizona Chapter of the AAP, Community Health Centers, Community Health
Nurses, and AzEIP to identify resources to ensure that children and youth receive Early and
Periodic Diagnosis and Treatment (EPSDT) services for children and youth.
The Arizona Community of Practice on Transition (AzCoPT) offers additional opportunities for
cooperation among Department of Education (ADE), Vocational Rehabilitation, Southwest
Institute for Families and Children with Special Health Care Needs, DDD, BHS, and young adults.
This partnership of stakeholders promotes collaboration and coordination for transition planning,
professional development and youth involvement. At the annual ADE Transition conference,
partners will co-present "Partnering for Transition," describing the role of each agency in
coordinating transition for young adults with disabilities and special health care needs. This
presentation will be available online to Vocational Rehabilitation, Behavioral Health, and DDD
case managers, as well as special educators, reinforcing collaboration across agencies, inclusive
of health care, for successful transition. ADHS also works with DES Family Assistance
Administration which provides families with nutrition assistance, cash assistance, emergency food
assistance and applications for AHCCCS health insurance. The agencies strategize ways to
include the nutritional needs of children with special health care needs in FAA policy and
programs allowing for better planning and access to resources to meet the needs of all children
and families who require nutrition assistance.
ADHS staff participates in a monthly Genetics Services Advisory Committee with the Arizona
Schools for the Deaf and Blind, EAR Foundation of Arizona, and pediatric genetics services
providers to discuss emerging practice around newborn screening, diagnosis and provision of
care to children with heritable disorders. Additionally, ADHS staff takes part in Mountain States
Genetics Regional Collaborative Center's (MSRGCC) annual meeting which includes
professionals and consumers from Texas, New Mexico, Arizona, Utah, Colorado, Wyoming,

32

Nevada and Montana. Staff participate in the Arizona Telemedicine Council to explore innovative
ways to expand the reach of heath care providers to underserved areas of the state.
Within ADHS, there is substantial collaboration among program areas. Children with Special
Health Care Needs and Women's and Children's Health work in tandem to assess needs of the
maternal and child health population, provide a Children's Information Center hotline, and provide
community nursing visits to infants through the High Risk Perinatal Program. Both offices work
closely with Newborn Screening, participating in the monthly Newborn Screening Partners
Meetings that include the Early Hearing Detection Coordinator, Arizona Chapter of the Academy
of Pediatrics representative for hearing and pediatric sub-specialists in genetics, endocrinology
and pulmonology. BWCH and OCSHCN collaborate with Bureau of Nutrition and Physical
Activity to coordinate services on an ongoing basis, and have worked with child care licensure to
develop new rules for licensed centers as well as educational materials and videos for childcare
providers.
ADHS has internal workgroups for early childhood, as well as injury prevention made up of staff
from throughout the department. Leadership from all of the public health bureaus (primary care,
nutrition/physical activity/WIC, tobacco/chronic disease, women's & children's health, disease
control, EMS, emergency preparedness, health statistics) meets regularly to enhance integration
of programs. WIC and OCSHCN have worked together to provide metabolic formula for children
0 -- 5 years, who have certain disorders and no insurance coverage.
Methods for partnering with tribal and Native American organizations are also in place. ADHS
leadership has quarterly meetings with the Indian Health Services directors located in Arizona.
Maternal and child health program have agreements in place with Indian Health Services for
sharing of injury data as well as delivery of oral health services. ADHS also has in place a tribal
consultation policy that was utilized as part of the public input process for this year's Title V needs
assessment and application when a special session was held specific to the Native American
population. The ADHS teen pregnancy prevention program has an intergovernmental
agreement in place with the Navajo Nation and a contract with the Inter-Tribal Council of Arizona.
ADHS staff participates in planning the annual Native American Disability Summit.
ADHS maternal and child health programs work with primary care providers in multiple ways.
Programs make referrals to primary care providers, and assist individuals and families in
accessing Medicaid and/or private providers that serve uninsured or underinsured individuals.
The MCH program works closely with the Bureau of Health Systems Development, which serves
as the ADHS primary care office. Programs share data about medically underserved areas and
MCH programs work with HSD when a provider shortage issue arises. The programs also
collaborate on workforce development programs.
The state MCH role with primary care providers also includes sharing information on new public
resources available, such as screening tools or patient education materials. The state MCH
program develops materials specifically for use among primary care providers, such as the new
preconception health Every Woman Arizona materials and materials on enhancing care for
children with special health care needs.
ADHS MCH program has partnerships with community health centers as well as school-based
health care. Community health centers are often partners in implementation of state
administered and or federally funded maternal and child programs. For example, community
health centers have been recipients of MCH Community Health Grants for reducing obesity, and
currently are partners in implementation of Project Connect integrating domestic violence
screening into primary care and family planning sites. With the implementation of health care
reform, the state MCH program will look for opportunities to assist primary care providers in
implementation of new preventive health requirements, as well as to inform the public and
partners about impacts on access to primary care services.

33

F. Health Systems Capacity Indicators
Introduction
Eligibility levels for enrollment in Arizona Medicaid (AHCCCS) remained the same across all
population groups in 2009. However, AHCCCS received permission to increase the premiums for
children and households/parents for FY 2010. In addition, a lack of state funding caused
AHCCCS to place an indefinite freeze on new enrollment in SCHIP (KidsCare) as of January 1,
2010. Therefore, no infants under one year of age will be served by the KidsCare program by
2011 and total enrollment will decline as the population of continuing enrollees ages out of the
program. On September 30, 2009, the KidsCare Parents program was eliminated, which had
served approximately 10,000 adults.
Health Systems Capacity Indicator 01: The rate of children hospitalized for asthma (ICD-9
Codes: 493.0 -493.9) per 10,000 children less than five years of age.
Health Systems Capacity Indicators Forms for HSCI 01 through 04, 07 & 08 - Multi-Year Data
Annual Objective and Performance Data
2005
2006
2007
2008
2009
Annual Indicator
29.1
27.4
28.1
28.9
28.9
Numerator
1299
1323
1400
1447
Denominator
446162 482344 499045 501481
Check this box if you cannot report the
numerator because
1.There are fewer than 5 events over the
last year, and
2.The average number of events over the
last 3 years is fewer than 5 and therefore a
3-year moving average cannot be applied.
Is the Data Provisional or Final?
Final
Provisional
Notes - 2009
Data for 2009 are not yet available. The estimate for 2008 is provisionally set at the 2008 rate
until data become available in the Fall of 2010.
Notes - 2008
Problems with hospital discharge data prevented reporting on this measure for 2002. Data for
2008 are not yet available. The estimate for 2008 is provisionally set at the 2007 rate until data
become available in the Fall of 2009.
Notes - 2007
Problems with hospital discharge data prevented reporting on this measure for 2002. Data for
2007 are not yet available. The estimate for 2007 is provisionally set at the 2006 rate until data
become available in the Fall of 2008.

Narrative:
The Bureau of Women's and Children's Health has direct access to Hospital Discharge data to
report on this measure. However, the Hospital Discharge data does not include Federal or Native
American facilities; therefore, the asthma estimate is incomplete because American
Indian/Alaskan Native children are underrepresented in the hospital discharge data.
Although the rate of hospitalization for asthma among this age cohort increased slightly in 2009,
when compared with 2004 (35.6 per 10,000 children) the 2009 rate (28.9 per10,000 children) was
significantly lower Chi-square=33.129 (1), p<0.00001. In 2009-2010 the Office of Oral collected
information on asthma prevalence among third grade school children across Arizona. Preliminary
results from the 2009 Arizona Healthy Smiles, Healthy Bodies Survey estimated current asthma

34

among pre-school and third grade students at 4.5 percent.

Health Systems Capacity Indicator 02: The percent Medicaid enrollees whose age is less
than one year during the reporting year who received at least one initial periodic screen.
Health Systems Capacity Indicators Forms for HSCI 01 through 04, 07 & 08 - Multi-Year Data
Annual Objective and Performance Data
2005
2006
2007
2008
2009
Annual Indicator
96.1
97.6
96.4
99.1
100.0
Numerator
54373 56520 58301 58861 57283
Denominator
56587 57884 60473 59373 57283
Check this box if you cannot report the numerator
because
1.There are fewer than 5 events over the last year,
and
2.The average number of events over the last 3 years
is fewer than 5 and therefore a 3-year moving
average cannot be applied.
Is the Data Provisional or Final?
Final
Final
Narrative:
The health plans that contract with AHCCCS (Arizona's Medicaid program) conduct various
interventions during the course of each year to increase EPSDT participation. Interventions
include outreach to members and providers related to well visits, dental, TB and lead screening,
immunizations and other preventive health services. The health plans monitor and evaluate the
effectiveness of interventions and report to AHCCCS quarterly.
According to 2009 data provided Arizona Medicaid (Arizona Health Care Cost Containment
System) 100 percent of infants enrolled in health plans that contract with AHCCCS received at
least one initial periodic screen. However, the number of enrollees declined by 3.5 percent in
2009 compared to 2008. AHCCCS continues to provide Early and Periodic Screening Diagnosis
and Treatment (EPSDT) services for Medicaid eligible children under age 21. AHCCCS data has
not been linked to other MCH data sources beyond payer fields within the AZ Birth Certificates
and Hospital Discharge Data system.

Health Systems Capacity Indicator 03: The percent State Childrens Health Insurance
Program (SCHIP) enrollees whose age is less than one year during the reporting year who
received at least one periodic screen.
Health Systems Capacity Indicators Forms for HSCI 01 through 04, 07 & 08 - Multi-Year Data
Annual Objective and Performance Data
2005 2006 2007 2008 2009
Annual Indicator
82.1 78.4 82.5 84.0 82.1
Numerator
517
580
721
646
320
Denominator
630
740
874
769
390
Check this box if you cannot report the numerator because
1.There are fewer than 5 events over the last year, and
2.The average number of events over the last 3 years is
fewer than 5 and therefore a 3-year moving average cannot
be applied.
Is the Data Provisional or Final?
Final Final

35

Narrative:
The estimate for KidsCare (SCHIP) enrollees under 1 year who received at least one periodic
screen declined from 84 percent to 82.1 percent. The total number of enrollees declined nearly 50
percent. In FY 2010 for children in households with incomes between 150-175percent FPL
premiums increased; (a) for one child, from $20 to $40; (b) for more than one child, from $30 to
$60. Premiums for children in households with incomes between 176-200percent FPL increased:
(a) for one child, from $25 to $50; (b) for more than one child, from $35 to $70. Premiums for
parents between 150-175percent FPL increased from 4percent of household income to 5percent
of household income. It was expected that an estimated 25,089 children were impacted by the
increased premiums. On January 1, 2010 due to a lack of funding for KidsCare, no further
children were enrolled in the program. Unless the cap is removed by future legislative action,
Arizona will not be able to report on this measure beyond 2010.

Health Systems Capacity Indicator 04: The percent of women (15 through 44) with a live
birth during the reporting year whose observed to expected prenatal visits are greater than or
equal to 80 percent on the Kotelchuck Index.
Health Systems Capacity Indicators Forms for HSCI 01 through 04, 07 & 08 - Multi-Year Data
Annual Objective and Performance Data
2005
2006
2007
2008
2009
Annual Indicator
70.1
69.8
70.3
71.7
72.5
Numerator
66943 70976
71865
70965 66838
Denominator
95486 101749 102246 98971 92162
Check this box if you cannot report the numerator
because
1.There are fewer than 5 events over the last year,
and
2.The average number of events over the last 3
years is fewer than 5 and therefore a 3-year
moving average cannot be applied.
Is the Data Provisional or Final?
Final
Final
Notes - 2008
Data for 2008 became available after all program narratives and data analyses were completed.
Notes - 2007
Data for 2007 are not yet available. The estimate for 2007 is provisionally set at the 2006 rate
until data become available in the Fall of 2008.

Narrative:
All data for analyzing prenatal care was obtained through the Arizona Birth Certificate database.
BWCH utilized 2009 birth certificate data to report on the Kotelchuck index. The fields used to
perform a Kotelchuck analysis include month prenatal care began and number of prenatal visits.
Both of these fields are self reported and as such may have reliability issues. Kotelchuck index
results appear to be similar in Arizona to national figures. The Healthy People 2010 goal for
women entering prenatal care during the first trimester is 90 percent. The percentage of Arizonan
women aged 15 through 44 who entered prenatal care during the first trimester in 2009 was 80.3
percent. This percentage varied by county of mother's residence. Apache 59.1percent, Cochise
80.0percent, Coconino 85.4percent, Gila 61.4percent, Graham 71.6percent, Greenlee
76.9percent, La Paz 74.7percent, Maricopa 84.4percent, Mojave 76.8percent, Navajo
65.8percent, Pima 71.8percent, Pinal 85.6percent, Santa Cruz 68.2percent, Yavapai 73.9percent,
and Yuma 59.6percent.
The percent of women with adequate prenatal care utilization on the Kotelchuck index varied
widely by county, from a low of 39.2percent of women in Greenlee County to a high of

36

80.9percent in Cochise County.
The BWCH Health Start program continues to strive to find women early in their pregnancies and
ensure they receive adequate prenatal care. Health Start Community Health Workers follow-up
with enrolled pregnant women regarding their prenatal visits and sometimes secure transportation
for participants to the appointments. Health Start is expected to continue to be funded through
lottery dollars that are not appropriated through the state budget process.
Arizona's illegal immigration laws may impact the number of women receiving adequate prenatal
care as undocumented pregnant women are more likely to avoid systems of care and support
available in the state, such as WIC.

Health Systems Capacity Indicator 07A: Percent of potentially Medicaid-eligible children
who have received a service paid by the Medicaid Program.
Health Systems Capacity Indicators Forms for HSCI 01 through 04, 07 & 08 - Multi-Year Data
Annual Objective and Performance Data
2005
2006
2007
2008
2009
Annual Indicator
73.7
74.5
74.7
76.8
78.5
Numerator
424014 432605 434205 468812 529527
Denominator
575577 580568 581632 610091 674385
Check this box if you cannot report the
numerator because
1.There are fewer than 5 events over the last
year, and
2.The average number of events over the last 3
years is fewer than 5 and therefore a 3-year
moving average cannot be applied.
Is the Data Provisional or Final?
Final
Final
Narrative:
The percent of children enrolled in Medicaid (AHCCCS) who have received a service paid by
AHCCCS increased over each year from 2004 (72.6 percent) to 2009 (78.5 percent) . The Bureau
of Women's and Children's Health receives this estimate from AHCCCS. The Bureau is not able
to determine the number of potentially AHCCCS-eligible children (the denominator) and AHCCCS
does not include this figure when it shares data with the Bureau. The measure reported is the
total number of Medicaid members age 1-20 with at least one paid service during the reporting
year divided by the total number of members age 1-20 eligible for Medicaid at any time during the
reporting year.

Health Systems Capacity Indicator 07B: The percent of EPSDT eligible children aged 6
through 9 years who have received any dental services during the year.
Health Systems Capacity Indicators Forms for HSCI 01 through 04, 07 & 08 - Multi-Year Data
Annual Objective and Performance Data
2005
2006
2007
2008
2009
Annual Indicator
45.5
54.1
56.6
59.6
58.9
Numerator
54909
66522
71063
80349
90721
Denominator
120763 122975 125470 134811 153910
Check this box if you cannot report the
numerator because
1.There are fewer than 5 events over the last
year, and

37

2.The average number of events over the last 3
years is fewer than 5 and therefore a 3-year
moving average cannot be applied.
Is the Data Provisional or Final?

Final

Final

Narrative:
Data for HSCI 07B is obtained through the HCFA 416 form provided to the maternal and child
health program by AHCCCS. Although the estimate dropped slightly from 59.6 percent in 2008 to
58.9 percent in 2009, the increase in the number of EPSDT children eligible for service increased
significantly (14.2 percent) in 2009. The Office of Oral Health provides referrals to high-risk
children to ensure they receive dental services. In 2008-2009 the ADHS dental sealant program
placed sealants on 1,620 EPSDT eligible children; this is a 43 percent increase from the 20072008 school year. In 2008-2009 the program served eight counties, in 2007-2008 the program
provided services in 6 counties. Tooth decay is still a significant health problem for Arizona
children with 75 percent of them experiencing tooth decay; a rate significantly higher than the
Healthy People 2010 target of 42 percent. For-profit mobile dental companies continue to provide
limited dental services to Medicaid eligible children but do not address the needs of uninsured or
privately insured children.
The Office of Oral Health continues to monitor AHCCCS Health Plans on policies for dental care
and case management, collaborates with counties to implement school-based sealant programs
to ensure success and partners with counties, private organizations and foundations to enhance
prevention activities. Through a new HRSA Work Force Grant, the Office is continuing to initiate
teledentistry programs in several rural/underserved locations with the addition of one site in 2010.
The Office continues to work with the Arizona Dental Association and Arizona Dental Hygiene
Association in an effort to improve the number of providers in underserved communities. The
dental sealant program continues to provide services to underserved children. The Office of Oral
Health will continue promoting a dental home by age one and provide training for those who
provide services to young children in childcare, learning and health care environments.
The Patient Protection and Affordable Care Act of 2010 includes language indicating states will
receive funding to improve oral health infrastructure, including school based dental sealant
programs.

Health Systems Capacity Indicator 08: The percent of State SSI beneficiaries less than 16
years old receiving rehabilitative services from the State Children with Special Health Care Needs
(CSHCN) Program.
Health Systems Capacity Indicators Forms for HSCI 01 through 04, 07 & 08 - Multi-Year Data
Annual Objective and Performance Data
2005
2006
2007
2008
2009
Annual Indicator
58.9
43.1
47.4
46.4
100.0
Numerator
8945
6627
7540
7630
17327
Denominator
15189 15392 15891 16443 17327
Check this box if you cannot report the numerator
because
1.There are fewer than 5 events over the last year,
and
2.The average number of events over the last 3 years
is fewer than 5 and therefore a 3-year moving
average cannot be applied.
Is the Data Provisional or Final?
Final
Final
Notes - 2009

38

All SSI beneficiaries less than 16 years old are automatically eligible for Arizona's Medicaid
Program, which provides comprehensive rehabilitative services. Title V's role is focused on
assuring families are aware of and enroll in SSI. The Social Security Administration provides
OCSHCN with the names and adresses of SSI applicants and OCSHCN mails information to
families of every applicant under age 21 to ensure that they know what potential services are
available. They are also given contact information for OCSHCN staff who is prepared to give
guidance on eligibility requirements and application processes for other services.
Notes - 2008
The measures for 2004 and 2005 contained duplicate members. The 2006, 2007, and 2008
measures are unduplicated. The 2006 measure looked at the SSI status at the end of the year.
Newer measures count a member as SSI eligible if they had any SSI eligibility at any time during
the year.
Notes - 2007
The measures for 2004 and 2005 contained duplicate members. The 2006 and 2007 measures
are unduplicated. The 2007 measure was correct from what was reported in the 2008 application
to include any member with SSI eligibility at any time during the year.

Narrative:
Previously, only SSI beneficiaries who were enrolled in CRS were counted as served by the Title
V program. However, consistent with other states who have universal Medicaid coverage for
these services, all 17,327 SSI beneficiaries who are identified by the Social Security
Administration as applying for SSI services are reported in both the numerator and the
denominator for this measure.
All SSI beneficiaries less than 16 years old are automatically eligible for Arizona's Medicaid
Program, which provides comprehensive rehabilitative services. Title V's role is focused on
assuring families are aware of and enroll in SSI. The Social Security Administration provides
OCSHCN with the names and adresses of SSI applicants and OCSHCN mails information to
families of every applicant under age 21 to ensure that they know what potential services are
available. They are also given contact information for OCSHCN staff who is prepared to give
guidance on eligibility requirements and application processes for other services. OCSHCN also
offers information about community resources and connect them with family support services.

Health Systems Capacity Indicator 05A: Percent of low birth weight (< 2,500 grams)
INDICATOR #05
Comparison of health
system capacity
indicators for Medicaid,
non-Medicaid, and all
MCH populations in the
State
Percent of low birth weight
(< 2,500 grams)

YEAR

2009

DATA SOURCE

payment source
from birth certificate

POPULATION
MEDICAID NONMEDICAID

ALL

7.3

7.1

6.9

Narrative:
The percent of low birth weight in Arizona remained at 7.1 percent in 2009. Although the percent
of low birth weight infants born to mothers on Medicaid (AHCCS) increased from 7.2 percent in
2008 to 7.3 percent in 2009, the increase was not significant.
The Bureau of Women's & Children's Health (BWCH) enhanced efforts directed toward
preconception health in 2009. Through a HRSA First Time Motherhood grant, BWCH produced

39

the "Live it Change it" campaign targeting preconception health of African Americans in Arizona.
In addition, "Every Woman Arizona" preconception health materials were produced and posted
on the Department's website. In 2010, Arizona held its first preconception health summit in
conjunction with the March of Dimes. BWCH has established a Preconception Health Taskforce
to develop a statewide preconception health plan. BWCH and its partners selected
preconception health as a new state MCH priority for the next five years. BWCH programs have
continued integration of preconception health concepts and activities, especially in the home
visiting programs -- Health Start and High Risk Perinatal Program (HRPP) Community Nursing.
Increased focus and funding on preconception health is intended to improve multiple birth
outcomes, include low birth weight.
The Arizona Chapter of the March of Dimes continues to promote awareness of prematurity and
has funded community-based projects to improve preconception health. The Maricopa Integrated
Health System has implemented an internatal project with women experiencing poor birth
outcomes at the county hospital. The Arizona Family Planning Council is training all Title X family
planning providers on preconception health and reproductive life plans.
The ADHS Bureaus of Physical Activity & Nutrition, Tobacco and Chronic Disease, Health
Systems Development, and Women's & Children's Health have chosen tobacco prevention &
cessation, physical activity, and nutrition as special areas of focus for integration of programming
and messaging. With multiple programs and bureaus promoting these healthy behaviors among
Arizonans, it is hoped that this will also have a positive impact on birth outcomes in the future.
The capacity of Arizona's public health system to impact low birthweight and other birth outcomes
may be increasing as a result of enhanced funding of home visiting programs through First
Things First and the new federal Maternal, Infant, and Early Childhood Home Visiting Program.

Health Systems Capacity Indicator 05B: Infant deaths per 1,000 live births
POPULATION
INDICATOR #05
YEAR
DATA SOURCE
Comparison of health
MEDICAID NONsystem capacity
MEDICAID
indicators for Medicaid,
non-Medicaid, and all
MCH populations in the
State
Infant deaths per 1,000
2009
matching data files
0
0
live births
Notes - 2011
Current insurance status is not indicated on the Arizona Death Certificate.

ALL

5.9

Narrative:
The total infant mortality rate per 1,000 live births decreased from 6.3 in 2008 to 5.9
in 2009. This marks the first time in this grant reporting period that Arizona's infant mortality rate
has remained fell under 6.0 per 1,000 live births. However, the estimate remained above the
healthy People 2010 Goal of 4.5 per 1,000. Infant death statistics in Arizona are not available by
payer.
The Bureau of Women's & Children's Health (BWCH) has taken action to reduce infant mortality
for at-risk populations of infants. BWCH received a 1st Time Motherhood Grant from HRSA. The
focus is on reducing infant mortality among African Americans through social marketing of
preconception health, promotion of existing programs, and community development. BWCH
produced the "Live it Change it" campaign. In addition, "Every Woman Arizona" preconception

40

health materials were produced and posted on the Department's website. In 2010, Arizona held
its first preconception health summit in conjunction with the March of Dimes. BWCH has
established a Preconception Health Taskforce to develop a statewide preconception health plan.
BWCH and its partners selected preconception health as a new state MCH priority for the next
year. Increased focus and funding on preconception health is intended to improve multiple birth
outcomes, including infant death.
In 2009, Child Fatality Review teams reviewed deaths for all children in Arizona, including infant
deaths. Recommendations regarding prevention of infant deaths included implementation of an
infant safe sleep message, evaluation of safe sleep education programs for parents at Arizona
Perinatal Trust site visits of birthing hospitals, and launching a preconception health awareness
campaign which includes messaging that targets African Americans in Arizona.
State budget cuts to programs such as Children's Rehabilitative Services, County Prenatal Block
Grant, Child Abuse Prevention, and Medicaid may impact the rate of infant death. However,
some areas of Arizona's public health system are increasing in their capacity to potentially impact
infant death. Arizona has experienced enhanced funding of home visiting programs through First
Things First and will receive new funding through the federal Maternal, Infant, and Early
Childhood Home Visiting Program. In addition, First Things First Regional Councils have funded
some injury prevention strategies, including Cribs for Kids.

Health Systems Capacity Indicator 05C: Percent of infants born to pregnant women
receiving prenatal care beginning in the first trimester
INDICATOR #05
Comparison of health
system capacity
indicators for Medicaid,
non-Medicaid, and all
MCH populations in the
State
Percent of infants born to
pregnant women receiving
prenatal care beginning in
the first trimester

YEAR

2009

DATA SOURCE

payment source
from birth certificate

POPULATION
MEDICAID NONMEDICAID

ALL

72.6

80.3

89.2

Narrative:
The percentage of Arizonan women aged 15 through 44 who entered prenatal care during the
first trimester increased insignificantly from 79.4percent in 2008 to 80.3percent in 2009 . Medicaid
(AHCCCS) enrollees also increased prenatal care at first trimester from 71.4percent in 2008 to
72.6percent in 2009. However, a significant disparity in the percent of women initiating first
trimester care (Chi-square=4011.18 (1), p<0.0001) continued to exist between the AHCCCS and
non-Medicaid population. Traditionally Medicaid populations in Arizona have higher percentages
of low birth weight infants, lower percentages of women entering prenatal care in the first
trimester, and lower percentages of women receiving adequate prenatal care. The AHCCCS data
has not been linked to other MCH data sources. The Bureau of Women's and Children's Health
requests all Medicaid and SCHIP data pertinent to the Title V Grant directly from AHCCCS.
The Pregnancy and Breastfeeding Hotline is a Title V funded statewide, bilingual service that has
been funded by the Arizona Department of Health Services (ADHS) since April 1988. One of the
many services that the Hotline provides is to assist Arizona's Medicaid program, the Arizona
Health Care Cost Containment System (AHCCCS), with pre-screening for the Baby Arizona
Program. Baby Arizona is a program that helps pregnant women begin the important prenatal
care they need by providing a simple, faster way to get health care before the application process
for AHCCCS health insurance is complete. If a pregnant woman is determined ineligible she can

41

still continue her visits with the provider but she and the provider will need to work out a
reasonable payment plan. If during the pre-screening process the woman appears ineligible, the
Hotline representative will provide information on low cost care available in the woman's
community.
Arizona's illegal immigration laws may impact the number of women accessing prenatal care in
the first trimester. Undocumented pregnant women are more likely to avoid systems of care and
support available in the state, such as WIC.

Health Systems Capacity Indicator 05D: Percent of pregnant women with adequate
prenatal care(observed to expected prenatal visits is greater than or equal to 80% [Kotelchuck
Index])
INDICATOR #05
Comparison of health
system capacity
indicators for Medicaid,
non-Medicaid, and all
MCH populations in the
State
Percent of pregnant
women with adequate
prenatal care(observed to
expected prenatal visits is
greater than or equal to
80% [Kotelchuck Index])

YEAR

2009

DATA SOURCE

payment source
from birth certificate

POPULATION
MEDICAID NONMEDICAID

ALL

65.3

72.5

80.8

Narrative:
There was a slight, but insignificant increase in the percentage of pregnant women with adequate
prenatal care from according to the Kotelchuck Index. However, a significant disparity exists
between the Medicaid (AHCCCS) and non-Medicaid populations. Only 61.9 percent of women on
AHCCCS had at least adequate prenatal care, while 79.4 percent of the non-AHCCCS population
had adequate care according to the Kotelchuck Index (19.4 percent difference). Traditionally
Medicaid populations in Arizona have higher percentages of low birth weight infants, lower
percentages of women entering prenatal care in the first trimester, and lower percentages of
women receiving adequate prenatal care. The AHCCCS data has not been linked to other MCH
data sources.
The Pregnancy and Breastfeeding Hotline and the Health Start Program continue to assist
women in accessing prenatal care.
For over ten years, the state County Prenatal Block Grant funded all 15 County Health
Departments to develop programs to support women in receiving adequate prenatal care.
However, the County Prenatal Block Grant was suspended at the end of the third quarter of the
2009 state fiscal year due to state budget reductions.
Arizona's illegal immigration laws may impact the number of women receiving adequate prenatal
care. Undocumented pregnant women are more likely to avoid systems of care and support
available in the state, such as WIC.

Health Systems Capacity Indicator 06A: The percent of poverty level for eligibility in the
State’s Medicaid and SCHIP programs. - Infants (0 to 1)

42

INDICATOR #06
YEAR PERCENT OF
The percent of poverty level for eligibility in the State's
POVERTY LEVEL
Medicaid programs for infants (0 to 1), children, Medicaid and
Medicaid
pregnant women.
Infants (0 to 1)
2009
140
INDICATOR #06
YEAR PERCENT OF
The percent of poverty level for eligibility in the State's SCHIP
POVERTY LEVEL
programs for infants (0 to 1), children, Medicaid and pregnant
SCHIP
women.
Infants (0 to 1)
2009
200
Notes - 2011
Enrollment in the Arizona KidsCare Program (SCHIP) has been frozen since January 1, 2010 due
to lack of funding for the program.

Narrative:
The percent of poverty for eligibility in the state Medicaid (AHCCCS) program and state CHIP
(KidsCare) for infants remained unchanged in 2009. However, enrollment in KidsCare was frozen
as of January 1, 2010 because of a lack of funding from the state legislature. By 2011 no infants
will be enrolled in KidsCare unless the cap is lifted and funding restored for new enrollment.
In FY 2010, AHCCCS increased KidsCare premiums for children and households/parents.
Premiums for children in households with incomes between 150-175% FPL increased: (a) for one
child, from $20 to $40; (b) for more than one child, from $30 to $60. Premiums for children in
households with incomes between 176-200% FPL increased: (a) for one child, from $25 to $50;
(b) for more than one child, from $35 to $70. Premiums for parents between 150-175% FPL
increased from 4% of household income to 5% of household income.

Health Systems Capacity Indicator 06B: The percent of poverty level for eligibility in the
State’s Medicaid and SCHIP programs. - Medicaid Children
INDICATOR #06
YEAR PERCENT OF
The percent of poverty level for eligibility in the State's
POVERTY LEVEL
Medicaid programs for infants (0 to 1), children, Medicaid and
Medicaid
pregnant women.
Medicaid Children
2009
(Age range 1 to 6)
133
(Age range 6 to 18)
100
(Age range to )
INDICATOR #06
YEAR PERCENT OF
The percent of poverty level for eligibility in the State's SCHIP
POVERTY LEVEL
programs for infants (0 to 1), children, Medicaid and pregnant
SCHIP
women.
Medicaid Children
2009
(Age range 1 to 18)
200
(Age range to )
(Age range to )
Notes - 2011
Enrollment in the Arizona KidsCare Program (SCHIP) has been frozen since January 1, 2010 due
to lack of funding for the program.

Narrative:

43

The percent of poverty level for Medicaid programs for infants, children, and pregnant women,
and Arizona SCHIP (KidsCare) remained the same in 2009. However, KidsCare enrollement was
frozen due to llack of funding and legislative decision. Consequently enrollment in KidsCare
declined 35 percent from April 2009 to April 2010. If the cap on new enrollment is not lifted in
2011, no infants under the age of one year will remain in KidsCare and overall enrollment will
continue to decline as children age out ot the program.

Health Systems Capacity Indicator 06C: The percent of poverty level for eligibility in the
State’s Medicaid and SCHIP programs. - Pregnant Women
INDICATOR #06
YEAR PERCENT OF
The percent of poverty level for eligibility in the State's
POVERTY LEVEL
Medicaid programs for infants (0 to 1), children, Medicaid and
Medicaid
pregnant women.
Pregnant Women
2009
150
INDICATOR #06
YEAR PERCENT OF
The percent of poverty level for eligibility in the State's SCHIP
POVERTY LEVEL
programs for infants (0 to 1), children, Medicaid and pregnant
SCHIP
women.
Pregnant Women
2009
200
Notes - 2011
Enrollment in the Arizona KidsCare Program (SCHIP) has been frozen since January 1, 2010 due
to lack of funding for the program.

Narrative:
The percent of poverty level for pregnant women in the state Medicaid program and state CHIP
(KidsCare) remained the same in 2009. However, KidsCare began a waiting list for all new
qualified enrolles as of January 1, 2010 for both pregnant women and children. Unless the freeze
on new enrollments is lifted, the number of pregnant women enrolled in KidsCare will decline to
zero by 2011.

Health Systems Capacity Indicator 09A: The ability of States to assure Maternal and Child
Health (MCH) program access to policy and program relevant information.
DATABASES OR
Does your MCH program have
Does your MCH program
SURVEYS
the ability to obtain data for
have Direct access to the
program planning or policy
electronic database for
purposes in a timely manner?
analysis?
(Select 1 - 3)
(Select Y/N)
ANNUAL DATA LINKAGES 2
Yes
Annual linkage of infant
birth and infant death
certificates
3
Yes
Annual linkage of birth
certificates and Medicaid
Eligibility or Paid Claims
Files
1
No
Annual linkage of birth
certificates and WIC
eligibility files
1
No

44

Annual linkage of birth
certificates and newborn
screening files
REGISTRIES AND
SURVEYS
Hospital discharge survey
for at least 90% of in-State
discharges

3

Yes

1

No

1

No

Annual birth defects
surveillance system
Survey of recent mothers at
least every two years (like
PRAMS)
Notes - 2011
Narrative:
The Arizona H72 Death Certificate System was replaced by the new VSIMS (Vital Statistics
Information Management System) on July 1, 2008. The Transax data is merged with VSIMS daily
allowing for more timely mortality surveillance. This advancement should have allowed for more
precise determination of infant underlying cause of death when complete VSIMS data is merged
with Arizona Birth Certificates. However, because of contractor error the new system failed to
code birth certificate numbers for more than 50 percent of infant deaths in 2008 and 2009.

Health Systems Capacity Indicator 09B: The Percent of Adolescents in Grades 9 through
12 who Reported Using Tobacco Product in the Past Month.
DATA SOURCES
Does your state
Does your MCH program have direct
participate in the YRBS
access to the state YRBS database for
survey?
analysis?
(Select 1 - 3)
(Select Y/N)
Youth Risk Behavior
3
No
Survey (YRBS)
Arizona Youth
3
No
Survey
Notes - 2011
Narrative:
The ADHS Bureau of Tobacco and Chronic Disease (BTCD) coordinated with the Arizona
Department of Education for the 2009 YRBS administration to eliminate the Youth Tobacco
Survey in high schools and decrease the burden on school districts. According to the 2009 YRBS,
19.7 percent of youth in grades nine through twelve reported smoking cigarettes in the past 30
days. The average age of initiation among Arizona's youth is about 12 years old, and adults
report an average age of 19 for becoming a regular smoker. Tobacco companies know that
youth, specifically ages 12-17, are extremely impressionable and tobacco companies use specific
marketing tactics to target this demographic.
BTCD has implemented a counter-marketing campaign aimed at youth to increase their
knowledge and reduce the initiation of tobacco use. This campaign utilizes traditional means (e.g.
television, radio) and innovative media and technologies favored by youth such as text
messaging, music and social networking sites like Facebook, MySpace and Twitter. This
counter-marketing campaign is referred to as "Venomocity: Brought to you by addiction". The

45

campaign demonstrates the idea that tobacco addiction embeds itself within the smoker and they
ultimately must surrender to the control of tobacco addiction. An integral part of the campaign is
to incorporate grassroots outreach that will engage and empower youth to directly attack the
manipulative efforts of tobacco companies, as well as improve policies around tobacco control,
change social norms and reduce smoking consumption and age of initiation. BTCD is developing
a statewide network of youth through a comprehensive coalition. The development of this network
allows the counter-marketing message to reach youth in and out of school, and they will work to
change the social norms to make tobacco less desirable, acceptable and accessible. The launch
of the statewide coalition network is the 2010 Arizona Youth Tobacco Coalition Conference in
June.

46

IV. Priorities, Performance and Program Activities
A. Background and Overview
Priorities
Arizona's selection of state Title V priorities for 2011-2016 was grounded in review of quantitative
and qualitative data, as well as careful consideration of capacity and public input. Input was
gathered through multiple means -- surveys, focus groups, and special public sessions.

Process for Priority-Setting -- General Maternal & Child Health
In selecting the general maternal and child health priorities, the Bureau of Women's & Children's
Health conducted a priority-setting session on May 7 that involved multiple stakeholders and
partners. Participants in the session not only included the BWCH leadership, epidemiologists and
program managers, and Children with Special Health Care Needs, but also included key partners
from county health departments, community health centers, March of Dimes, county hospital
system, and Academy of Pediatrics; and leadership from other parts of ADHS (Behavioral Health
Services, Local Health, Tobacco & Chronic Disease, Health Systems Development, Nutrition &
Physical Activity, Immunizations, and Epidemiology & Disease Control.)
In order to help prioritize the group considered the following decision criteria: 1) the need is
supported by the data (disparity, magnitude, severity, trend); 2) interventions are available and
effective/action will have an impact on the target population (within five years); 3) the issue is
feasible to address/ADHS has the ability to address it; and 4) the issue is complementary (action
on this issue can be leveraged by or leverage action on other issues). Participants reviewed the
list of current MCH priorities, which are: 1) teen pregnancy and access to reproductive health
services; 2) obesity/overweight among women and children; 3) preventable infant mortality; 4)
injuries, unintentional and intentional; 5) prenatal care among the underserved; 6) oral health; and
7) mental health (integration with general health care). To this list, they added: 8) preconception
health/internatal; 9) substance abuse (alcohol and other drugs); 10) preventive health for children;
11) post-partum depression; and 12) breastfeeding. Participants then utilized the scoring criteria
and rated the issues ‘low,' ‘medium,' and ‘high'. The issues that ranked the highest were: i)
preventive health for children; ii)obesity/overweight among children; iii) preconception
health/internatal, and injuries; and iv)unintentional and intentional injuries
The group also discussed the different ways in which some of the issues could be combined with
one another, but final determination was left to Bureau of Women's & Children's Health with the
understanding that all issues would be addressed even if not specifically identified as a priority.
For example, there are national performance measures related to breastfeeding and prenatal
care, so those issues are certain of being addressed in the annual application. The Bureau also
considered any national or federal priorities that may support and contribute to the state's
capacity to address the issues.
The following priorities will be continued: teen pregnancy, oral health, injury prevention, and
obesity/overweight. The previous priority of integration with mental health was broadened to
encompass behavioral health to include substance abuse as well as post-partum depression and
mental health. The two new priorities are preventive health for children and preconception health.
Two previous priority areas will be addressed as part of preconception health: access to
reproductive health services will be a primary strategy under preconception health, and
preventable infant mortality is expected to be an outcome of improved preconception health.

PROCESS FOR PRIORITY-SETTING -- CHILDREN WITH SPECIAL HEALTH CARE NEEDS

47

The OCSHCN needs assessment team compiled suggested priorities from community partners
into an evaluation tool. The needs assessment team plus key staff and community partners
convened a meeting in which each of the suggested priorities was rated. A list of priorities was
compiled and evaluated, with numerical ratings of 0 through 3 for each dimension: numbers
affected, severity or importance, known interventions, resources to implement intervention,
interest of partners, likelihood of impact, and annually measurable.
Potential topics included early identification of special needs, hearing, access to follow up
services, health insurance that adequately covers special health care needs, mental health
services, therapies, childcare, inclusion, fragmentation of the system of care for CSHCN, the
need for care coordination, genetics testing, and transition. After all topics were rated, scores
were summarized, and the topics with the highest scores across all areas evaluated were
hearing, inclusion, and transition. Three priorities were selected as the top priorities for CSHCN,
which are newly defined priorities since the last needs assessment. In general, OCSHCN's
community partners are more likely to perform enabling services around each of these priorities,
while OCSHCN's role for each can best be described as infrastructure building. OCSHCN efforts
for each priority are centered around analysis, policy and guideline development, and developing
resources and training.

B. State Priorities
The following is a description of State Title V priorities for 2011 -- 2016 for Arizona's maternal and
child health population, including children with special health care needs. Priorities not presented
in any particular order; each is of equal importance.

PRIORITY 1: REDUCE THE RATE OF TEEN PREGNANCY AMONG YOUTH LESS THAN 19
YEARS OF AGE.
While Arizona's rates of teen pregnancy and teen births have been declining over the past
decade, Arizona still ranks within the top five highest teen birth rates in the nation. Support for
continuation of teen pregnancy as a state priority was evidenced during the public input process.
Along with public support, Arizona also has capacity to address this priority through state lottery
dollars that total over $3 million annually. Additional funding for comprehensive teen pregnancy
and abstinence education is expected through the Affordable Care Act. Addressing teen
pregnancy is primarily a population-based strategy through education and youth development
services, with infrastructure support to local providers through provider training and technical
assistance. Arizona will measure and report on progress through national performance measure
#8, which measures the rate of birth for teens ages 15 -- 17 years.
PRIORITY 2: IMPROVE THE PERCENTAGE OF CHILDREN AND FAMILIES WHO ARE AT A
HEALTHY WEIGHT.
Arizona's percentage of children who are overweight or obese has increased at higher rates than
any other state. For youth 10 to 17 years of age, there was a 45.9 percent increase in the
prevalence of obesity from 2003 to 2007, which was the greatest increase in the nation. Nearly
half of all reproductive age women in Arizona are either overweight or obese. Public input
sessions further confirmed the need to continue to maintain addressing obesity and overweight
as a priority. Public support, as well as national and state momentum to address this priority has
clearly been increasing. Arizona is working on policy initiatives to address obesity through federal
funding as well as state actions such as the Empower Program. There is little funding to address
strategies to improve the percentage of children and families at a healthy weight, especially on a
local level. Title V funds can be used to help support critical infrastructure and population-based
strategies to implement this priority. Progress will be measured through the national priority
measure on percentage of children, ages 2 to 5 years, receiving WIC services with a Body Mass

48

Index (BMI) at or above the 85th percentile, and the state performance measure on the percent of
high school students who are overweight or obese.
PRIORITY 3: IMPROVE THE HEALTH OF WOMEN PRIOR TO PREGNANCY.
Since 2006 when the Centers for Disease Control issued its recommendations on how to improve
the health of women prior to pregnancy -- known as preconception health -- there has been
growing attention both nationally and in Arizona about the critical nature of preconception health.
Participants of public input sessions identified this as a priority area, and stakeholders
recommended preconception health be added as a state priority area during the May 7 prioritysetting session. Preconception health comprehensively addresses multiple areas of women's
health, including reproductive health, nutrition, physical activity, tobacco use, substance abuse
and mental health. Because it is so comprehensive, Arizona has great potential and
opportunities to improve preconception health. However, the state lacks resources dedicated
specifically to preconception health. ADHS is leading development of a statewide preconception
health action plan, which will provide direction on future strategies. Strategies are likely to be
population-based and infrastructure-building. Progress on preconception health will be measured
through multiple performance measures, including the national performance measure on smoking
during pregnancy, and the state performance measure on percent of high school students who
are overweight or obese. In addition, a new state performance measure has been developed to
help measure the important strategy of birth spacing; Arizona will measure the percent of women
having a subsequent pregnancy during the inter-pregnancy interval of 18-59 months. Lastly,
health status indicators related to low birth weights will also serve as indicators of preconception
health.
PRIORITY 4: REDUCE THE RATE OF INJURIES, BOTH INTENTIONAL AND
UNINTENTIONAL, AMONG ARIZONANS.
Injuries are the leading causes of death for Arizonans ages 1 -- 44. Homicides and suicides
remain a significant issue for teens and young adults, and dating violence among Arizona high
school students increased significantly between 2003 and 2007. Arizona has strong
infrastructure at the state level to implement injury prevention through the state's injury prevention
program, domestic violence programs in ADHS and other state agencies, and sexual violence
prevention programs. Capacity at the local level, especially for unintentional injury, could be
strengthened. Capacity for violence prevention is weakened by lack of funding. Strategies to
prevent intentional and unintentional injuries are population-based and infrastructure-building,
and all maternal and child health population groups will be addressed. Multiple performance
measures will be used to assess progress on this priority area, including the national measures of
the rate of deaths of children ages 14 years and younger caused by motor vehicle crashes and
the rate of suicide deaths among youths aged 15-19. Arizona will continue to use state measure
on emergency department visits for unintentional injuries among children 1-14. In order to
monitor progress and report on violence prevention efforts to reduce unintentional injuries,
Arizona will be using a new state measure on dating violence among high school students.
PRIORITY 5: IMPROVE ACCESS TO AND QUALITY OF PREVENTIVE HEALTH SERVICES
FOR CHILDREN.
The new priority of preventive health services for children was identified by the group of
stakeholders and ADHS staff was charged with setting general MCH priorities. This new priority
ranked highest of any other priority during this session. Arizona has some increasing capacity to
provide preventive health services for children ages 0 -- 5 through funding from the Early
Education and Health Development Board (First Things First), and potential funding for home
visiting programs through the Affordable Care Act. At the same time, Arizona is experiencing
decreased capacity due to cuts in the state Medicaid program and a waiting list for children to
access the state SCHIP program, Kids Care. Strategies for implementing this new priority will
primarily be enabling services, as the state strives to assist children with accessing available

49

services and establish new resources to the extent possible. Several national performance
measures will be used to help measure progress in various areas of preventive health services
for children. These include: percent of newborns who received timely follow-up by the newborn
screening program; percent of 19 to 35 months olds who received full schedule of age
appropriate immunizations; percent of third grade children who received protective sealants on at
least one permanent tooth; percent of children without health insurance; and percent of very lowbirth weight infants delivered at facilities for high-risk deliveries and neonates. The state
performance measure on Medicaid enrollees ages 1-18 who received at least one preventive
dental service within the last year will also be utilized.
PRIORITY 6: IMPROVE THE ORAL HEALTH OF ARIZONANS.
The oral health of children residing in Arizona is significantly worse than for their national peers.
Arizona's Healthy Smiles, Healthy Bodies survey reported that 31 percent of children ages 2-5
years in Arizona had untreated tooth delay, compared to only 16 percent of their peers nationally.
Public input sessions and the BWCH partner and community surveys all confirmed oral health as
a critical need in Arizona. Capacity to improve oral health may be increasing through HRSA oral
health workforce grant that is helping to implement teledentristry sites, through additional funding
from First Things First for local organizations to address oral health needs of young children, and
through possible future funding through the Affordable Care Act that will strengthen the state
infrastructure and school-based sealant program. Strategies for improving oral health fall in all
levels of the pyramid. For example, teledentristry builds infrastructure in the state but will also
provide children with direct dental care. All maternal and child health populations are addressed
by this priority area. Progress on this priority area will be measured by the national performance
measure of third graders who have dental sealants on at least one permanent tooth, and the state
performance measure on percent of Medicaid enrollees ages 1-18 who received at least one
preventive dental service within the past year.
PRIORITY 7: IMPROVE THE BEHAVIORAL HEALTH OF WOMEN AND CHILDREN.
While quantitative data is lacking to fully assess the behavioral health status of women and
children, both the BWCH partner survey and community survey, and input provided by
stakeholders, indicated that mental health and substance use/abuse (including alcohol as well as
illegal drug use) are critical issues that need to be addressed. Areas of particular concern
identified during public input sessions included post-partum depression, substance abuse among
adolescents, substance abuse among pregnant women, depression among women, and mental
health of children. The capacity of Arizona to address behavioral health is a bit uncertain as
budget cuts have begun to impact access to behavioral health services, particularly to those who
are not eligible for Medicaid. However, women and children remain a priority for treatment within
the behavioral health system. The Title V program has opportunities to promote overall mental
wellness, prevention of substance abuse, and further integration of perinatal depression
screening. Strategies to address this critical need will be a combination of enabling services,
population-based, and infrastructure-building. Improvement in behavioral health will be monitored
through the national performance measure on suicide deaths among 15 -- 19 year olds, and a
new state performance measure on percent of women ages 18 and older who suffer from
frequent mental distress will also be utilized.
PRIORITY 8: REDUCE UNMET NEED FOR HEARING SERVICES.
While every newborn in Arizona is screened for hearing loss, approximately one third of those
who fail the initial screening do not receive appropriate follow up services. The needs
assessment data shows a relatively high proportion of unmet need related to hearing, with one in
four of the CSHCN with an identified need for hearing aids or hearing care failing to have those
needs met. Early Hearing Detection and Intervention Program and the EAR Foundation are very
interested in collaborating with OCSHCN to ensure that all children in Arizona receive appropriate
follow up services for hearing-related problems. These partners are well prepared with known

50

effective interventions, and through collaborating with OCSHCN will have an opportunity to
extend their reach. While the EAR Foundation is effective at raising funds for specific needed
services, they have not been able to develop their analytic capabilities to support strategic
planning. OCSHCN will support this aspect of their strategies, as well as extend their reach
through making the e-Learning platform available for training, and through the use of the
telemedicine system. Training and technical assistance will be provided through community
health centers, physician offices, and Early Head Start. OCSHCN will also work with First Things
First, who will assist with ensuring that children receive needed second screenings and audiology
services. OCSHCN will monitor progress on this priority by creating a state performance
measure, which will track the percent of newborns who fail their initial hearing screening who
receive appropriate follow up services. The baseline for this measure in 2008 is 72%. The fiveyear goal for this measure is to reach 90% by 2013.
PRIORITY 9: PREPARE CYSHCN FOR TRANSITION TO ADULTHOOD.
Although adolescents represent a relatively small proportion of all CSHCN, most CSHCN will
eventually become adults and will require transition services. In addition, the transition process
begins long before adolescence. Whether a child will grow to live independently or require some
kind of assistance, every family must address how health care needs will be met as well as all of
the requirements of everyday living. All avenues of public input emphasized the importance of
transition, and several community partners have some kind of programmatic activity directed
towards it. OCSHCN has long had an emphasis on developing resources and training on
transition, and will continue to collaborate with community partners on all aspects of transition.
The most appropriate measure for tracking progress on transition over the long term is through
the MCH National Performance Measure #6: Percent of youth with special health care needs
who received services necessary to make transition to all aspects of adult life, including health
services, work, and independence.
PRIORITY 10: PROMOTE INCLUSION OF CSHCN IN ALL ASPECTS OF LIFE.
Inclusion of CSHCN in childcare, school, sports, work, and even in Department of Health
Services wellness activities, such as nutrition and physical activity, and injury prevention,
presented many opportunities for improvement. During public input, families often spoke about
the lack of accommodations for CSHCN to participate in all aspects of life, and how important
these were to address. Interventions sometimes were as simple as including OCSHCN staff in
larger prevention initiatives, such as participation in the State Injury Prevention Plan, or adapting
wellness messages to accommodate special needs. These activities present opportunities to
leverage others' resources on behalf of CSHCN. OCSHCN will continue to participate in policy
development to include CSHCN, as well as collaborate with partners, such as school nurses, to
ensure that the needs of CSHCN and barriers to their participation are understood and
addressed. The most appropriate measure for tracking progress on inclusion over the long term
is through the MCH National Performance Measure #5: Percent of CSHCN age 0-18 whose
families report the community-based service systems are organized so they can use them easily.

C. National Performance Measures
Performance Measure 01: The percent of screen positive newborns who received timely
follow up to definitive diagnosis and clinical management for condition(s) mandated by their
State-sponsored newborn screening programs.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and Performance
Data
Annual Performance Objective

2005

2006

2007

2008

2009

100

100

100

100

100

51

Annual Indicator
Numerator
Denominator
Data Source

100.0
80
80

100.0
79
79

100.0
85
85

2010
100

2011
100

2012
100

Check this box if you cannot report
the numerator because
1.There are fewer than 5 events over
the last year, and
2.The average number of events over
the last 3 years is fewer than 5 and
therefore a 3-year moving average
cannot be applied.
Is the Data Provisional or Final?
Annual Performance Objective

100.0
93
93
AZ Office of
Newborn
Screening

100.0
115
115
AZ Office of
Newborn
Screening

Final
2013
100

Final
2014
100

a. Last Year's Accomplishments
The Newborn Screening Program (NBS) reported 89,160 initial bloodspot screens. Of those
screened, 115 were diagnosed with clinically significant disorders, including 55 cases of primary
congenital hypothyroidism; 4 cases of congenital adrenal hyperplasia (CAH); 1 case of
biotinidase deficiency; 2 cases of classic galactosemia; 12 cases of sickle cell anemia, 2 cases of
sickle beta thalassemia and 5 cases of hemoglobin SC--all hemoglobinopathies; 1 case of
homocystinuria; 7 cases of classic phenylketonuria; 1 case of citrullinemia; 4 cases of medium
chain acyl-CoA dehydrogenase deficiency (MCADD); 1 case of very long-chain acyl-CoA
dehydrogenase deficiency; 1 case of isovaleric academia; 4 cases of methylmalonic academia; 1
case of propionic acidemia, and 14 cases of cystic fibrosis (CF). This year was the third full year
of CF screening. Through a partnership with the statewide CF centers, each baby with abnormal
results was referred for further evaluation and testing. The Newborn Screening program located
100% of affected infants who had screen results suggestive of target diseases.
Licensed midwifes participate in education about newborn screening. The midwife licensing
program provides information from the Newborn Screening program and the importance of
screening. If a parent chooses not to have the screening completed, the midwives inform the
parents about their rights and what the screening covers for their babies. There were 695
reported home deliveries over the past calendar year from January 1, 2009 through December
31, 2009. For the women who chose no screening for their infants, the midwife must document
provision of informed consent so the parents have knowledge to make a good decision about the
screenings. Data collected by licensed midwives is limited to "screened" and "not screened". If a
pattern of refusals of the screening is seen with a specific licensed midwife, an investigation is
conducted to determine the quality of information that is shared with parents about testing for
their newborn.
The Office for Children with Special Health Care Needs (OCSHCN) and the Newborn Screening
Program (NBS) developed notification letters and fact sheets for families of newborns identified
with sickle cell disease, other hemoglobin traits and abnormal Cystic Fibrosis test results. The
letters and fact sheets provided resource and education information and instructed families to call
OCSHCN for additional resources or help with applying for services. OCSHCN staff and parent
partners reviewed the letters and fact sheets for readibility, family centeredness, and provided
translation services.
OCSHCN's Information and Referral Project responded to 42 calls generated by the NBS
notification letters. Uninsured and underinsured families received information about health care
coverage, prescription medication resources, testing available at community health centers, and

52

resources for metabolic formula. OCSHCN collaborated with Arizona Physicians IPA-CRS and
the Arizona Department of Health Services WIC Program on a contract that provided metabolic
formula to 17 uninsured and underinsured children.

Table 4a, National Performance Measures Summary Sheet
Activities
1. OCSHCN directs families identified through the NBS Program
to healthcare, services, and family support.
2. Newborn screening has expanded collaboration with key
stakeholders.
3. Newborn screening protocols have been revised by the NBS
Advisory Committee.
4. Newborn Screening continued to educate parents about the
need for second screens.
5. Newborn Screening continued to offer cystic fibrosis
screening.
6. Midwife Licensing Program provided information to all
midwifes about NBS.
7. The Community Health Nurses educated families about the
importance of a second newborn screen.
8. OCSHCN supports family partners to assist in the
development and review of NBS materials, funds translation of
family materials and letters, works with NBS partners to identify
system barriers for newly diagnosed newborns.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X
X
X
X
X
X

X

b. Current Activities
In an effort to provide more effective case management services, the Newborn Screening
Program is streamlining processes. Protocols are being revised, partnerships with specialists are
being redefined, and CLIA regulations are being implemented. Expanding collaboration with
partners ensures timely diagnosis and clinical management by creating tiered levels of support
based on high risk criteria. Sub-specialists intervene earlier, often resulting in better long term
outcomes for infants. Peer-on-peer training and case management review is being expanded.
Additionally, the Medical Director continues to provide consultation to the program and acts as
liaison within the medical community.
Averaging 20,000 hits per year, the Newborn Screening web site continues to offer parents and
providers educational resources and training tools. Specific email accounts are established to
communicate with partners based on specific disorder categories; electronic comments from the
general public are welcome and reviewed.
Community nurses from HRPP act as agents in the community to locate children who have had a
positive screen when the NBS is unable to contact the families
OCSHCN modifies and translates notification letters and fact sheets for families and responds to
calls the letters generate. Families review to ensure readibility and family centeredness.
OCSHCN hosts online hearing screener training and attends monthly NBS Partners meetings to
share information about best practices for CYSHCN.

c. Plan for the Coming Year

53

Through continuous education and data analysis, Newborn Screening goals are to reduce the
numbers of unsatisfactory and batched specimens received, and to refine the positive and
negative predictive values of analytes, thereby improving testing specificity. Also, using culturally
sensitive materials, the Newborn Screening Program continues to educate parents about the
need for a second screen, timely referrals to specialists, and access to Children's Rehabilitative
Services, Office for Children with Special Health Care Needs, Arizona Early Intervention
Program, and other local resources. Performance measures will be reviewed to ensure laboratory
standards are met. Newborn Screening Program will review and update brochures, as well as
expand provider educational materials. As new disorders are added or analyte cut off values
changed, materials will be revised. Internal employee training manuals will be updated, and
continuous education on evidence based laboratory and case management services will be
explored The Medical Director will continue to provide consultation, technical assistance and
identify any bottlenecks in the medical community that can potentially impact the NBS program.
If the need arises, Community Health Nurses will be utilized by the Office of Newborn Screening
to find families that cannot be reached by conventional means. Community Health Nurses will
continue to educate families about the need for a second newborn screen and facilitate referral to
a medical home for those screens. In an effort to ensure comprehension of the urgency of the
screens, the Program will continue to ensure that Community Health Nurses have bilingual staff
available. HRPP program managers work with hospitals during Arizona Perinatal Trust site visits
to identify and try to resolve any issues with NBS process.
OCSHCN and NBS will continue to revise and translate notification letters and fact sheets for all
disorders identified by NBS. OCSHCN is working with hospitals, the AZ EHDI program, and
providers to establish a telemedicine connection for hearing screening follow up.

Form 6, Number and Percentage of Newborns and Others Screened, Cases
Confirmed, and Treated
The newborn screening data reported on Form 6 is provided to assist the reviewer analyze
NPM01.
Total Births by
Occurrence:
Reporting
Year:
Type of
Screening
Tests:

Phenylketonuria
(Classical)
Congenital
Hypothyroidism
(Classical)
Galactosemia
(Classical)
Sickle Cell
Disease

93314
2009
(A)
Receiving at
least one
Screen (1)

(B)
No. of Presumptive
Positive Screens

(C)
No. Confirmed
Cases (2)

No.
89160

%
95.5

No.
104

No.
7

(D)
Needing
Treatment
that
Received
Treatment
(3)
No.
%
7
100.0

89160

95.5

585

4

4

100.0

89160

95.5

91

2

2

100.0

89160

95.5

1025

12

12

100.0

54

Cystic Fibrosis
Homocystinuria
Maple Syrup
Urine Disease
betaketothiolase
deficiency
Tyrosinemia
Type I
Very LongChain Acyl-CoA
Dehydrogenase
Deficiency
Sickle C
Disease
Argininosuccinic
Acidemia
Citrullinemia
Isovaleric
Acidemia
Propionic
Acidemia
Carnitine
Uptake Defect
3MethylcrotonylCoA
Carboxylase
Deficiency
Methylmalonic
acidemia (Cbl
A,B)
Multiple
Carboxylase
Deficiency
Trifunctional
Protein
Deficiency
Glutaric
Acidemia Type I
Medium-Chain
Acyl-CoA
Dehydrogenase
Deficiency
Long-Chain L-3Hydroxy AcylCoA
Dehydrogenase
Deficiency
3-Hydroxy 3Methyl Glutaric
Aciduria
Methylmalonic
Acidemia
(Mutase

89160
89160
89160

95.5
95.5
95.5

161
237
158

14
1
0

14
1
0

100.0
100.0

89160

95.5

0

0

0

89160

95.5

94

0

0

89160

95.5

6

1

1

100.0

89160

95.5

1025

5

5

100.0

89160

95.5

7

0

0

89160
89160

95.5
95.5

7
21

1
1

1
1

100.0
100.0

89160

95.5

17

1

1

100.0

89160

95.5

3

0

0

89160

95.5

10

0

0

89160

95.5

17

4

4

89160

95.5

17

0

0

89160

95.5

0

0

0

89160

95.5

12

0

0

89160

95.5

9

4

4

89160

95.5

0

0

0

89160

95.5

10

0

0

89160

95.5

17

0

0

100.0

100.0

55

Deficiency)
S-Beta
Thalassemia
Pregnancy
Tests
Pap tests
Hearing
Screening

89160

95.5

1025

2

2

11077

11.9

4741

0

0

4806
535001

5.2
573.3

0
12904

0
1259

0
1259

100.0

100.0

Performance Measure 02: The percent of children with special health care needs age 0 to 18
years whose families partner in decision making at all levels and are satisfied with the services
they receive. (CSHCN survey)
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and Performance Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source
Check this box if you cannot report the numerator
because
1.There are fewer than 5 events over the last year,
and
2.The average number of events over the last 3 years
is fewer than 5 and therefore a 3-year moving average
cannot be applied.
Is the Data Provisional or Final?
Annual Performance Objective

2005
54
51.4

2010
54

2006
55
51.4

2011
54

2007
56
53.6

2012
54

2008
54
53.6

2009
55
53.6

SLAITS

SLAITS

Final
2013
54

Final
2014
54

Notes - 2009
Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. The same questions were used to generate the NPM02 indicator for both the 2001 and the
2005-2006 CSHCN survey. No new data has been released for this measure since last year's
application.
Notes - 2008
Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. The same questions were used to generate the NPM02 indicator for both the 2001 and the
2005-2006 CSHCN survey. No new data has been released for this measure since last year's
application.
Notes - 2007
Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. The same questions were used to generate the NPM02 indicator for both the 2001 and the
2005-2006 CSHCN survey.
a. Last Year's Accomplishments
Family and youth involvement was incorporated into all OCSHCN activities from development
through implementation, including program design, contract and grant development, and
evaluation of proposals and contract awards. BHS, BWCH, and OCSHCN awarded contracts to
two community agencies to recruit, train and support families, youth, and consumers to
participate in policy and resource development, training, and to participate on committees, such

56

as cultural competence and quality management.
OCSHCN provided education and technical assistance on family involvement to other offices
within ADHS, AHCCCS health plans, NICU staff and families, the Governor's Council on TBI/SCI,
and community agencies and organizations. The Raising Special Kids Family to Family Health
Information Center (RSK F2F-HIC) contract provided family centered care training to 131 medical
and dental students and coordinated resident-in-training home visits with 50 host families and 6
youth focused on learning about the daily lives of families with CSHCN.
A Parent Action Council (PAC) is a part of each CRS regional clinic site to give a family
perspective on the CRS delivery system, and advocate for families in planning at the local level.
PAC members participated in administrative meetings at the state level to share family concerns.
OCSHCN partnered with United Cerebral Palsy, ADHS Office of Nutrition and Physical Activity
and Licensing Services to produce a training video to be used by licensed childcare providers to
promote healthy lifestyles for CSHCN.
OCSHCN staff, RSK, and Quest to Cure, a local sickle cell family information and support
agency, developed newborn screening materials responsive to family needs. Volunteers reviewed
the CRS member handbook, OCSHCN website as well as contractor websites, and several
RFPs, developed and updated curriculum, training, policies and procedures, facilitated meetings
and reviewed OCSHCN's website. Through a contract with RSK, OCSHCN provided 2,293
families with information, support or training on navigating the system of care.
The 2010 CRS Family Centered Survey, conducted in both English and Spanish, asked several
questions about decision-making. Overall, families felt they were well informed and involved in
decision-making. 91% reported usually or always being offered choices about their child's health
care. 89% reported usually or always being asked to tell the health care provider what choices
they prefer. 94% were usually or always involved as much as they wanted, and families were very
satisfied with services. Care was rated at an average of 9.0 on a 10-point scale, with 10 being the
highest level. 89% of respondents gave their child's specialist a score of 8 or higher.
When asked about the way clinic staff treated children and families, 89% said staff were always
as helpful as they should be, 85% said providers always answered their questions, 86% always
received information that was needed from their providers, and 86% reported that clinic staff
always listened carefully to them. 92% said that clinic staff always explained things to them in a
way they could understand. 92% reported that CRS doctors or other health providers always
showed respect for what they had to say. 88% said CRS doctors or other health providers always
made it easy to discuss their questions and concerns. 93% reported they were always treated
with courtesy and respect. Of the respondents needing an interpreter, 94% always received
translation services when requested. 98% were satisfied or very satisfied with the interpreters'
assistance.
Twelve questions were added to the Survey to gather information on satisfaction with wheelchairs
and wheelchair services. 82% rated manual wheelchairs as very reliable and 90% rated power
wheelchairs as very reliable. 91% of respondents said power wheelchairs met their needs very
well. 72% of respondents said manual wheelchairs met their needs very well. Of the respondents
that received a wheelchair-related service in the last year, 96% were satisfied or very satisfied
with the equipment or service provided.
OCSHCN keeps a log of all calls from families and regularly analyzes concerns, identifies
problems and opportunities to improve OCSHCN programs as well as work with other programs
to continuously improve systems of care for CSHCN.

Table 4a, National Performance Measures Summary Sheet

57

Activities
1. Parents and youth develop and review contracts, policies,
curriculum, training, OCSHCN website and resources.
2. Family satisfaction surveys are used to determine if families
are satisfied and feel involved in decision making. Survey
results are used to modify policies and programs.
3. Building Partnership for Quality Care contractors will recruit,
train, and support the development of family, consumer and
youth leaders to partner in all levels of decision making.
4. The OCSHCN webpage has a place for comments, questions
and feedback. OCSHCN also has an email address listed that
encourages comments and input.
5. Parent and youth leadership curriculum and training to support
the development of family and youth involvement in decision
making.
6. OCSHCN contracts include a requirement to include families
and youth in all levels of decision making.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X

X

X

X

X

X

X

b. Current Activities
OCSHCN uses a variety of methods to promote family participation in decision-making.
OCSHCN is taking the lead on behalf of BWCH and BHS in managing the ADHS Building
Partnerships for Quality Care contract, which provides for family, consumer, and youth to
participate in policy development and decision-making with ADHS. Through this contract,
families are developed as leaders and trained on agency processes so that they are prepared to
participate in decision-making. Contractors recruit, train and support family, consumers and youth
who reflect the diversity of Arizona's population. Participation extends beyond ADHS as families
are made available to other agencies so that family participation can be incorporated into their
activities. OCSHCN works with the Medicaid agency by providing training to AHCCCS health
plans on incorporating family-centered practices for CSHCN. OCSHCN also sponsors resident
and physician training related to CSHCN.
OCSHCN incorporates family involvement in its day-to-day management, including participation
in committees (e.g., management team, cultural competence, quality management, proposal
evaluation), development of RFPs, contracts, grants, policies, curriculum and other materials.
Families review websites for family-centeredness, cultural competence and ease of use, including
ADA compliance. Family feedback mechanisms are built into all programmatic activities, which
are regularly analyzed for opportunities to improve systems of care.

c. Plan for the Coming Year
OCSHCN will continue to incorporate family participation in all of its day-to-day management
activities, including serving on several ongoing committees, and will continue to manage the
ADHS Building Partnerships for Quality Care contract, which provides for family, consumer, and
youth to participate in policy development and decision-making within ADHS and other agencies.
Through this contract families and youth will participate in planning for Arizona's 20th Anniversary
celebration of the Americans with Disabilities Act celebration. Arizona Department of Education
will also involve participants made available through this contract for their annual transition
conference. OCSHCN will work with Arizona's Special Olympic Program to increase the

58

participation of children and youth in the Special Olympics Steps to Better Health Program.
OCSHCN will continue to develop curriculum and training to support the development of family,
youth, and consumer involvement in decision-making, as well as promote families as decisionmakers in other child-serving agencies, including Medicaid, education, and early intervention by
providing technical assistance and training, and sharing resources. OCSHCN will also continue
to sponsor resident and physician training, which takes place in the homes of families of CSHCN
to better acquaint them on day-to-day life issues related to special health care needs, as well as
to learn how to make decisions with families as partners.
Family feedback mechanisms, including surveys, call logs, and website input will be regularly
analyzed for opportunities to improve systems of care, and family and youth participants will
continue to review websites and participate in policy updates. OCSHCN will provide technical
assistance to its contractors on family involvement for CYSHCN.
OCSHCN will explore new ways to get input from families and youth, including social networking
technologies, such as Facebook and Twitter. Families, youth and consumers will partner in these
activities. OCSHCN will continue to encourage other agencies, organizations and ADHS offices to
include family and youth participation in contract language. Technical assistance will be provided
on how to develop mechanisms to support parents and youth, recognizing their time, leadership,
travel and accommodations.
OCSHCN plans to partner with The Arizona Council on Developmental Disabilities, the two state
University Centers of Excellence for Developmental Disabilities, families, and youth, to develop
and apply for grants that support improvements in systems of care and development of families
and youth as leaders.

Performance Measure 03: The percent of children with special health care needs age 0 to 18
who receive coordinated, ongoing, comprehensive care within a medical home. (CSHCN Survey)
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and Performance Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source
Check this box if you cannot report the numerator
because
1.There are fewer than 5 events over the last year,
and
2.The average number of events over the last 3 years
is fewer than 5 and therefore a 3-year moving average
cannot be applied.
Is the Data Provisional or Final?
Annual Performance Objective

2005
51.5
50.5

2010
40

2006
52
50.5

2011
40

2007
52.5
40.4

2012
40

2008
41
40.4

2009
41
40.4

SLAITS

SLAITS

Final
2013
40

Final
2014
40

Notes - 2009
Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. Compared to the 2001 CSHCN survey, there were wording changes, skip pattern revisions
and additions to the questions used to generate the NPM03 indicator for the 2005-2006 CSHCN

59

survey. The data for the two surveys are not comparable for PM #03. No new data has been
released for this measure since last year’s application.
Notes - 2008
Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. Compared to the 2001 CSHCN survey, there were wording changes, skip pattern revisions
and additions to the questions used to generate the NPM03 indicator for the 2005-2006 CSHCN
survey. The data for the two surveys are not comparable for PM #03. No new data has been
released for this measure since last year’s application.
Notes - 2007
Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. Compared to the 2001 CSHCN survey, there were wording changes, skip pattern revisions
and additions to the questions used to generate the NPM03 indicator for the 2005-2006 CSHCN
survey. The data for the two surveys are not comparable for PM #03.
a. Last Year's Accomplishments
Medical home is a key component of all outreach activities. OCSHCN staff worked with other
ADHS programs, state agencies and community partners to educate on best practices for
CSHCN, including medical home. The medical home concept is integrated into contracts, training,
presentations, published materials and new staff orientation.
Through a contract with Raising Special Kids, 131 physicians and dental students received
training on the medical home model of care. The Arizona Medical Home Care Coordination
Manual includes information on eligibility requirements of various state programs and information
on how to apply for them. All of this information was revised to reflect changes due to statewide
budget cuts. 200 manuals were distributed to physicians and families, and manuals were also
given to the Arizona Chapter of American Academy of Pediatrics (AZAAP) Medical Services
Project to share with providers. OCSHCN and AZAAP identified opportunities to work together to
raise awareness of the need for medical homes that are knowledgeable about programs and
resources for CYSHCN.
OCSHCN trained 54 physical therapists at the Arizona Physical Therapists Association annual
statewide meeting. Training focused on navigating the system of care for CSHCN and the
challenges of maintaining a medical home in the face of budget cuts to programs that served
CSHCN. Information was provided on changing eligibility requirements and scopes of services for
various programs in all of the child-serving agencies. Attendees received education on care
coordination and strategies to improve communication between various caregivers and families.
OCSHCN provided this same information to its community partners through regular email
communications. OCSHCN participated in the Arizona School Nurse Consortium annual
conference providing information on the medical home model of care to 84 RNs, 7 LPNs and 25
other health professionals.
OCSHCN developed an outreach plan to engage new community partners, awarding small dollar
contracts to agencies to work on targeted, short-term projects promoting best practices around
the Medical Home model of care.
When families call OCSHCN for information and referral services, staff help families to
understand their rights and responsibilities regarding their health insurance, the importance of
partnering with a primary care provider, how to identify aspects of a medical home, and how to
communicate their needs and preferences to their primary care providers. The Arizona Medical
Home Care Coordination Manual provided sample questions on what to ask providers and
templates for letters that families and providers could use.
The Children's Rehabilitative Services (CRS) Program provided medical services as a carveout to
Medicaid recipients with special health care needs under age 21. Care was provided to more

60

than 26,000 CSHCN through four family-centered, multi-specialty interdisciplinary clinics. CRS
covers over 350 chronic and disabling health conditions including cerebral palsy, cleft lip/cleft
palate, spina bifida, cystic fibrosis, sickle cell anemia, metabolic and endocrine disorders, and
many congenital anomalies. Many members are medically fragile and require complex care from
multiple pediatric physician subspecialists that are frequently in short supply. CRS managed a
statewide network of specialists to provide timely access to CSHCN throughout the state.
Strategies to ensure access included the use of field clinics in which specialists travel to remote
areas of the state, as well as using innovative techniques such as telemedicine to minimize travel
for both families and physicians.
During 2009, plans to develop an electronic infrastructure were implemented, beginning with the
development of service plans for each child, which identified a care coordinator and contained
historical information such as previous hospitalizations, medications, labs, and relevant medical
and family history. A performance improvement project was developed to monitor the
implementation of an electronic health record, which will ultimately include electronic medical
records with real time access at the point of service. Through promotion of medical home
concepts for CSHCN within CRS, OCSHCN was able to leverage beyond the CRS program
because a large proportion of physicians who practice through CRS also see other CSHCN in
their private practices.

Table 4a, National Performance Measures Summary Sheet
Activities
1. OCSHCN’s information and referral services helps families
identify aspects of a medical home and communicate their
needs, preferences and expectations to providers.
2. The medical home concept is integrated into all training,
presentations, published materials, resources, contract language
and new employee orientation.
3. The Arizona Care Coordination Manual is updated to reflect
the changing systems of care and distributed to other ADHS
offices, state agencies, providers, community partners and family
organizations.
4. OCSHCN offers technical assistance and training to
physicians, dental students, therapists, nurses, health plans, and
educators, and family support organizations on how to integrate
and implement best practices for CSHCN, including medical
home.
5. OCSHCN’s CRS Program Contractor is responsible for
coordinating member care consistent with the principles of a
patient-centered medical home.
6. Service plans are developed for each CRS member. Plans
identify a care coordinator and include treatment plans, family
support services, hospitalizations, medications, labs, and
relevant medical and family history.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X

X

X

X

X

X

X

X

X

X

X

X

b. Current Activities
OCSHCN staff works with other ADHS programs, state agencies and community partners to
educate on best practices for CSHCN, including medical home. The medical home concept is

61

integrated into contracts, training, presentations, published materials and new staff orientation.
OCSHCN trains physicians, dental students, therapists, nurses, health plans, and educators on
the medical home model of care, and maintains the Arizona Medical Home Care Coordination
Manual and distributes it to physicians and families. OCSHCN staff meet weekly with therapists
and DDD care coordinators at various state agencies to coordinate services.
OCSHCN information and referral services help families to understand their rights regarding their
health insurance, and how to partner with a primary care provider, identify aspects of a medical
home, and communicate their needs and preferences to their primary care providers.
The CRS program manages a network of pediatric sub-specialists who provide multi-specialty
interdisciplinary care to Medicaid recipients with special health care needs. Medical record
information is captured at the time of application and creates an electronic Service Plan.
Elements of the Service Plan, which is included in a member's medical record. Service Plans are
available electronically to the four regional clinics through a secure website.

c. Plan for the Coming Year
Information on the medical home model will continue to be integrated into training, presentations,
published materials, contracts and new staff orientation. Education and training on care
coordination and medical home best practices will continue to be provided to other ADHS offices,
agencies and community partners. The Arizona Medical Home Care Coordination Manual will
continue to be adapted to reflect the changing system of eligibility requirements and services
offered through state agencies as they respond to budget pressures. The manuals will continue to
be distributed to providers, families, and others.
OCSHCN will work with the AzAAP Medical Services Project to survey physicians on what
information or resources they need to provide a medical home for CYSHCN. OCSHCN will
continue to develop educational materials, connect families with resources and support medical
home activities that empower families to develop individual service plans and act as their own
advocates. OCSHCN will continue to provide resident and physician training through a contract
with RSK on medical home concepts.
OCSHCN will offer trainings on best practices for CSHCN to AHCCCS health plans, school
nurses, and therapists. Best practice information will be presented at each AHCCCS quarterly
MCH meeting during state fiscal year 2009-2010. OCSHCN will provide training to support the
Arizona Therapy Association and the Arthritis Foundation annual conferences, as well as the
Statewide Arizona School for the Deaf and Blind Conference and the AHCCCS American Indian
Health Program conference. Medical home information and Arizona Medical Home Care
Coordination manuals will be provided to conference participants. OCSHCN will explore
converting its Breaking the Diagnosis training to video format. This training focuses on how both
families and physicians experience being confronted with a diagnosis and how that information is
processed and communicated.
Electronic infrastructure development will continue to merge existing health information on CRS
members into a new electronic health record, which will incorporate an electronic medical record
into the existing service plan data, which will be available at the four regional clinics, and
eventually will be available at other points of service.
OCSHCN will continue working with refugee resettlement programs to develop programs and
resources for families of CSHCN who are new to the US. Technical assistance will be provided
on cultural brokering and understanding Arizona's complex system of care, how to be a selfadvocate, and what questions to ask health care providers. Translation services for the
Navigating the Systems of Care training will be provided. OCSHCN will continue to invite staff

62

from other child serving agencies to participate in its monthly cultural competency trainings, and
to offer translation services for both written materials and videos to community partners on behalf
of CSHCN.

Performance Measure 04: The percent of children with special health care needs age 0 to 18
whose families have adequate private and/or public insurance to pay for the services they need.
(CSHCN Survey)
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and Performance Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source
Check this box if you cannot report the numerator
because
1.There are fewer than 5 events over the last year,
and
2.The average number of events over the last 3 years
is fewer than 5 and therefore a 3-year moving average
cannot be applied.
Is the Data Provisional or Final?
Annual Performance Objective

2005
61
60.8

2010
58

2006
61
60.8

2011
58

2007
61
58.1

2012
58

2008
59
58.1

2009
59
58.1

SLAITS

SLAITS

Final
2013
58

Final
2014
58

Notes - 2009
Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. The same questions were used to generate the NPM04 indicator for both the 2001 and the
2005-2006 CSHCN survey. No new data has been released for this measure since last year’s
application.
Notes - 2008
Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. The same questions were used to generate the NPM04 indicator for both the 2001 and the
2005-2006 CSHCN survey. No new data has been released for this measure since last year’s
application.
Notes - 2007
Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. The same questions were used to generate the NPM04 indicator for both the 2001 and the
2005-2006 CSHCN survey.
a. Last Year's Accomplishments
Through an IGA with AHCCCS, OCSHCN administers the CRS program for Medicaid recipients
under age 21 with special health care needs. Care was provided to more than 26,000 CSHCN
through four family-centered, multi-specialty interdisciplinary clinics. CRS covers over 350 chronic
and disabling health conditions including cerebral palsy, cleft lip/cleft palate, spina bifida, cystic
fibrosis, sickle cell anemia, metabolic and endocrine disorders, and congenital anomalies. Many
members are medically fragile and require complex care from multiple pediatric physician
subspecialists that are frequently in short supply. CRS managed a statewide network of
specialists to provide timely access to CSHCN throughout the state.

63

Before March 2009, CRS enrolled any resident with a qualifying medical condition into the CRS
program, regardless of income. CRS members who were not enrolled in AHCCCS were referred
to as state-only members. State only members in families whose incomes were below 200% of
the FPL had their medical expenses covered by the state. Those with higher incomes could
enroll in the program, but were responsible to pay for their own medical expenses, which were
capped at AHCCCS fee schedule rates.
In March 2009, due to budget cuts, CRS discontinued covering medical expenses for state only
members, but continued to allow participation in the program. In December of 2009, CRS
suspended the enrollment of approximately 4,000 state-only members, due to additional budget
cuts. On January 1, 2010, enrollment was frozen in Kidscare, which is Arizona's SCHIP program.
The most recent estimate of the percent of CSHCN with adequate insurance to cover their special
health care needs was 58%, as reported in the 2005/2006 National Survey of Children's Health.
Recent budget cuts combined with the effects of rising unemployment rates are likely to result in
fewer families reporting that they have adequate insurance to cover their children's needs in the
upcoming survey.
OCSHCN has several systems in place to help families access public and private insurance.
Information and Referral services provided health care and resource information to 627 callers.
Families were told how to use health plan member and provider services, member handbooks,
and were given guidance on how to negotiate rates with doctors. OCSHCN followed up with
community health centers on behalf of uninsured and underinsured families, when they were
identified by the Newborn Screening Program as requiring a second screening.
A therapy, drug discount and drug study resource list was developed to share with families who
lacked resources to get needed care. Families were informed about applications for SSI,
AHCCCS and early intervention services. OCSHCN and the ADHS Birth Defects Registry
developed letters for families of newborns with spina bifida and cleft lip/cleft palate to provide
information about resources and health care.
OCSHCN educated community partners and providers about state budget cuts and their impact
on CSHCN, and shared information about program cuts with advocacy groups so they could
prepare for requests for assistance. Families, providers, community organizations and advocacy
groups were educated about appeal rights, filing grievances and requesting state fair hearings
when denied services to which they thought they were entitled.
1,665 letters were sent to SSI applicants informing them of potential services for which they might
be eligible, and giving them family resource contact information, including OCSHCN's contact
information. These letters frequently generated follow up calls from families who received further
assistance with applying for services and identifying resources for such things as prescription
medication and metabolic formula.
OCSHCN worked with the Children's Information Services Hotline and Community Nursing
Program to educate families about AHCCCS and other potential sources of health care coverage.
OCSHCN funds helped to support the Community Nursing Program, which served 173 families of
CSHCN. The plan to convert the training on navigating Arizona's health care systems to an online interactive class was delayed due to changing enrollment and eligibility requirements caused
by budget cuts. OCSHCN referred CSHCN to the Ear Foundation for hearing aids, cochlear
implant batteries, repairs and audiology testing for children identified by the Newborn Screening
Program and for others who did not qualify for AHCCCS or CRS.

Table 4a, National Performance Measures Summary Sheet
Activities

Pyramid Level of Service
DHC ES
PBS
IB

64

1. OCSHCN develops resources and training materials, offers
training and education to providers, community partners, family
support organizations, families and youth about working with
private and public health plans.
2. Contractors are required to assist and encourage families to
apply for AHCCCS.
3. Systems are in place with other state agencies and ADHS
offices, community partners, family organizations and the Social
Security Administration to help link families to services and
resources for CYSHCN.
4. OCSHCN has an Interagency Service Agreement with
Arizona’s Title XIX and XXI agency (AHCCCS) to administer the
CRS Program for over 26,000 children and youth with certain
medical and disabling conditions.
5. OCSHCN provides information and technical assistance to
help families understand eligibility requirements, learn how to
apply for services and understand their rights and
responsibilities.
6.
7.
8.
9.
10.

X

X

X

X

X

X

X

X

X

X

b. Current Activities
OCSHCN administers the CRS program for Medicaid recipients under age 21 with special health
care needs as a service carve out, managing a statewide network of pediatric physician subspecialists to provide access to needed specialty services throughout the state.
Information and Referral services provide information on how to use health plan member and
provider services, member handbooks, and give guidance on negotiating rates with doctors.
OCSHCN assists families who are uninsured and underinsured to identify potential resources for
needed services. Families, providers, community organizations and advocacy groups are
educated about eligibility requirements, how to apply for services, appeal rights, filing grievances
and requesting state fair hearings when denied services to which they thought they were entitled.
OCSHCN sends letters to all SSI applicants under age 21 informing them of potential resources.
OCSHCN and the ADHS Birth Defects Registry send letters to families of newborns with spina
bifida and cleft lip/cleft palate to provide information about resources and health care.
OCSHCN works with the Children's Information Services Hotline, Community Nursing Program,
school nurses, and other ADHS programs to educate families about potential sources of health
care coverage. OCSHCN is converting the training on navigating Arizona's health care systems
to an on-line interactive class to reflect changes to enrollment and eligibility requirements caused
by budget cuts

c. Plan for the Coming Year
OCSHCN will continue to work with families and providers to find coverage for medical care and
services. Families will be educated to use their health plan's member and provider services,
member handbook, negotiate with their doctor about rates for services and navigate the system
of care. Families will continue to receive information about SSI, AHCCCS programs and early
intervention services. Letters will be mailed to families identified by the NBS Program, the Arizona

65

Birth Defects Registry and SSI to inform them about medical coverage and programs for which
they might be eligible. Telephone call log data will track barriers identified by families in gaining
access to services and health insurance. This information will be shared with responsible
agencies.
OCSHCN will educate school nurses, providers, and other community partners on eligibility
requirements and services available to CSHCN. OCSHCN will continue to support the CIS
Hotline and the Community Nursing Programs through funding and training about public and
private health insurance options, services and programs for CYSHCN.
OCSHCN will leverage the CRS contract to collaborate with the CRS contractor to identify
opportunities for families, regardless of CRS enrollment, to participate in studies, research
projects and other financial supplement programs to obtain prescription medication for which they
would otherwise not qualify. OCSHCN will continue to require that the CRS contractor identify a
primary care provider for youth transitioning into adult health care. OCSHCN will continue to
identify charitable funds, such as the United Health Care Charitable Fund, to help families offset
medical costs.
OCSHCN will explore options available through federal health reform initiatives for opportunities
to serve CSHCN, including the development of risk pools and new requirements to prevent
insurance companies from excluding children with pre-existing conditions from coverage, as well
as requirements to allow parents to include children up to age 26 on their health care plans.
OCSHCN will research options and communicate them to its partners. OCSHCN will explore
developing, educating and recruiting businesses to participate in a pilot project to provide
education to families on evaluating health care plans for care and services for CYSHCN.
OCSHCN will continue to work on converting its training on navigating Arizona's system of care
into an on-line interactive class with updated information on changing enrollment and eligibility
requirements caused by budget cuts.

Performance Measure 05: Percent of children with special health care needs age 0 to 18
whose families report the community-based service systems are organized so they can use them
easily. (CSHCN Survey)
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and Performance Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source
Check this box if you cannot report the numerator
because
1.There are fewer than 5 events over the last year,
and
2.The average number of events over the last 3 years
is fewer than 5 and therefore a 3-year moving average
cannot be applied.
Is the Data Provisional or Final?
Annual Performance Objective

2005
73
70.9

2010
86

2006
74
70.9

2011
86

2007
75
86.5

2012
86

2008
87
86.5

2009
87
86.5

SLAITS

SLAITS

Final
2013
86

Final
2014
86

Notes - 2009

66

Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. Compared to the 2001 CSHCN survey, there were revisions to the wording, ordering and
the number of the questions used to generate the NPM05 indicator for the 2005-2006 CSHCN
survey. The data for the two surveys are not comparable for PM #05. No new data has been
released for this measure since last year’s application.
Notes - 2008
Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. Compared to the 2001 CSHCN survey, there were revisions to the wording, ordering and
the number of the questions used to generate the NPM05 indicator for the 2005-2006 CSHCN
survey. The data for the two surveys are not comparable for PM #05. No new data has been
released for this measure since last year’s application.
Notes - 2007
Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. Compared to the 2001 CSHCN survey, there were revisions to the wording, ordering and
the number of the questions used to generate the NPM05 indicator for the 2005-2006 CSHCN
survey. The data for the two surveys are not comparable for PM #05.
a. Last Year's Accomplishments
Information and Referral staff responded to over 600 family calls in which families are assisted in
navigating the system of care, identifying services for which they may be eligible, and given
guidance on the various application processes. Families receive assistance with understanding
their rights in school, healthcare and community settings, including grievance procedures and
appeal rights. 1,665 letters were sent to families of SSI applicants informing them of services for
which they might be eligible in their community. The NBS Program directed families to OCSHCN
for assistance in its follow up correspondence to families.
Training was provided to 131 medical and dental students on family centered care practices and
promoted family home visits. 50 faculty families and 6 youth hosted residents. Staff trained school
nurses on supporting children so that they can stay in school and participate in the least
restrictive and most inclusive school environment. Training focused on strategies for
communicating with physicians, school IEP teams, child-serving agencies, and families, and their
role in helping students become self advocates. Training on how nurses can assist and support
families in navigating the systems of care included information on eligibility rules and application
processes and available community resources as well as an overview of public and private
insurance.
Ronald McDonald House Charities, Phoenix, provides specialized services in overnight facilities
to families who travel away from home to get medical care and treatment for their seriously ill
children. OCSHCN's partnership with Ronald McDonald House provided 132 visits averaging 1215 days in which families could stay near their hospitalized CSHCN.
OCSHCN took advantage of an opportunity to work with ADHS Child Care Licensing to craft rules
that were more inclusive of CSHCN because of the need to modify Administrative Rules on child
care centers to accommodate larger ADHS initiatives regarding nutrition. New Rules were
crafted recognizing CSHCN concerns regarding transportation, physical environment, and
nutrition. ADHS training materials were also developed, including a video, which for the first time
specifically addresses including CSHCN in childcare settings and routines.
OCSHCN staff represented ADHS on the AzEIP Interagency Coordinating Council, and kept
them informed on changing aspects of the system of care for CSHCN. OCSHCN also participated
in the Injury Prevention Plan, ensuring that issues related to CSHCN were addressed as part of
the Plan, including car seat safety, TBI/SCI, and training for first responders on CSHCN.
The Telemedicine Program provided medical services to over 100 children living in areas without

67

access to pediatric orthopedists and neurologists in their communities. OCSHCN met with the
Arizona Early Hearing Detection and Intervention Program, University of Arizona, and Yuma
Regional Medical Center, to bring
expanded hearing screening services to the rural southwest part of the state. OCSHCN staff met
with Flagstaff Regional Medical Center, to establish a telemedicine link to a medical center
serving the Navajo Reservation. OCSHCN's new contract for Children's Rehabilitative Services
(CRS) expanded laboratory, pharmacy, therapy, and vision services across the state to make
services available in community settings closer to members' homes. Member Services were also
expanded to be available 24-hours/day, seven days/week to answer questions about benefits,
services, complaints, and grievances.
An Eligibility and Enrollment Performance Improvement Project reduced the proportion of
eligibility referrals that resulted in a pended status for insufficient medical documentation (from a
baseline of 49% before implementation, to 81% in the last quarter of 2009), which had been
identified as a barrier to timely enrollment. The 2010 CRS Family Centered Survey included
questions about the ease of using services. 88% reported that it was not a problem to see a
specialist when needed. 81% had seen a specialist in the past 12 months. 81% reported usually
or always getting the help or advice they needed when they called the clinic during regular hours.
88% reported being satisfied or very satisfied with how long it took to get care. 87% reported
being satisfied or very satisfied with how long it took to get an appointment at a CRS clinic. 95%
reported that they usually waited 45 minutes or less before being taken to the exam room.

Table 4a, National Performance Measures Summary Sheet
Activities
1. Information and Referral staff identify services for which
CSHCN may be eligible, guide families on application processes
and help them understand their rights in school, healthcare and
community settings.
2. OCSHCN offers training to school nurses and child care
providers on strategies to support CYSHCN to participate in
school and child care settings in the least restrictive and most
inclusive environment.
3. Family satisfaction surveys ask respondents if services are
arranged so that they are easy to use. Survey responses guide
program and policy changes.
4. OCSHCN funds Ronald McDonald House to enable families to
stay near their hospitalized CSHCN.
5. Program eligibility and enrollment has been simplified for the
CRS Program.
6. OCSHCN’s Arizona Telemedicine Program for CYSHCN
providers a statewide system to conduct clinical and follow up
services at geographically separate sites to members living in
remote areas without access to specialists.
7. Resources and technical assistance is provided to the Building
Partnerships for Quality Care contractors regarding the changing
requirements and services offered through the state’s systems of
care.
8. OCSHCN partners with Ryan House to provide respite and
pediatric palliative care in a home-like setting for CYSHCN and
their families.
9. OCSHCN’s CRS Program has 4 regional multispecialty
interdisciplinary clinics and a statewide network of labs,

Pyramid Level of Service
DHC ES
PBS
IB
X
X

X

X

X

X

X
X
X

X

X

X

X

X

X

X

68

pharmacy, therapy, vision and hearing care and provider offices
that are often in or near a member’s community.
10.
b. Current Activities
Information and Referral staff identify services for which CSHCN may be eligible, and guide
families on application processes, and help them understand their rights in school, healthcare and
community settings. OCSHCN sends letters to SSI applicants and works with NBS to direct
families to services.
OCSHCN trains school nurses on strategies to support CSHCN so that they can stay in school
and participate in the least restrictive and most inclusive school environment. Residents are
trained on family-centered practices and are encouraged to visit families' homes.
OCSHCN works with other programs with ADHS to influence polices to be inclusive of CSHCN in
areas focused on wellness, injury prevention, and childcare; and with First Things First,
Education, Arizona Developmental Disabilities Planning Council, Economic Security,
Developmental Disabilities, Vocational Rehabilitation, and serves on the AzEIP ICC, keeping
participants informed on changing aspects of the system of care for CSHCN. OCSHCN supports
the BWCH Community Nursing Program and the CIS Hotline and trains staff to help callers
access systems of care for CYSHCN. The Information and Referral and SSI Projects refer
families to community-based services.
OCSHCN funds Ronald McDonald House to provide enable families to stay near their
hospitalized CSHCN. The telemedicine program makes specialty services available to CSHCN in
remote areas of the state and works to expand both the number of locations and types of
services.

c. Plan for the Coming Year
OCSHCN will continue to offer information and referral services to identify services, provide
guidance on application processes, and assist with understanding CSHCN rights in school,
healthcare and community settings. OCSHCN will continue to send letters to SSI applicants to
inform them of services in their community, and will continue to work with the NBS Program on
developing processes and resources for families and providers, and the NBS Program will
continue to direct families to OCSHCN for assistance.
OCSHCN will continue to train medical and dental students on family centered care practices and
promote family home visits. School nurses will be trained on supporting children so that they can
stay in school and participate in the least restrictive and most inclusive school environment.
Training will focus on strategies for communication with physicians, school IEP teams, childserving agencies, and families and the nurses' role in helping students become self advocates.
Training for school nurses will include information on eligibility rules, application processes, and
available community resources as well as an overview of public and private insurance to share
with families navigating the changing systems of care. Training plans are being expanded to
include therapists. OCSHCN will load an online training on navigating the system of care for
CSHCN for families, providers, and child-serving agencies, when updates to reflect recent budget
cuts are completed.
OCSHCN will partner with Ryan House to provide inpatient respite and pediatric palliative care in
a home-like setting. Support to Ronald McDonald House will be expanded to more locations to
enable more families to stay near their hospitalized CSHCN.
The electronic infrastructure for CSHCN will expand telemedicine to include more specialty
services (e.g., genetics, metabolic nutrition, audiology, and cardiology), as well as expand

69

existing specialty services for neurology and orthopedics to more locations. eHRs, which
currently include service plans, will incorporate eMRs, which will facilitate expansion of services
to community settings outside of CRS regional clinics.
OCSHCN will partner with Arizona Special Olympics to promote wellness for CSHCN of all ages,
share resources and data. OCSHCN will continue to identify opportunities to encourage inclusion
of CSHCN in wellness activities, childcare, behavioral health services, and injury prevention.
OCSHCN is planning to work with Arizona's two UCEDD programs and Arizona's Developmental
Disabilities Planning Council to increase opportunities and services for CSHCN. OCSHCN will
continue to represent ADHS on the AzEIP Interagency Coordinating Council, and keep them
informed on changing aspects of the system of care for CSHCN. OCSHCN will continue to
participate in the Injury Prevention Plan, ensuring that issues related to CSHCN are addressed as
part of the Plan, including car seat safety, TBI/SCI, and training first responders on CSHCN.

Performance Measure 06: The percentage of youth with special health care needs who
received the services necessary to make transitions to all aspects of adult life, including adult
health care, work, and independence.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and Performance Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source
Check this box if you cannot report the numerator
because
1.There are fewer than 5 events over the last year,
and
2.The average number of events over the last 3 years
is fewer than 5 and therefore a 3-year moving average
cannot be applied.
Is the Data Provisional or Final?
Annual Performance Objective

2005
6
5.8

2010
39

2006
6
5.8

2011
39

2007
6
39.4

2012
39

2008
39
39.4

2009
40
39.4

SLAITS

SLAITS

Final
2013
39

Final
2014
39

Notes - 2009
Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. Compared to the 2001 CSHCN survey, there were wording changes, skip pattern
revisions, and additions to the questions used to generate the NPM06 indicator for the 2005-2006
CSHCN survey. There were also issues around the reliability of the 2001 data because of the
sample size. The data for the two surveys are not comparable for PM #06 and the 2005-2006
may be considered baseline data. No new data has been released for this measure since last
year’s application.
Notes - 2008
Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. Compared to the 2001 CSHCN survey, there were wording changes, skip pattern
revisions, and additions to the questions used to generate the NPM06 indicator for the 2005-2006
CSHCN survey. There were also issues around the reliability of the 2001 data because of the
sample size. The data for the two surveys are not comparable for PM #06 and the 2005-2006
may be considered baseline data. No new data has been released for this measure since last
year’s application.

70

Notes - 2007
Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. Compared to the 2001 CSHCN survey, there were wording changes, skip pattern
revisions, and additions to the questions used to generate the NPM06 indicator for the 2005-2006
CSHCN survey. There were also issues around the reliability of the 2001 data because of the
sample size. The data for the two surveys are not comparable for PM #06 and the 2005-2006
may be considered baseline data.
a. Last Year's Accomplishments
Youth participated on RFP review teams on injury prevention and contracts, and participated in
development of resources, such as curriculum, member handbooks, fact sheets and brochures
and participated on the OCSHCN web review team to review web pages and other materials for
readability, relevance, and ADA compliance. OCSHCN revised contract language, policies, and
procedures to require youth involvement. Building Partnerships for Quality Care Contractors
recruited youth with various disabilities and cultural backgrounds, and who represent various
areas of the state. Youth were added to the OCSCHN Family Centered Cultural Competency
Committee and the CRS Quality Management Committee requirements were changed to add
youth involvement.
OCSHCN partnered with past youth leaders who were formerly on the Integrated Services Task
Force and committees and are now in consultant positions or are employed by other agencies,
such as the Developmental Disabilities Planning Council, Southwest Autism Research and
Resource Center (SARRC), Spinal Cord Injury Association, and Southwest Institute for Families
and Children with Special Needs (SWI) to develop transition training for healthcare providers. The
training was converted to an online e-learning format.
Best practices on transition were promoted through sharing resources with the Arizona
Developmental Disabilities Planning Council, Department of Education, school nurses, Special
Olympics, the CRS contractor, Division of Developmental Disability, AHCCCS Health Plans,
families and providers. CRS contractors initiated transition plans by a member's 15th birthday and
documented the plans in members' medical records. CRS contractors identified adult care
providers for youth aging out of the program.
OCSHCN participated as an Arizona Community of Practice on Transition (AzCoPT) member.
AzCoPT is a partnership of state agencies promoting collaboration and coordination for transition
planning, professional development and youth and family involvement to improve school and
post-school outcomes for youth. Members include the Departments of Education, Economic
Security, and Health Services. AzCoPT provided guidance to parents, students, educators and
state agency staff working with transitioning youth. OCSHCN developed language and
information about health care transition, which was added to AzCOPT's Vision, Mission, Guiding
Principles and Purpose document and to training that was developed to explain the role of each
agency in the transition process. The training was pilot tested to parents, educators and agency
staff in Yuma, Flagstaff, Tucson and Phoenix. Feedback provided from the pilot was incorporated
into the training.
Training was provided to school nurses to promote best practice information on health care
transitions and the role of the school nurse in ensuring that CYSHCN are healthy enough to
participate in activities and ensuring that CYSHCN learn to be as responsible and knowledgeable
about their own health care management so they are prepared to direct their own healthcare as
adults. Health care is stressed as an important aspect of self determination. OCSHCN
information and referral services assist youth in identifying potential services for which they may
be eligible and assist them with the application process, and in understanding their rights.
OCSHCN met with Ryan House to discuss adopting a more self-determined perspective for youth
with life-threatening conditions.

71

OCSHCN participates in the Arizona Children's Executive Committee, comprised of AHCCCS
Administration, Regional Behavioral Health Authorities, Juvenile Corrections, Vocational
Rehabilitation, Division of Developmental Disabilities, and the BHS medical directors. OCSHCN
was invited to present information to the group and share resources on transition.
OCSHCN collaborated with Southwest Institute for Families (SWI) on the youth strand of the
annual ADE transition conference. OCSHCN provided a nutritionist to speak at one of SWI's
conference sessions. Healthcare and other information on transitioning to adulthood was
provided for youth, families, and educators at transition fairs. A major part of activities at fairs
were directed towards explaining changes to state services as a result of budget cuts. OCSHCN
also provided training sessions on all aspects of transition, including guardianship, adult care
providers, transportation, education and work

Table 4a, National Performance Measures Summary Sheet
Activities
1. OCSHCN requires direct service contractors to develop
transition plans before the 15th birthday of their members.
2. Youth develop and review contracts, policies, curriculum,
training, resources, and OCSHCN website and are members of
several OCSHCN committees including cultural competence and
quality management.
3. OCSHCN and the Governor’s Council on Spinal and Head
Injuries partner on the Arizona TBI Transitions Project helping
youth transition to adult health care, understand their rights and
responsibilities, and learn how to access community support
system
4. Transition training modules for physicians and school nurses
are updated to include reminders about EPSDT screening for
adolescents. CME-CEU’s are offered for the on-line training.
5. OCSHCN participates in community health and transition fairs,
community partner meetings and conferences to offer resources,
technical assistance and workshops on the importance of
understanding healthcare for transitioning young adults.
6. OCSHCN staff offer transition resources and training to other
ADHS offices and state agencies, including AHCCCS Health
Plans
7. OCSHCN is a member of the AzCOPT team and offers
training to inform students, parents, educators, and others about
state agency processes.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X

X

X

X

X

X

X

X

X

X

X

X

b. Current Activities
Transition resources are provided at community fairs and conferences. OCSHCN is an AzCoPT
member ensuring that the needs of YSHCN are included in school and post-school transition
plans. AzCoPT training is used to inform students, parents, educators and others about state
agency transition processes.
Contractors are monitored to ensure that appropriate transition services are provided. The
Building Partnerships for Quality Care grant includes a youth partner component. CRS
contractors begin transition plans for members before they reach age 15. Plans must be age

72

appropriate, address member needs, identify an adult health care provider.
OCSHCN and the Governor's Council on Spinal and Head Injuries partner on the Arizona TBI
Transitions Project helping youth transition to adult health care and support systems. OCSHCN
and Behavioral Health Services are exploring ways to provide information, resources and
services to youth with TBI. OCSHCN shares information and transition resources with behavioral
health contractors at BHS Arizona Children's Executive Committee meetings and with the
Catholic Charities Refugee Relocation Program. OCSHCN and SWI are looking at ways to
increase collaboration around transition.
OCSHCN is revising it's transition training module for physicians and school nurses to include
information about EPSDT screening for adolescents, and is seeking CME-CEU's for the training.

c. Plan for the Coming Year
OCSHCN contracts will continue to require transition planning, and contractors will be trained on
transition practices. OCSHCN will use the Building Partnerships for Quality of Care contract to
recruit, support, train, and provide leadership development for youth, and develop an OCSHCN
youth council to participate in management. Training developed by youth about what makes
transition successful will be made available online for physicians serving adults with disabilities.
OCSHCN is planning to partner with SARRC to provide resources and training materials for a
transition project that educates hospital staff and physicians about youth with autism and places
youth with autism to work in a large metropolitan hospital.
OCSHCN will continue as an AzCoPT member to ensure that the health care needs of YSHCN
are considered in school and post school transition plans, and will continue to exhibit at transition
fairs and conferences. OCSHCN will work with ADE to develop a medical/social empowerment
track for the annual Transition Conference, and will offer scholarships for youth and families to
attend and translate conference materials. OCSHCN will translate an AzCOPT training explaining
the role of each state agency in the transition process into Spanish, and make both an English
and Spanish version available on DVD for distribution.
OCSHCN will continue partnership with the Governor's Council on Spinal and Head Injuries on
the Arizona TBI Transitions Project providing best practice information on transition for CYSHCN.
OCSHCN will continue to identify opportunities to partner with SWI and will explore funding SWI's
Transition Team activities at the annual ADE Transition Conference. OCSHCN will continue to
explore ways to incorporate youth transition practices into Medicaid health plan training.
OCSHCN has begun to explore with the Sonoran University Center of Excellence on
Developmental Disabilities (UCEDD) and Special Olympics Arizona to promote wellness through
diet, nutrition, sports, and stress management for children and youth with disabilities. Special
Olympics has already developed materials and training, and is collecting data on 11,000 athletes,
both children and adults, who are currently getting physicals through Special Olympics every two
years. These three entities are planning to develop a pilot project to design measurements for
tracking the success of the program in promoting wellness and look for early and continuous
opportunities for establishing healthy lifestyles in children and youth, and carrying them into
adulthood. OCSHCN will also work with Sonoran UCEDD to expand their medical home
transition project that supports youth as they move from CRS to adult providers and services.

73

Performance Measure 07: Percent of 19 to 35 month olds who have received full schedule of
age appropriate immunizations against Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus,
Pertussis, Haemophilus Influenza, and Hepatitis B.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and
Performance Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source

2005

2006

2007

2008

2009

78
78.6

79
79.2

79.5
76.2

80
76.7

80
76

National
Immunization
Survey

National
Immunization
Survey

Final
2013
80

Final
2014
80

Check this box if you cannot report
the numerator because
1.There are fewer than 5 events
over the last year, and
2.The average number of events
over the last 3 years is fewer than 5
and therefore a 3-year moving
average cannot be applied.
Is the Data Provisional or Final?
Annual Performance Objective

2010
80

2011
80

2012
80

Notes - 2009
The source of immunization data is the CDC National Immunization Survey
(http://www.cdc.gov/vaccines/stats-surv/nis/tables/0607/tab03_antigen_state.xls). Previously, the
reported rate represented the coverage level for 4DPT, 3OPV and 1 MMR only, because data
were not reliably available for the full series recommended by the CDC, which also includes 3
doses of Hep B and 3 doses of Hib. No data were available for this measure for 1998, but the
data points for 1999 forward have been changed to reflect the full 4:3:1:3:3 series. Performance
objectives were also changed to reflect the change in the measure. Estimates for data points are
based on reports for the following date ranges:
1999 = July 1998 through Jun 1999
2000 = "2000"
2001 = Jan 01 through Dec 01
2002 = Jul 01 through Jun 02
2003 = Jul 02 through Jun 03
2004= Jul 03 through Jun 04
2005= Jan 04 through Dec 04
2006=Jan 05 through Dec 05
2007= Jul 06 through Jun 07
2008= Jul 07 through Jun 08
2009=Jul 08 through Jun 09
The 2009 estimate reflects the immunization status of children by age two for children who were
19-35 months of age, born between July 2005 and December 2008. The estimate tolerates 5.9
error at a 95% confidence level. There was no significant decrease in this immunization measure
in 2009
Notes - 2008
The source of immunization data is the CDC National Immunization Survey
(http://www.cdc.gov/vaccines/stats-surv/nis/tables/0607/tab03_antigen_state.xls). Previously, the
reported rate represented the coverage level for 4DPT, 3OPV and 1 MMR only, because data

74

were not reliably available for the full series recommended by the CDC, which also includes 3
doses of Hep B and 3 doses of Hib. No data were available for this measure for 1998, but the
data points for 1999 forward have been changed to reflect the full 4:3:1:3:3 series. Performance
objectives were also changed to reflect the change in the measure. Estimates for data points are
based on reports for the following date ranges:
1999 = July 1998 through Jun 1999
2000 = "2000"
2001 = Jan 01 through Dec 01
2002 = Jul 01 through Jun 02
2003 = Jul 02 through Jun 03
2004= Jul 03 through Jun 04
2005= Jan 04 through Dec 04
2006=Jan 05 through Dec 05
2007= Jul 06 through Jun 07
2008= Jul 07 through Jun 2008
The 2008 estimate reflects the immunization status of children by age two for children who were
19-35 months of age, born between July 2004 and December 2007. The estimate tolerates 7.5
error at a 95% confidence level.
Notes - 2007
The source of immunization data is the CDC National Immunization Survey
(http://www.cdc.gov/vaccines/stats-surv/nis/tables/0607/tab03_antigen_state.xls). Previously, the
reported rate represented the coverage level for 4DPT, 3OPV and 1 MMR only, because data
were not reliably available for the full series recommended by the CDC, which also includes 3
doses of Hep B and 3 doses of Hib. No data were available for this measure for 1998, but the
data points for 1999 forward have been changed to reflect the full 4:3:1:3:3 series. Performance
objectives were also changed to reflect the change in the measure. Estimates for data points are
based on reports for the following date ranges:
1999 = July 1998 through Jun 1999
2000 = "2000"
2001 = Jan 01 through Dec 01
2002 = Jul 01 through Jun 02
2003 = Jul 02 through Jun 03
2004= Jul 03 through Jun 04
2005= Jan 04 through Dec 04
2006=Jan 05 through Dec 05
2007= Jul 06 through Jun 07
The 2007 estimate reflects the immunization status of children by age two for children who were
19-35 months of age, born between July 2003 and December 2005. The estimate tolerates 5.4%
error at a 95% confidence level.
a. Last Year's Accomplishments
The Bureau of Women's & Children's Health provided Title V funding to support The Arizona
Partnership for Immunizations (TAPI). TAPI activities reported in this application include
programs funded by Title V as well as programs supported by other community programs. The
TAPI home web page, www.whyimmunize.org allows parents to ask medical experts questions
about vaccines and immunizations and was updated to include more information for providers.
English and Spanish parent education flyers, "Is Your Child Protected?" and vaccine safety
concern flyers were revised and distributed. Reminder/recall postcards were printed and widely
distributed to immunization providers throughout the state. Additional materials updated and
distributed in 2009 included:
1) A parent education flyer to help overcome parent immunization concerns; 2) "Cloud Award"
brochures nomination form given to providers who have achieved a 90%+ immunization coverage
level of their two year old patients; 3) postcard to guide parents and providers to
www.whyimmunize.org; 4) clinical guide on giving shots
with easy to follow picture instructions for providers; and 5) teen parent education flyers and post

75

cards.
Over 75,000 educational pieces were distributed to schools, child care facilities, private providers,
county health departments, community health centers, managed care organizations and WIC
sites in 2009.
TAPI conducted ten regional immunization programs with the Vaccines for Children Program and
the Arizona State Immunization Information System for providers statewide. Four hundred
individuals from provider offices and health departments participated in the trainings. The
programs emphasized the importance of using resources such as reminder/recall cards and
parent education flyers. TAPI also partnered with ADHS/AIPO to educate healthcare providers on
immunization educational tools at 9 professional conferences.
TAPI partnered with the ASU School of Nursing in a training seminar for graduate level
community nursing students to instill the value of community partnerships in immunization, and
fostered continued hands on learning through several internships. TAPI and ASU hosted a web
based training program for provider offices on common questions about flu and how to organize
a mass immunization clinic.
In cooperation with AIPO, TAPI designed and mailed an Arizona State Immunization Information
System (ASIIS)user satisfaction survey to 2,300 provider sites. Forty eight percent (48%) of the
surveys were completed and returned by the December 31, 2009. Survey data indicated 90% of
respondents are overwhelmingly very satisfied/satisfied with the program; 98% strongly
agreed/agreed ASIIS representatives are knowledgeable and helpful; 78% strongly
agreed/agreed that using ASIIS decreased missed opportunities, 70% routinely used ASIIS to
look up immunization records of their patients.
TAPI developed a curriculum for pediatric offices that have fallen below the national average for
immunization coverage of their patient population. This year TAPI partnered with county
immunization clinics on recouping the admin fee for Medicaid patients.
The Health Start Program educated pregnant and postpartum women about immunizations and
many other health and behavioral health topics during and between pregnancies. The Community
Health Workers provided visits with the clients to verify that they and their children up to age two
are attending medical appointments and receiving needed immunizations. Referrals are made to
immunization clinics and social and behavioral health programs as needed. Approximately 92%
of Health Start children were fully immunized and 8% were not fully
immunized.
The High Risk Perinatal Program (HRPP) Community Health Nurses monitored the immunization
status of the children enrolled in their program and continued to promote and facilitate
immunizations. In order to communicate with all clients the importance of maintaining the
immunization schedule many of the HRPP utilized bilingual Community Health Nurses and, if
necessary, translation services.

Table 4a, National Performance Measures Summary Sheet
Activities
1. TAPI is designing, printing and distributing immunization
materials for parents and providers
2. TAPI works with managed health care plans to promote ontime immunizations for enrolled children/adolescents
3. TAPI conducts educational/training programs to improve
immunization practices
4. TAPI continues programs and partnerships that promote

Pyramid Level of Service
DHC ES
PBS
IB
X

X
X

76

childhood immunizations
5. Health Start Community Health Workers educate pregnant
and postpartum women about the importance of immunization.
6. High Risk Perinatal Program Community Health Nurses
monitor the immunization status of enrolled infants.
7. Arizona WIC participants are screened and referred for proper
timing of the DtaP.
8.
9.
10.

X
X
X

b. Current Activities
TAPI is continuing to print and distribute immunization materials to public and private providers
throughout the state, and updating web site and print materials to keep current with established
immunization recommendations and practices. TAPI is planning and conducting at least ten
immunization workshops for staff of public and private clinics, medical offices, schools and other
VFC enrolled sites. TAPI is developing an educational program for childcare centers on the
importance of immunizations. They are also meeting with managed care plans to promote and
institute methods to ensure local health departments are reimbursed vaccine administration costs
for AHCCCS enrolled children. TAPI is working with immunization service providers to ensure
immunization services are available in underserved areas ("pockets of need") - locations where
children lack access to immunization services. TAPI is developing educational materials for new
parents on the importance of adult pertussis vaccines in protecting babies.
Other MCH programs continue to promote and monitor immunization status. Health Start
Community Health Workers and HRPP Community Health Nurses continue to monitor the
immunization status of the children enrolled in their programs and continue to promote and
facilitate immunizations. Bureau of Nutrition & Physical Activity coordinates statewide
immunization record screening and referral by WIC staff to ensure proper timing of shots in WIC
children.

c. Plan for the Coming Year
TAPI will continue to print and distribute immunization materials to public and private providers
throughout the state. TAPI will conduct additional trainings to certify Medics in immunization
delivery. TAPI will plan and conduct at least ten immunization workshops for staff of public and
private clinics, medical offices, schools and other VFC enrolled sites. TAPI will meet and confer
with managed care plans to promote and institute methods to ensure local health departments
are reimbursed vaccine administration costs for AHCCCS enrolled children. TAPI will work with
immunization service providers to ensure immunization services are available in underserved
areas ("pockets of need") - areas/locations identified where children lack access to immunization
services. TAPI will revise and update website and print materials as needed to keep current with
established Immunization recommendations and practices. TAPI will assist fire departments in
developing new clinics in underserved areas, and develop materials for new parents in hospitals
and childcare centers.
Health Start Program will obtain the most current immunization requirements and distribute to
contractors. A new immunization checklist will be required as part of the child's information in the
client chart. Program will continue to review each immunization record of each woman and child
up to age two to ensure immunizations are up to date.
The Community Health Workers will continue to provide education on the importance of
immunizations for the whole family and will direct them to immunization providers and other
resources within their community.
The HRPP Community Health Nurses will continue to monitor the immunization status of the

77

children enrolled in their program and continue to promote and facilitate immunizations. In order
to communicate with all clients the importance of maintaining the immunization schedule, many of
the HRPP Community Health Nurse are bilingual and if they are not bilingual they will continue to
utilize appropriate translation services.
Bureau of Women's & Children's Health will work with TAPI and ADHS Immunization Program to
help disseminate educational materials for new parents on the importance of adult pertussis
vaccines in protecting babies. The Office for Children with Special Health Care Needs will work
with TAPI and the ADHS Immunization Program to dissiminate educational materials that are
specific to children with special health care needs.
The Bureau of Nutrition & Physical Activity will continue to train WIC staff to screen and refer WIC
participants to receive the proper timing of the DtaP shots. The Office of Immunizations will
continue to provide screening and referral training to WIC staff.

Performance Measure 08: The rate of birth (per 1,000) for teenagers aged 15 through 17
years.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and
Performance Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source

2005

2006

2007

2008

2009

35
34.1
4179
122496

35
34.0
4450
130905

34
32.3
4361
134897

33
30.3
4151
137022
AZ Birth
Certificates

32
25.3
3501
138280
AZ Birth
Certificates

2010
23.5

2011
23

2012
22.5

Final
2013
22

Final
2014
21.5

Check this box if you cannot report
the numerator because
1.There are fewer than 5 events
over the last year, and
2.The average number of events
over the last 3 years is fewer than 5
and therefore a 3-year moving
average cannot be applied.
Is the Data Provisional or Final?
Annual Performance Objective

Notes - 2008
The 2008 data was not available prior to completion of the narrative sections in this grant.
Notes - 2007
2007 data are not yet available. The rate is provisionally set at the 2006 rate until the data
becomes available in Fall 2008.
a. Last Year's Accomplishments
In 2009, the Bureau of Women's and Children's Health Teen Pregnancy Prevention Program
funded 13 of the 15 Arizona county health departments with lottery revenue to provide Teen
Pregnancy Prevention programming to youth and parents. The program also provided funding to
the Navajo Nation directly while three other tribes (Tohono O'odham San Lucy District, Fort
McDowell, and Colorado River Indian Tribe) were funded through a contract with the Inter-Tribal
Council of Arizona. A total of 11,636 youth and 218 parents received services in 2009.

78

Many funded programs implemented a youth development/service learning focus and/or provided
parent education related to talking with your teens about responsible sexual health through the
use of evidence-based/promising practices curricula. Programs reached high risk youth by
developing successful partnerships with county juvenile probation offices in order to encourage
participation among youth on probation. Some programs provided classes in juvenile detention
centers. One program implemented a sexual health text messaging system known as "Sex FYI"
that informs young people about sexual health resources available in the community.
Seven abstinence programs were federally funded until June 30, 2009, and continued providing
services with funding from Arizona lottery dollars. Projects focused on youth
development/service learning and peer leadership as well as classroom instruction. From July
2008 through June 2009, 4,479 young people and 181 parents received services.
Arizona participated in a roundtable sponsored by the National Campaign to Prevent Teen and
Unplanned Pregnancy on teen pregnancy and youth in foster care. The state agency responsible
for oversight of the foster care system has incorporated training on sexual health of teens in their
direct staff training.

Table 4a, National Performance Measures Summary Sheet
Activities
1. The Teen Pregnancy Prevention Program provides a youth
development/service learning program to Juvenile Probation
Youth and other high risk youth.
2. The Teen Pregnancy Prevention Program provides parent
education on how to talk to teens about responsible sexual
behavior.
3. The Teen Pregnancy Prevention Program provides technical
assistance to providers of teen pregnancy prevention services.
4. The Teen Pregnancy Prevention Program provides abstinence
education programming.
5.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X

X

X
X

b. Current Activities
The ADHS Teen Pregnancy Prevention Program continues to use lottery dollars to fund the 13
county health department projects and four tribal projects as described above. The Program is
working on adding two more tribal programs through the Inter-Tribal Council of Arizona.
Abstinence Education programs describe above also are continuing.
ADHS is providing technical assistance to community organizations applying for federal
comprehensive teen pregnancy prevention grants (Replication of Evidence-Based Program and
Promising Practices.) ADHS will coordinate with all funded agencies to best maximize our
funding and explore establishment of a statewide coalition.
Teen Pregnancy Prevention program continues to work with the Office of HIV, STD, and Hepatitis
Services to integrate STD prevention in programming.

79

c. Plan for the Coming Year
Lottery revenue is expected to continue and ADHS will continue to fund the existing county health
department, tribal programs, and abstinence education. ADHS Bureau of Women's & Children's
Health plans to apply for the federal Abstinence Education funding that was reauthorized through
the federal Affordable Car Act, as well as the new Personal Responsibility Education Program
(PREP). ADHS plans to target high risk populations such as youth in foster care, teen parents,
Latinos, African Americans, and males using PREP funds.
With the new infusion of federal funds for teen pregnancy expected in 2010, ADHS will convene
and coordinate with any new providers.
The Teen Pregnancy Prevention Program will work with Office for Children with Special Health
Care Needs to identify how to best address sexual health issues among this population.

Performance Measure 09: Percent of third grade children who have received protective
sealants on at least one permanent molar tooth.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and Performance Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source

2005
25
36.2

2006
36.5
36.2

2007
36.5
36.2

Check this box if you cannot report the
numerator because
1.There are fewer than 5 events over the
last year, and
2.The average number of events over the
last 3 years is fewer than 5 and therefore a
3-year moving average cannot be applied.
Is the Data Provisional or Final?
Annual Performance Objective

2010
47.1

2011
47.1

2012
47.1

2008
36.5
36.2

2009
36.5
47.1

AZ Office of
Oral Health
survey

AZ Office of
Oral Health
survey

Final
2013
47.1

Final
2014
47.1

Notes - 2009
The Healthy Smiles Healthy Bodies survey was conducted for a random sample of 3rd Grade
students in 2009. It is important to note that some differential misclassification bias may have
occurred during the visual examination for sealants. The ADHS Office of Oral Health received
some reports of oral health examiners having difficulty telling the difference between a sealant
and resins on molars. This threat to the validity of the estimate will be corrected prior to the next
survey in 2015.
Notes - 2008
The figure for 2008 is from a statewide oral health survey of over 80 communities, for 1999-2003.
This survey will be re-done for each needs assessment year, with the next survey scheduled for
2010.
Notes - 2007

80

The figure for 2007 is from a statewide oral health survey of over 80 communities, for 1999-2003.
This survey will be re-done for each needs assessment year, with the next survey scheduled for
2010.
a. Last Year's Accomplishments
The Arizona Dental Sealant Program provided dental screenings and referrals to 9,164 children
attending eligible public schools; 7,362 children received 25,406 dental sealants. Eligible
schools are those with at least 65 percent of students participating in the National School Lunch
Program (free/reduced lunch program). Students may participate if they attend an eligible school,
are in 2nd or 6th grade, have informed parental consent, and do not have private dental
insurance. Uninsured children, Medicaid and SCHIP beneficiaries, those covered by Indian
Health Services or by state-funded tobacco tax health care program are eligible to receive
sealants. In an effort to increase the rate of returned consent forms, individual informational
meetings were held with nurses in eight participating schools. The results demonstrated that
these informational/ educational meetings did not increase the number of children who
participated in the program.

Table 4a, National Performance Measures Summary Sheet
Activities
1. Office of Oral Health provides dental sealants to high-risk
children.
2. Office of Oral Health evaluates the dental sealant program.
3. Office of Oral Health collaborates with key stakeholders to
expand services.
4. Office of Oral Health is piloting teledentristry sites
5.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X
X

b. Current Activities
The Office of Oral Health continues to provide a school-based sealant program in six Arizona
counties. The program has been discontinued in one county due to lack of dental providers and
contracting difficulties. Lack of dental providers in rural areas is a barrier to expansion to rural and
underserved populations. One strategy for expansion in rural areas is the introduction of three
pilot teledentistry sites through the current HRSA Oral Health Workforce Grant. In an effort to
increase student participation, several new incentive programs were implemented in selected
schools. In an effort to increase the proportion of public schools served by the program, the
previous school eligibility requirement of 65% National School Meal Program enrollment will be
reduced to 50% beginning in the 2010-11 school year, thereby expanding the program to schools
not previously qualified to participate. After 20 years of fairly steady growth, the program has
seen a plateau and there is evidence that there has been a decrease in the number of children
served by the sealant program. This may be attributed to several factors including the increasing
presence of "for profit" dental vans, and the reluctance of parents/guardians to sign consent
forms. The Office of Oral Health completed a statewide oral health, BMI and asthma survey of
over 3,100 third grade children in 2010, the Healthy Smiles Healthy Bodies Survey.

c. Plan for the Coming Year
The Arizona Dental Sealant Program will continue to provide school-based dental sealant
programs to high risk children in eligible public schools throughout Arizona. The focus is to

81

identify those children who are at highest risk of decay and increase the number and proportion of
children served. Collaborations and outreach to expand the program to new service areas will
continue. In an effort to increase the proportion of public schools served by the program, the
current school eligibility requirement of 65% National School Meal Program enrollment will be
reduced to 50% beginning in the 2010-11 school year, thereby expanding the program to schools
not previously qualified to participate. The Office of Oral Health will review the efficiency of the
dental sealant program and make recommendations for improvement. New teledentistry sites
being established through the HRSA grant will increase to four active sites in 2011. This model
will be evaluated for effectiveness and future potential to deliver services to rural areas.
The Office for Children with Special Health Care Needs will work with the Office of Oral Health on
how best to provide dental sealants to children with special health care needs when they are
identified to be at risk of decay.

Performance Measure 10: The rate of deaths to children aged 14 years and younger caused
by motor vehicle crashes per 100,000 children.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and
Performance Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source

2005

2006

2007

2008

2009

5
4.2
56
1347557

4.2
4.0
55
1390127

4
4.0
57
1412725

4
2.7
39
1429459
AZ Death
Certificates

3.8
3.5
50
1434985
AZ Death
Certificates

2010
3.5

2011
3.4

2012
3.3

Final
2013
3.2

2014
3.1

Check this box if you cannot
report the numerator because
1.There are fewer than 5 events
over the last year, and
2.The average number of events
over the last 3 years is fewer
than 5 and therefore a 3-year
moving average cannot be
applied.
Is the Data Provisional or Final?
Annual Performance Objective

Notes - 2009
The rate increased 29.6 percent from 2008, but this was not a significant increase as the total
counts for mortality are low (p=0.25). The 2008 rate may have been a historical anomaly because
of the effect of the economic recession and spike in summer gas prices on total per capita miles
driven.
Notes - 2008
Data for 2008 were not available when the descriptive analyses and program narratives were
completed. Estimates for 2001 on reflect motor vehicle death rates for all children ages 0-14.
Prior to 2001, estimates were based on ages 1-14.
Notes - 2007

82

Data for 2007 are not yet available. The estimate for 2007 is provisionally set at the 2006 rate
until data become available in the Fall of 2008. Estimates for 2001 on reflect motor vehicle death
rates for all children ages 0-14. Prior to 2001, estimates were based on ages 1-14.
a. Last Year's Accomplishments
The Child Fatality Review Program identified 82 deaths among children in Arizona due to motor
vehicle crashes in 2008, a significant decline from previous years. Fifty-seven percent of the
victims were children ages 14 years and younger (n=47). Twenty-seven children were killed in
crashes involving alcohol and/or drug impaired drivers. Thirty-one children were not properly
restrained in vehicles. Fifty-two percent of the children who were not properly restrained were
ages 14 years and younger (n=16). The most frequent contributing factors to all motor vehicle
crash deaths during 2008 were lack of vehicle restraints, drugs and/or alcohol, and excessive
driving speed.
Under previous grant funding Navajo County Public Health formed the Community Health Injury
Prevention Program (CHIPP). The CHIPP program reaches all areas of both Apache and Navajo
counties providing car seat and seat belt education to all residents. One of the primary focuses of
this grant has been to raise vehicle safety awareness among Native Americans. Navajo County
provided Indian Health Services (HIS) with assistance to enhance their existing car seat/seat belt
safety program by providing the funding for tribal staff to receive and continue training as Child
Passenger Safety Technicians. Navajo County subcontracted with the Navajo Tribe to provide
car seats and they provide the safety technicians to instruct the courses and safety checks.
Navajo County attended the Hopi Tribe's car seat coalition and provided them with seats and
assisted with the Tribe's car seat clinics. During 2009, 271 Native American participants
completed the alcohol portion of the car seat safety course, and 113 completed the car seat
safety course. During 2009, Navajo County provided 257 residents with car seat safety course
consisting of checking current seats and installations, video discussion and seat overview, having
them properly install and adjust the seat for their child. Booster seat education consisted of six
major booster campaigns that provided 330 children with booster seat assessments and 387
parents received education on importance of booster seat use. Apache County provided classes
to 308 preschool and kindergarten children on proper use of booster seats; a total of 373 fourth
and sixth graders received injury prevention classes related to seat belts, skateboards, bus, bike,
sports and gun safety.
Title V funds helped Maricopa County Integrated Health System to reach 2,248 parents and
caregivers with information and education about preventing transportation related injury. In
addition, 64 medical residents have completed a child passenger safety education module during
clinical rotations to educate families in the emergency room and at birth.
The Health Start Program funded eight Community Health Workers to attend Car Seat Safety
Technician training and nine to receive recertification training. The Community Health Workers
provided 10 car seat safety education classes and educated over 150 pregnant women and their
families.
The Injury Prevention Program built capacity for child passenger safety through providing certified
car seat training, particularly in tribal communities. The program worked with Indian Health
Services to update and evaluate the Safe Native American Passengers curriculum, and offered a
CEU training on using car seats for Arizona's Child Passenger Safety Technicians. The Injury
Prevention Program also collaborated on a Road Safety Audit with Az Dept of Transportation to
improve safety in a tribal community.
An ATV Stakeholders Group was formed and outcomes included collaboration among partners
from healthcare, emergency services, law enforcement, recreation, and users to develop a
Governor's Proclamation and individual awareness activities.
Injury Prevention Program assisted the Governor's Office of Highway Safety in developing a
database to track course and student information for the Children Are Priceless Passengers

83

(CAPP) program. The program offers a child restraint education course and child restraint
distribution to students cited by law enforcement for transporting an improperly restrained child.
The course is also presented as a low-cost means for obtaining and child restraint and education
on the use of the restraint.

Table 4a, National Performance Measures Summary Sheet
Activities
1. Child Fatality Review Program reports on motor vehicle
crashes among children.
2. Title V Community Health Grants provides child car seat
safety education
3. Injury Prevention Program provides car seat safety technician
training.
4.
5.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X

b. Current Activities
The 16th annual Child Fatality Review annual report recommends that legislation be reintroduced in the 2010 session related to reduction of motor vehicle crash deaths, including a
proposed enactment of booster seat legislation and primary seatbelt legislation. The annual
report recommends enhanced law enforcement and education efforts regarding the dangers
associated with children riding or driving all terrain vehicles. The Child Fatality Review Program
will review the deaths of children due to all causes, including motor vehicle crashes. The Child
Fatality Review Program will continue to provide specialty data reports for local, statewide, and
national initiatives to reduce preventable child fatalities.
The Title V Community Health Grant Program continues to fund the four contractors through 2010
that are addressing motor vehicle crashes among children and promoting vehicle safety.
The Injury Prevention Program builds capacity for child passenger safety through providing
certified training and continuing education for recertification. Courses will add 40-50 more
technicians throughout Arizona. The program is also collaborating with OCSHCN to ensure
Children's Rehabilitative Clinics are connected to car seat safety technicians trained in special
needs child safety seats. The Injury Prevention Program collaborates with AZ Dept of
Transportation in conducting Road Safety Audits.

c. Plan for the Coming Year
The Child Fatality Review Program will continue to review the deaths of all children in Arizona to
identify preventable factors and to conduct surveillance of the causes and circumstances
surrounding these deaths. The 17th annual report will be produced in 2010 and will include
information on the deaths that occurred in Arizona during 2009. The Child Fatality Review
Program will analyze any trends observed due to the enactment of graduated driving license
restrictions for teen drivers (enacted July 1, 2008).
Health Start will continue to fund Car Seat Safety Technician and recertification training for

84

Community Health Workers.
HRPP Community Health Nurses will continue to monitor car seat usage with every home visit
and continue to educate the families on the importance of car seat usage.
The Injury Prevention Program will continue to build capacity in the state by training new car seat
safety technicians.
The Injury Prevention Program will continue to lead the ATV stakeholder's to address morbidity
and mortality among youth.
The Injury Prevention Advisory Council and Injury Prevention Program will be updating the state
injury prevention plan. The Bureau of Women's & Children's Health will consider which strategies
the bureau's programs can help implement, and whether any strategies would benefit from Title V
funding.

Performance Measure 11: The percent of mothers who breastfeed their infants at 6 months
of age.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and
Performance Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source

2005

2006

2007

2008

2009

37.6

38
46.5

38
43.7

50
48.2

50
45.3

CDC National
Immunization
Survey

CDC National
Immunization
Program

Final
2013
54

Final
2014
55

Check this box if you cannot report
the numerator because
1.There are fewer than 5 events
over the last year, and
2.The average number of events
over the last 3 years is fewer than
5 and therefore a 3-year moving
average cannot be applied.
Is the Data Provisional or Final?
Annual Performance Objective

2010
53

2011
53

2012
54

Notes - 2009
The CDC National Immunization Survey data for 2009 (2006 birth cohort) uses a small sample
size, thus the confidience intervals for the 2009 estimate are wide (+/- 7.4) . The estimate is not a
statisitcally significant difference from 2007, nor is it significantly different from the U.S. rate of
43.4.
Notes - 2008
The CDC National Immunization Survey data for 2008 (2005 birth cohort) became available after
all program narratives and data analyses were completed.The survey used a smaller sample size
than was used in previous years, thus the confidience intervals for the 2008 estimate are wide
(+/- 6.1) and the estimate is not a statisitcally significant difference from 2007. In addition the
survey had fewer than 100 respondents from Maricopa County--Arizona's largest county.

85

Prior to 2006 the source of this performance measure was the "Mother's Survey", Ross Products
Division, Abbott Laboratories, Inc.
Notes - 2007
Source: The CDC National Immunization Survey ; Table 2. Geographic-specific Breastfeeding
Rates among Children born in
2004(http://www.cdc.gov/breastfeeding/data/NIS_data/data_2004.htm). Prior to 2006 the source
of this performance measure was the "Mother's Survey", Ross Products Division, Abbott
Laboratories, Inc.
a. Last Year's Accomplishments
The Health Start Program educated pregnant and postpartum women about prenatal care,
nutrition, and the benefits of breastfeeding. Community Health Workers received training on
breastfeeding and many other topics. The program increased outreach to the most vulnerable
populations, Native Americans and African Americans, in targeted communities to focus on new
prenatal enrollments. Approximately 73% of the prenatal clients committed to breastfeeding their
baby in 2009.
The High Risk Perinatal Program (HRPP) contracted with every Newborn Intensive Care Unit
(NICU) in the state. Each NICU had a lactation consultant available to help encourage and
support breastfeeding. The hospitals also facilitated the use of a breast pump for mothers of
infants unable to breastfeed at that time. When mothers were discharged they were able to either
contact the NICU with concerns about breastfeeding or discussed the concern with the HRPP
Community Health Nurse during a home visit. Many of the Community Health Nurses are
Certified Lactation Consultants.
The Title V and WIC funded Pregnancy & Breastfeeding & WIC Hotlines were staffed by two
bilingual Certified Lactation Consultants who answered 632 calls from around the state with
concerns about breastfeeding. BWCH and WIC worked together to ensure that an International
Board Certified Lactation Counselor is available to answer all breastfeeding questions after
normal business hours and to answer technical questions 24 hours a day, seven days a week.
The Arizona Department of Health Services (ADHS), Bureau of Nutrition and Physical Activity
continues the statewide coalition called LATCH-AZ, which aims to serve as an umbrella coalition
to bring together breastfeeding advocates with the WIC community and provide educational and
networking opportunities.
Scholarships to lactation courses were offered to WIC staff and selected community partners and
CLC training was provided to 180 WIC and Community partners. Funding was increased to a total
of seven WIC agencies to continue breastfeeding peer counseling programs. Additional breast
pumps have been purchased for the breast pump loan program through WIC so that wait lists can
be avoided and Lactina hospital grade pumps are made available to WIC participants in addition
to the Medela Pump-In-Style to support mom's returning to work or school.
In 2009, the Arizona Nutrition Network had two partners (Navajo Area Agency on Aging and Teen
Outreach Program) that conducted 4,862 breastfeeding interventions, including contacts, support,
and educations.
WIC has eight new International Board Certified Lactation Counselor s among Arizona WIC staff.
The Nurse Family Partnership program in Yavapai County is partly funded through a Title V
Community Health Grant. The Nurse Family Partnership program is an evidence-based national
program that provides education and support for first time mothers through regular home visits
from a public health nurse. Each participant received education and support related to
breastfeeding. Of all infants born to mothers participating in the program, 100% were

86

breastfeeding at the time of discharge from the hospital.
The Office of Oral Health's initiative of First Dental Visit by Age One promoted breastfeeding and
discouraged use of sippy cups as well as having infant off bottle by age one.

Table 4a, National Performance Measures Summary Sheet
Activities
1. Health Start Community Health Workers educate pregnant
and postpartum women about breastfeeding.
2. Baby Steps Program educates hospitals on evidence-based
maternity care practices that support breastfeeding.
3. HRPP Community Health Nurses assisted with breastfeeding.
4. Bilingual Certified Lactation Consultants answer Pregnancy
and Breastfeeding Hotlines.
5. WIC conducts free lactation education and networking events
and provided scholarships for training.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X
X
X

b. Current Activities
The High Risk Perinatal Program (HRPP) contracts with every Newborn Intensive Care Unit
(NICU) in the state. When mothers are discharged they can contact the NICU with concerns
about breastfeeding or discuss the concern with the HRPP Community Health Nurse during a
home visit.
The Hotlines are staffed by two bilingual Certified Lactation Consultants who answer calls
regarding breastfeeding. An International Board Certified Lactation Counselor is available to
answer all breastfeeding questions after normal business hours and to answer technical
questions 24 hours a day, seven days a week.
The 5-year Breastfeeding Strategic Plan has been finalized and distributed to WIC and
community partners. Free, quarterly lactation education is provided to urban and rural health
professionals and paraprofessionals through LATCH-AZ.
ADHS received Communities Putting Prevention to Work Grant to help hospitals in Arizona
implement five maternity care practices that have the greatest impact on breastfeeding duration.
Arizona Baby Steps for Breastfeeding Success includes social marketing initiative that focuses on
peer support, professional support, and maternal education.
Bureau of Nutrition & Physical Activity and Office for Children with Special Health Care Needs
(OCSHCN) are working together to produce videos for child care centers on breastfeeding, infant
nutrition, physical activity, and family style meals. Modules will address children with special
health care needs.

c. Plan for the Coming Year
The Health Start Program will continue to provide access to breastfeeding education classes so
that Community Health Workers have the knowledge and training to promote and encourage all

87

clients to commit to breastfeeding.
The Program will increase the number of Community Health Workers that are certified
breastfeeding counselors, certified lactation counselors and certified breastfeeding educators.
HRPP will continue to contract with every NICU in the state. Each NICU has a lactation
consultant available to help encourage and support breastfeeding. The hospitals will also
continue to facilitate the use of a breast pump for mothers of infants who are still too ill to
breastfeed. When mothers are discharged they will be able to either contact the NICU with
concerns about breastfeeding or discuss the concern with the HRPP Community Health Nurse
during a home visit. Many of the Community Health Nurses are Certified Lactation Consultants.
The Title V and WIC Hotlines will continue to be staffed by two bilingual Certified Lactation
Consultants who will answer calls from around the state with concerns about breastfeeding. An
International Board Certified Lactation Counselor will be available to answer all breastfeeding
questions after normal business hours and to answer technical questions 24 hours a day, seven
days a week.
The breast pump loan program will continue to be a service through WIC local agencies. Peer
counseling services will be provided through selected local WIC agencies and expanded to serve
all counties. WIC staff from local agencies will perform outreach efforts through the "Adopt a
Doctor" program. This involves having staff visit clinics and to inform providers about WIC
breastfeeding support. The state will support this initiative by tracking visits and providing
materials for local agencies to use in this effort.
Bureau of Nutrition & Physical Activity will provide training to hospitals for the Baby Steps
Initiative. They will also provide Train the Trainer to interested partners, such as Indian Health
Services.
OCSHCN will explore if the videos developed for childcare centers can be more widely distributed
to provide education to other community partners on breastfeeding, infant nutrition, physical
activity, and family style meals for families of CSHCN.Pending adoption of final rules revisions for
licensed child care centers, as of November 1, centers will have enhanced accommodations for
breastfeeding mothers and children with special health care needs. WIC will be launching
Introduction to Breastfeeding Course to all WIC staff.
ADHS will be producing 30 second commercials promoting breastfeeding and how to involve
dads and grandparents.

Performance Measure 12: Percentage of newborns who have been screened for hearing
before hospital discharge.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and
Performance Data
Annual Performance
Objective
Annual Indicator
Numerator
Denominator
Data Source

2005

2006

2007

2008

2009

98.5

98.8

97

97

98

98.2
94750
96487

96.3
98363
102095

95.4
97986
102687

98.3
97496
99215
AZ Early
Hearing
Detection and
Intervention

98.4
91824
93314
AZ Early
Hearing
Detection and
Intervention

88

Prog.
Check this box if you cannot
report the numerator
because
1.There are fewer than 5
events over the last year, and
2.The average number of
events over the last 3 years
is fewer than 5 and therefore
a 3-year moving average
cannot be applied.
Is the Data Provisional or
Final?
Annual Performance
Objective

Prog.

Final
2010
100

2011
100

2012
100

2013
100

2014
100

Notes - 2008
All 49 birthing hospitals in Arizona continue to voluntarily screen for hearing and follow the
mandate to report initial and subsequent screens. Of the infants not screened prior to hospital
discharge, 44 % returned for outpatient screens, most within 30 days.
Notes - 2007
The data reported are estimated from 45 of 49 birthing hospitals. There are now 49 reporting
hospitals; 48 birthing facilities and 1 children's hospital that provide screens to neonatal intesive
care unit infants. All sites voluntarily screen and are mandated to report data weekly. Although
97, 986 infants were screened prior to hospital discharge, another 475 were given an initial
screen as part of outpatient services. This occurred because some infants were transferred prior
to screening.
a. Last Year's Accomplishments
Arizona is surpassing the Healthy People 2010, Object 28-11 goal of screening 90% of all infants
by one month of age, as 98.4% (91,824) of those babies born in Arizona in 2009 received a
hearing screen prior to discharge. All 49 birthing hospitals continue to voluntarily screen for
hearing and follow the mandate to report initial and subsequent screens. Of the infants not
screened prior to hospital discharge, 56% returned for outpatient screens, most within 30 days.
The Arizona Early Hearing Detection and Intervention (AzEHDI) program has made significant
progress in several areas over the past year. Most notably are changes in the Arizona
Department of Health Services (ADHS) follow-up program, education of audiologists, medical
home providers and hospital programs, development of a Guide By Your Side (GBYS) program
through the Arizona Chapter of Hands and Voices and expansion of the involvement of
stakeholders in the EHDI process. Hearing screening is mandated in all private, public,
transitional, and charter schools in Arizona.
In 2009 the Arizona Department of Health Services, Sensory Program used Title V funding to
contract with University of Arizona Train the Trainer (T3) Program to provide Vision Screening
training, in addition to Hearing Screening. During school year 2009, 19 new T3 hearing and vision
screening trainers were trained and approximately 760 hearing screeners were trained. In the
school year 2008-2009, 535,001students were screened and 1,259 were identified for the first
time with a hearing disorder. The Sensory Program monitors school compliance with the Arizona
Hearing Screening Rules. The Program loans hearing screening equipment to schools upon
request. The Program also is responsible for ensuring this equipment has been properly
calibrated and repaired if needed.
The Sensory Program participated in the Statewide Vision Screening Initiative. This taskforce was

89

convened by Vision Quest 20/20 in partnership with St. Luke's Health Initiative and the Arizona
Department of Health Services. Members invited to attend task force meetings included
representatives from Vision Quest 20/20, the Sensory Program, the Arizona Department of
Education, Arizona School for the Deaf and Blind, the Arizona School Nurse Consortium, the
School Nurse Organization of Arizona, optometrists, ophthalmologists, and others. The taskforce
developed recommendations for promoting better children's vision health.
ADHS reviewed with licensed midwifes regarding who is completing the hearing screening
following the infant's birth. Thus far only 1 midwife is completing the hearing screening tests. The
remainder of the midwives have been provided information regarding where to obtain the testing
or are referring the families to a pediatrician or hospital facility for review of the newborns ability to
hear.

Table 4a, National Performance Measures Summary Sheet
Activities
1. Newborn Screening Program provided on-site technical
assistance and training for hearing screening.
2. Newborn Screening Program is enhancing education for
parents and providers.
3. Sensory Program collaborated with the University of Arizona
to train hearing screening trainers.
4. Sensory Program disseminated information about mandatory
school hearing screening and ADHS Rules.
5. Sensory Program purchased, repaired and calibrated hearing
screening equipment to loan to Arizona’s Schools.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X
X
X

b. Current Activities
The ADHS Newborn Screening follow-up team continues work to determine small tests of change
that might impact the number of families who are able to meet the 1-3-6 goals. Changes in the
program that have been tested and found effective include: close contact with hospital screening
programs to ensure that state follow-up efforts are focused on those infants who are not already
in the screening or diagnostic process; on-site technical assistance to screening programs
incorporating strategies to ensure that screeners more accurately record the disposition of infants
including transfers, deceased, parental refusals; scheduled rescreens and inpatient versus
outpatient screening results; and optimizing the timing of calls to hospitals versus parents or
medical home providers. As well, increased focus of follow-up efforts on those who are
considered at greater risk will be assessed, including those who have failed a two stage screen
and those who referred on an inpatient screen and had a neonatal intensive care unit stay of
greater than 5 days.
Office for Children with Special Health Care Needs (OCSHCN) is working with the state's
InteragencyCoordinating Council to identify who does follow-up hearing screening and what
resources exist for families with children ages 0-5. Survey results should be complete by the end
of summer. OCSHCN and AzEHDI are offering online training for hospital-based hearing
screeners.

90

c. Plan for the Coming Year
Through continuous education and data analysis, our goals are to reduce the numbers of batched
and unsatisfactory specimens received, and to refine the positive and negative predictive values
of analytes, thereby improving testing specificity. Also, through culturally sensitive materials,
continue to educate parents about the need for a second screen, timely referrals to specialists,
and access to CRS, OCSHCN, AzEIP, and other local resources. Performance measures will be
reviewed to ensure laboratory standards are met. Reviewing and updating brochures as well as
expanding provider educational materials are planned. As new disorders are added or analyte cut
off values changed, materials will be revised. Internal employee training manuals will be updated,
and continuous education on evidence based laboratory and case management services will be
explored.
The Sensory Program will continue to utilize Title V funding to train hearing and vision screening
trainers, disseminate newsletters to all known schools, and continue to provide technical
assistance to school health nurses. The Sensory Program will work with Vision Quest 20/20 and
other stakeholders to continue implementation of recommendations to improve vision screening
in Arizona.
The Midwife Licensing Program will set up training for midwifery community with the Newborn
Screening Program as new information comes available.
Community Health nurses and Health Start workers will review hearing screening results with
parents. BWCH will work with home visiting programs to determine how programs can enhance
review of hearing screening. BWCH will work on getting midwives the Arizona Parent Kit to
provide to parents who do home birth.
OCSHCN and the AzEIP Interagency Coordinating Council survey that identifies who does followup hearing screening and resources for families with children ages 0-5 will be disseminated.
OCSHCN directs families to the Ear Foundation for hearing aids, cochlear implant batteries,
repairs and audiology testing for children. OCSHCN and AzEHDI will partner with North Dakota to
use the North Dakota hearing telemedicine protocol developed under a HRSA grant.

Performance Measure 13: Percent of children without health insurance.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and Performance Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source

2005
14
16.7

2006
14.5
17

2007
16.5
17

Check this box if you cannot report the numerator
because
1.There are fewer than 5 events over the last year,
and
2.The average number of events over the last 3
years is fewer than 5 and therefore a 3-year moving
average cannot be applied.
Is the Data Provisional or Final?
Annual Performance Objective

2010
15.8

2011
15.6

2012
15.4

2008
16.3
13.8

2009
16
16

US
Census

US
Census

Final
2013
15.2

Final
2014
15

91

Notes - 2009
Because of ongoing budget shortfalls, Arizona has frozen enrollement in the state S-CHIP
(KidsCare). The freeze and continuing recession may result in a greater proportion of children
without health insurance during future reporting periods.
Notes - 2008
Estimates were revised based adjustments made by the US Census
(http://www.census.gov/hhes/www/hlthins/historic/hihistt5.xls). The point estimate has a standard
error of 1.50. The final data estimate for 2008 not yet available.
Notes - 2007
Estimates were revised based adjustments made by the US Census
(www.census.gov/hhes/www/hlthins/historic/hihistt5.html). Data for 2007 not yet available. The
estimate for 2007 is provisionally set at the 2006 estimate until the data become available in the
Fall of 2008..
a. Last Year's Accomplishments
Bureau of Women's & Children's Health provided Title V funding to the Medical Services Project.
Administered through the Arizona Chapter of the American Academy of Pediatrics, the Medical
Services Project was designed to increase access to and utilization of primary care services for
Arizona's uninsured children from low-income families. The Medical Services Project provides
delivery of medical services in participating physicians' offices to children without health
insurance and to those who do not qualify (or are in the process of qualifying) for public
assistance. The Medical Services Project creates a system of linkages between medical
providers and school nurses to assist with health care provision to the target population. School
nurses identify children who are eligible to participate in the Medical Services Project and
facilitate their enrollment. To be eligible for the Medical Services Project a child must have no
health insurance, must not be eligible for AHCCCS, KidsCare, or Indian Health Services; and
must have a household income less than 185 percent of the federal poverty level. For children
who appear to be eligible for AHCCCS or KidsCare, the school nurse is encouraged to identify
resources to assist families with the application process. A child with an acute illness may be
seen through the Medical Services Project while in the qualifying process. The child is provided
with a referral form to a participating health care provider and the school nurse makes the
appointment.
A network of physicians (pediatricians, family practice physicians, and specialists) provides care
to children qualifying for the Medical Services Project for a fee of either $5 or $10 as payment-infull for an office visit. The health care providers agree to provide a certain number of appointment
slots to Medical Services Project children each month. In addition, prescription medications,
diagnostic laboratory services and eyeglasses are provided as necessary to qualifying children.
In 2009, the Medical Services Project served 242 individual children.
The Medical Services Project developed collaborative partnerships with the following
organizations: Keogh Foundation, Desert Community Health Center, Neighborhood Christian
Clinic, ASU School of Nursing, Arizona Health Care Cost Containment System, WellCare
Foundation, Arizona School Based Health Care Clinics, Health Care Connect, Maricopa
Integrated Health Services, Health Net Health Plan, Phoenix Children's Hospital, Mountain Park
Health Center and Scottsdale Healthcare Neighborhood Outreach Action (NOAH). By developing
collaborative partnership with these organizations, we are better able to assist Medical Services
Project (MSP)participants. Children who are not eligible for MSP are often referred to these
organizations for assistance. The High Risk Perinatal Program (HRPP) Community Health
Nurses assessed the health insurance status of each client throughout program enrollment.
Families were educated about the importance of establishing and maintaining a medical home
and assisted in overcoming the barriers to accessing health care. With every home visit the
Community Health Nurses assessed the insurance status of the family and assisted the family to

92

access insurance.
The Health Start Program Community Health Workers reviewed and assessed the health
insurance status of every client throughout enrollment in the program. Families were provided
assistance in applying for coverage and finding prenatal care providers in their community.
Approximately 26% of Health Start clients are without insurance.
Pregnancy & Breastfeeding/Children's Information Center Hotline assisted callers with accessing
Arizona's Medicaid health plan and linked them to needed services.

Table 4a, National Performance Measures Summary Sheet
Activities
1. Medical Services Project provides uninsured children with
health care service
2. Medical Services Project screen children for AHCCCS
eligibility and refer as appropriate.
3. HRPP Community Health Nurses educate the family on the
importance of maintaining a medical home.
4. High Risk Perinatal Program & Health Start assists families in
accessing health care
5. Hotline help families seeking health care to apply for AHCCCS
or find community services
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X
X
X

b. Current Activities
Medical Services Project continues to provide a network of physicians for uninsured children. The
project is currently operating in seven Arizona counties with 58 referring schools. The primary
care provider network consists of 28 active primary care providers, 17 active specialty care
providers (e.g. cardiology, dermatology, ears nose throat, orthopedics, pulmonology, and one
dentist). The Medical Services Project is coordinating a mapping of all health care clinics that
provide services to low income children so the project can target expanding into areas with the
fewest services.
The HRPP Community Health Nurses continue to assess the health insurance status of each
client. Families are educated about the importance of establishing and maintaining a medical
home and assisted in overcoming the barriers to accessing health care. The program works
closely with AHCCCS, Arizona's Medicaid agency, to ensure families receive coverage as quickly
as possible. Health Start Program also reviews and assesses the health insurance status of
clients. Families are linked to medical resources available in their community and encouraged to
establish a medical home.
The Pregnancy & Breastfeeding/Children's Information Center Hotline staff assists callers with
accessing Arizona's Medicaid health plan and links them to needed services.

c. Plan for the Coming Year

93

The Medical Services Project will continue to foster collaborative partnerships and link acute care
services to uninsured children. OCSHCN and the Medical Services Project will queary providers
to identify what information or resources are needed to provide a medical home for CYSHCN.
OCSHCN will develop resources, training, and information for school nurses to share with
families with CYSHCN who receive services through the Medical Services Project.
The HRPP Community Health Nurses will continue to assess the health insurance status of each
client throughout program enrollment. Families will continue to be educated about the importance
of establishing and maintaining a medical home and assisted in overcoming the barriers to
accessing health care. With every home visit the Community Health Nurses will continue to
assess the insurance status of the family and assist the family to access insurance.
The bilingual Pregnancy & Breastfeeding/Children's Information Center Hotline staff will continue
to assist callers with accessing Arizona's Medicaid health plan as well as providers that serve the
uninsured, and will link them to needed health and social services.
The Health Start Program and Family Planning Programs will continue to ensure all eligible
clients apply for insurance coverage through AHCCCS, the state's Medicaid agency.

Performance Measure 14: Percentage of children, ages 2 to 5 years, receiving WIC services
with a Body Mass Index (BMI) at or above the 85th percentile.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and Performance
Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source

2005

2006

2007

2008

2009

35.1
31345
89325

35
35.6
31537
88620

35
36.9
34535
93555

34.5
37.3
38670
103755
AZ WIC
Program
database

34.5
36.6
41859
114507
AZ WIC
Program

2010
34.5

2011
34

2012
34

Final
2013
34

Final
2014
34

Check this box if you cannot report the
numerator because
1.There are fewer than 5 events over the
last year, and
2.The average number of events over the
last 3 years is fewer than 5 and therefore
a 3-year moving average cannot be
applied.
Is the Data Provisional or Final?
Annual Performance Objective

a. Last Year's Accomplishments
The Bureau of Nutrition and Physical Activity Community Programs Team continues to work
closely with AHCCCS(Arizona Health Care Cost Containment System--Medicaid) in promoting
early intervention in childhood obesity and appropriate referrals for WIC children.
"Fit WIC" group classes and incentives in association with Arizona Nutrition Network continued in
21 Arizona WIC local agencies including nutrition and physical activity education curriculum for
healthy lifestyles after a successful pilot with Mariposa Community Health Center. The goals of
the Fit WIC program for children is to increase their physical activity through caregiver education;

94

introduce children to good nutrition; and stress the importance of physical activity through
activities in WIC.
WIC implemented new food package which incorporated fresh fruits and vegetables and whole
grains, and decreased amount of juice we provide to children. Hotline staff helped to disseminate
information about the new WIC package. Post implementation survey testing concluded that the
implementation of the new WIC food package has increased overall consumption of fruits and
vegetables by 30% among WIC participants.
Pima County child care health consultants provided 34 encounters providing technical assistance
to child care centers related to nutrition.
The Office of Oral Health provided Train-the-Trainer modules to teachers and care providers in
child care settings including Navajo Nation and White Mountain Apache Head Start staff and
administration and all Head Start grantees in Maricopa County. The modules educated child care
providers on the importance of the role of fermentable carbohydrates and appropriate feeding
practices. Educational materials included posters and brochures outlining appropriate feeding
practices.

Table 4a, National Performance Measures Summary Sheet
Activities
1. Continue Fit WIC programs
2. Empower Program sets standards related to obesity
prevention for child care providers
3. WIC outreach focuses on promoting healthy lifestyles.
4.
5.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X

b. Current Activities
ADHS is implementing the new Empower Program with licensed child care providers. Title V,
tobacco tax, and WIC lottery dollars are being used to incentivize licensed child care providers to
adopt 10 standards promoting physical activity, healthy eating, and tobacco prevention in
exchange for reduced licensing fees. ADHS child care surveyors monitor whether providers are
implementing the standards. ADHS is also revising its administrative rules for child care centers
to incorporate many of the standards.
Bureau of Nutrition and Physical Activity and Office for Children with Special Health Care Needs
(OCSHCN) are producing videos for child care centers on breastfeeding, infant nutrition, physical
activity, and family style meals. Modules address children with special health care needs.
First Things First Child Care Health Consultants are incorporating Empower into their curriculum.
Pima County child care health consultants continue providing technical assistance to child care
centers.
Arizona WIC continues to work closely with Arizona Nutrition Network (AZNN) and the "Grow a
Healthy Child" campaign. The integrated marketing campaign includes AZNN, Arizona WIC, and
Nutrition and Physical Activity Program (NUPA). Other campaigns include "Fruits and Veggies --

95

More Matters", Physical Activity, and "Go Low".
Arizona State WIC has completed branding and distribution of new emotion-based education
materials for obesity prevention.

c. Plan for the Coming Year
ADHS will evaluate new Empower Program and disseminate results nationwide. As new child
care rules take effect that incorporate current Empower standards, ADHS will work with partners
to determine how to build upon the current standards with additional developmental standards
appropriate for child care centers.
The Bureau of Nutrition & Physical Activity will continue to assist Health Care Providers in
Arizona in counseling and referring children to overweight prevention programs. Common
statewide prevention messages will be developed and distributed. OCSHCN will partner on
creating nutrition curriculum that will be developed for the management of overweight and obesity
in children with special healthcare needs with emphasis of coordinated efforts in the management
of energy needs in WIC children on tube feeds or supplemental nutrition products.
ADHS Nutrition & Physical Activity Program will be working on revision of state plan with
stakeholders. Intent is to make state plan consistent with Let's Move Initiative and White House
Report on Prevention of Childhood Obesity. OCSHCN will help to identify information specific to
CYSHCN.
Bureau of Nutrition & Physical Activity will provide Hotline staff enhanced education to talk to
callers about childhood nutrition.
The Office of Oral Health will continue to facilitate training additional "master trainers," to provide
materials and expand the training on appropriate feeding practices to additional counties through
the regional Oral Health Coordinators and First Things First.

Performance Measure 15: Percentage of women who smoke in the last three months of
pregnancy.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and Performance
Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source
Check this box if you cannot report
the numerator because
1.There are fewer than 5 events over
the last year, and
2.The average number of events over
the last 3 years is fewer than 5 and
therefore a 3-year moving average
cannot be applied.
Is the Data Provisional or Final?

2005

2006

2007

2008

2009

5.4
5128
95798

5
5.1
5225
102042

5
4.7
4826
102687

4.5
4.9
4859
99215
AZ Birth
Certificates

4.2
4.8
4461
92616
AZ Birth
Certificates

Final

Final

96

Annual Performance Objective

2010
4

2011
3.8

2012
3.6

2013
3.4

2014
3.2

Notes - 2009
The State of Arizona does not have a survey like PRAMS that would collect data related to
smoking during the last 3 months of pregnancy. The only data available is from the birth
certificate, which records wether or not the mother smoked during the pregnancy, but is not
specific to the last 3 months of the pregnancy. Therefore, the percent reported is the percent of
women giving birth in 2009 who smoked at any time during pregnancy.
Notes - 2008
The State of Arizona does not have a survey like PRAMS that would collect data related to
smoking during the last 3 months of pregnancy. The only data available is from the birth
certificate, which records wether or not the mother smoked during the pregnancy, but is not
specific to the last 3 months of the pregnancy. Therefore, the percent reported is the percent of
women giving birth in 2008 who smoked at any time during pregnancy.
Notes - 2007
The State of Arizona does not have a survey like PRAMS that would collect data related to
smoking during the last 3 months of pregnancy. The only data available is from the birth
certificate, which records wether or not the mother smoked during the pregnancy, but is not
specific to the last 3 months of the pregnancy. Therefore, the percent reported is the percent of
women giving birth in 2007 who smoked at any time during pregnancy.
a. Last Year's Accomplishments
For calendar year 2008, 3,304 women utilized the ASHline, of which 43 reported being pregnant
and using tobacco. This accounted for 1.3% of all women who utilized the ASHline. For calendar
year 2009, 4,132 women utilized ASHline, of which 66 reported being pregnant and using
tobacco. This accounted for 1.6% of all women who utilized ASHline. According to Campaign for
Tobacco-Free Kids, Arizona has the 7th lowest smoking during pregnancy rate in the Nation at
6.3%.
According to the Behavioral Risk Factor Surveillance System, Arizona's smoking rates remained
relatively constant from 2008 (15.6%) to 2009 (16.1%). Some of the reasons for this include; 1)
2008 was the first complete year of the Smoke Free Arizona Act, which contributed to a 21% drop
from 2007 to 2008. 2) ASHline's capacity has increased, and 3) nicotine replacement therapies
are covered for Arizona residents who are insured by AHCCCS and who enroll in quit line
services.
The Licensed Midwife Program provided informational materials to all midwives about the
negative health outcomes associated with smoking during pregnancy and state MCH smoking
cessation resources for pregnant women.
The BWCH bilingual Hotline staff referred pregnant women who called requesting smoking
cessation information to the Arizona Smokers' Helpline (ASHline) for cessation services.
The Health Start Program provided the Every Woman Arizona Preconception Health Education
materials to contractors which are being utilized during family follow-up visits with the postpartum
clients. The topics address risk factors related to smoking, a smoking survey and techniques to
help women quit or cut down on smoking during and between pregnancies. Community Health
Workers refer any pregnant or postpartum woman who is using tobacco to local cessation
programs and to the Ashline to provide education on the health risks and steps to stop smoking.
The Health Start Program partnered with the ADHS Bureau of Tobacco and Chronic Disease to
integrate Basic Tobacco Intervention Skills Certification training on tobacco cessation strategies
for pregnant and postpartum women and their families in February 2010. The training was

97

attended by 15 community health workers and coordinators representing 6 contractors. The
training included practice on providing a brief intervention to clients who disclosed smoking during
pregnancy as well as the resources available on the Arizona Smokers Helpline at the
www.ashline.org.
The Title V Family Planning/Reproductive Health Program collaborates with the county level
Tobacco Education and Prevention Program to provide brief interventions and referrals for clients
who are using tobacco. If a patient identifies herself as someone who uses tobacco during an
exam or a pregnancy test, clinic staff provides information on smoking cessation and a referral to
the county Tobacco Education and Prevention Program.

Table 4a, National Performance Measures Summary Sheet
Activities
1. The Midwife Licensing Program provides materials to the
midwifery community regarding tobacco prevention programs.
2. Bilingual Hotline staff refer pregnant women to ADHS
tobacco education and cessation programs.
3. Health Start and Family Planning Programs provide training
to contractors on tobacco cessation.
4. Breastfeeding program and tobacco prevention/cessation
program are implementing methodology for referring new moms
to the Arizona Smokers Helpline.
5.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X
X

b. Current Activities
Bilingual Hotline staff continue to refer at-risk pregnant women to Arizona Smokers' Helpline
(ASHline) for cessation services.
Public Health Prevention Services bureaus are collaborating on better integration of tobacco
prevention and cessation strategies into existing programs. The ADHS Bureau of Tobacco and
Chronic Disease, in partnership with the Bureau of Nutrition and Physical Activity (BNPA), was
recently awarded the Communities Putting Prevention to Work grant from CDC. Under this grant,
the BNPA Breastfeeding Program has developed a methodology for referring women to the
Arizona Smokers' Helpline (ASHline) for cessation services. After giving birth, a woman receives
breastfeeding information from her provider. The provider will conduct basic tobacco intervention
utilizing the two A's and a R (Ask. Advise. Refer.). ASHline receives the referral and will contact
the women within 24 hours for enrollment into the cessation services offered. The ASHline Client
Intake Form now records whether or not the women is breastfeeding.
New public service announcements advertising the ASHline have resulted in a dramatic increase
in calls for cessation services.
Community nurses provide interconception education to moms who have had a baby in the
Newborn Intensive Care Unit for 5 days or more. Health Start provides training on tobacco
cessation strategies as described above.

98

c. Plan for the Coming Year
Bilingual Hotline staff will continue to refer at-risk pregnant women to smoking cessation
information provided by the Tobacco Education and Prevention Program.
The Health Start Program will conduct another training workshop on Tobacco Education and
Cessation Strategies with Pregnant and Postpartum Women for the Community Health Workers
and Coordinators for all contractors in 2011. The Program will use the Basic Tobacco Intervention
Skills for Maternal and Child Health Guidebook developed by the University of Arizona Health
Care Partnership. Community nursing and other home visiting programs will integrate tobacco
prevention & cessation information, particularly regarding second hand smoke in the home.
The Title V Family Planning/Reproductive Health Program will continue to work with the Tobacco
Education and Prevention Program to provide smoking cessation interventions and referrals as
needed.
Public Health Prevention Services bureaus will continue to collaborate on better integration of
tobacco prevention and cessation strategies into existing programs. The Arizona Smoker's
Helpline is increasing outreach efforts to priority populations, like pregnant women, by partnering
with WIC and other programs. The funding for this effort is provided through CDC ARRA stimulus
funds through the Communities Putting Prevention to Work grant. Utilizing these funds, ASHline
in collaboration with BTCD plans to target the 21,000 seriously mentally ill population within the
behavioral health system in Arizona. Rather than providing direct services to the clients, ASHline
and BTCD are working to create a systemic change within the behavioral health system. The
systemic change is a sustainable referral system created within two of the four overarching
Regional Behavioral Health Associations (RBHAs).

Performance Measure 16: The rate (per 100,000) of suicide deaths among youths aged 15
through 19.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and
Performance Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source

2005

2006

2007

2008

2009

9.5
14.1
61
431964

11.5
13.0
57
439190

13.5
8.5
38
444825

13
12.4
56
451910
AZ Health
Status and
Vital
Statistics

12
10.7
49
456079
AZ Health
Status and
Vital
Statistics

2010
10

2011
9.5

2012
9

Final
2013
8.5

Final
2014
8

Check this box if you cannot
report the numerator because
1.There are fewer than 5 events
over the last year, and
2.The average number of events
over the last 3 years is fewer than
5 and therefore a 3-year moving
average cannot be applied.
Is the Data Provisional or Final?
Annual Performance Objective

99

Notes - 2008
The 2008 data was not available prior to completion of the narrative sections in this grant.
Notes - 2007
Data for 2007 not yet available. The estimate for 2007 is provisionally set at the 2006 rate until
data become available in the Fall of 2008.
a. Last Year's Accomplishments
In 2009, the 16th Annual Child Fatality Report was produced, summarizing reviews of child
deaths that occurred in Arizona during 2008. For the fourth time since its inception, the Child
Fatality Review Program reviewed 100 percent of child deaths that occurred in Arizona.
During 2009, Child Fatality Review Teams reviewed the circumstances surrounding the suicides
of 35 children that occurred during 2008. Twenty-six (74 percent) of the suicides were among
children 15 through 17 years, and nine children (26 percent) were 14 years and younger. The
most common methods of suicide were hangings and gunshot wounds. The most commonly
identified contributing factors to child suicides were access to firearms, drug and/or alcohol use,
and lack of mental health treatment.
The Injury Prevention Program collaborated with the Division of Behavioral Health Services on a
grant application that would include depression screening in emergency departments. The
program also assisted with the new state plan on suicide prevention.
The Division of Behavioral Health Services provided information to BWCH program managers
regarding behavioral health resources for women and children.
The Injury Prevention Program responded to four requests for suicide-related data in 2009.

Table 4a, National Performance Measures Summary Sheet
Activities
1. Child Fatality Review Program produces an annual report on
the causes of child suicide.
2. Division of Behavioral Health Services works closely with
Injury Prevention, Child Fatality Review, and other maternal and
child health programs.
3.
4.
5.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X

b. Current Activities
For 2009, recommendations in the annual Child Fatality Review Report related to child suicides
included developing a Suicide Investigation Checklist for use by law enforcement while
investigating child suicides. Such a checklist would standardize the investigation procedures and
provide valuable information on risk and protective factors that may assist in preventing other
youth suicides.
Prescription drug drop-off event details and how-to information was presented to Injury

100

Prevention Advisory Council partners to introduce a promising practice for drug diversion and
youth suicide prevention.
The Injury Prevention Program presented a webinar to Behavioral Health Services (BHS) on the
use of injury data in planning interventions.
The Injury Prevention Program brought partners from Behavioral Health Services to the Arizona
Firearm Injury Prevention Coalition (AFIPC) to encourage collaboration between the groups.
AFIPC aims to prevention firearm-related injuries among children, including those from firearmrelated suicide/self-harm. The groups are partnering to bring information on firearm safety and
disposal to a BHS intervention program in hospital emergency departments.

c. Plan for the Coming Year
The Child Fatality Review Program will continue to review the deaths of all children to identify
preventable factors and will continue to conduct surveillance of causes and circumstances
surrounding child suicides in Arizona. The Child Fatality Review Program staff will continue to
provide technical assistance to the local child fatality teams in the development and
implementation of local, culturally sensitive teams and will identify and promote campaigns to
educate the public on preventing suicide among children. The Annual Child Fatality Report will be
produced in November and will include data on suicides and recommendations to prevent
suicides among children.
The Division of Behavioral Health Services will continue to participate in the ADHS Injury
Prevention Advisory Council and the ADHS Internal Injury Prevention Workgroup. Programs in
the Bureau of Women's & Children's Health will continue to collaborate with the Division of
Behavioral Health Services to help partners understand existing resources and service system.
Using federal materials from HRSA and SAMSHA, Bureau of Women's & Children's Health will
work on promoting mental wellness messaging in existing maternal and child health programs.

Performance Measure 17: Percent of very low birth weight infants delivered at facilities for
high-risk deliveries and neonates.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and Performance Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source

2005
82
77.6
868
1119

2006
82
77.5
960
1238

2007
82
78.8
971
1232

2010
91

2011
91.5

2012
92

Check this box if you cannot report the
numerator because
1.There are fewer than 5 events over the
last year, and
2.The average number of events over the
last 3 years is fewer than 5 and therefore a
3-year moving average cannot be applied.
Is the Data Provisional or Final?
Annual Performance Objective

2008
82.5
76.4
890
1165
AZ Birth
Certificates

2009
83
90.0
995
1106
AZ Birth
Certificates

Final
2013
92.5

Final
2014
93

101

Notes - 2009
The 2009 estimate is based on the inclusion of Level II EQ hosptials. The Arizona Perinatal Trust
certifies a Level II EQ to care for neonates at 28 weeks gestation or greater. The American
Academy of Pediatrics expanded their classification system for neonatal care in 2004. The new
classification system describes a neonatal intensive care Level IIIA as one that can provide care
for infants born at more than 28 weeks gestation. Prior to 2009 only Level III hospitals were
included in the analysis.
Notes - 2008
The 2008 data was not available prior to completion of the narrative sections in this grant.
Notes - 2007
The data source for this measures is birth certificate data for live births. Births in which the birth
weight was recorded as being under 450 grams are excluded as a data quality measure, as it is
unlikely that these records represent actual birth weights. Only facilities certified by the Arizona
Perinatal Trust as level III facilities are included in the numerator. Banner Desert Samaritan
became certified as a Level III on 10/1/02. Data for 2007 are not yet available. The estimate for
2007 is provisionally set at the 2006 rate until data become available in the Fall of 2008.
a. Last Year's Accomplishments
The maternal transport component of the High Risk Perinatal program (HRPP) continued funding
for a centralized Information and Referral Service. This 1-800 telephone line offered toll free 24/7
consultation services by board certified Maternal Fetal Medicine (MFM) specialists throughout
Arizona to providers caring for pregnant women who presented with high risk factors. Providers
made one telephone call to be connected with this service. If a transport was deemed necessary,
the board certified Maternal Fetal Specialists determined the availability of the appropriate level of
perinatal bed and authorized and provided medical direction for the transport regardless of the
woman's ability to pay. The MFM was able to utilize the perinatal screen of the EMSystem, a
web-based program with real time information of perinatal bed availability in Arizona, including
high-risk labor and delivery and Newborn Intensive Care Unit (NICU) beds. The program
continued to fund all uncompensated care associated with the transport itself of pregnant women
to Level II Enhanced Qualification or Level III perinatal centers. During 2009, 900 women
received maternal transport to the appropriate level of perinatal care. The HRPP continued to visit
hospitals and providers to educate them about the availability of the transport system. During
Arizona Perinatal Trust site visits to birthing hospitals, maternal transports were reviewed for
appropriateness and technical assistance is provided to the hospital.
The High Risk Perinatal Program is funded primarily with state general funds; while the transport
component is funded with EMS operating revenue. State budget cuts resulted in a 60% decrease
in funding for the program. As a result, the program modified eligibility criteria, reduced
community nursing visits, and reduced payments to providers. Reduced funding has not
impacted transport of moms or neonates. Title V funds were used to offset the magnitude of the
budget cuts, but program continues to operate at reduced capacity.
The Licensed Midwife Program reviewed quarterly reports from licensed midwives for any infants
that were below 3000 grams. If the infant was below that weight the Program contacted the
midwife who delivered the infant to determine if there were problems with either the delivery or
the pregnancy.

Table 4a, National Performance Measures Summary Sheet
Activities
1. High Risk Perinatal Program transported high risk pregnant

Pyramid Level of Service
DHC ES
PBS
IB
X

102

women to appropriate level of care regardless of ability
to pay.
2. High Risk Perinatal Program promoted public awareness of
availability of transport.
3.
4.
5.
6.
7.
8.
9.
10.

X

b. Current Activities
The maternal transport component of the High Risk Perinatal Program (HRPP) continues funding
a centralized Information and Referral Service. This 1-800 telephone line offers toll free 24/7
consultation services by board certified Maternal Fetal Medicine (MFM) specialists throughout
Arizona to providers caring for pregnant women who present with high risk factors. If a transport
is deemed necessary, the board certified Maternal Fetal Specialists determines the availability of
the appropriate level of perinatal bed and authorizes and provides medical direction for the
transport regardless of the woman's ability to pay. The MFM is able to utilize the perinatal screen
of the EMSystem, a web based program with real time information of perinatal bed availability in
Arizona, including high risk labor and delivery and NICU beds. The program continues to fund all
uncompensated care associated with the transport itself of pregnant women to Level II Enhanced
Qualification or Level III perinatal centers.

c. Plan for the Coming Year
The maternal transport component of the High Risk Perinatal program (HRPP) will continue
funding for a centralized Information and Referral Service. This 1-800 telephone line will continue
to offer toll free 24/7 consultation services by board certified Maternal Fetal Medicine (MFM)
specialists throughout Arizona to providers caring for pregnant women who presented with high
risk factors. Providers will be able to continue to make one telephone call to be connected with
this service. If a transport is deemed necessary, the board certified Maternal Fetal Specialists will
determine the availability of the appropriate level of perinatal bed and authorize and provide
medical direction for the transport regardless of the woman's ability to pay. The MFM will continue
to utilize the perinatal screen of the EMSystem, a web based program with real time information
of perinatal bed availability in Arizona, including high risk labor and delivery and NICU beds. The
program plans to continue to fund all uncompensated care associated with the transport itself of
pregnant women to Level II Enhanced Qualification or Level III perinatal centers. The HRPP will
continue to visit hospitals and providers to educate them about the availability of the transport
system.
Due to significantly reduced state funding, Title V funds will be used to help support continued
community nursing visits to enrolled families after the infant returns home. In addition, the Health
Start program will be allowing community nursing visits to families in the contractors' services
areas who have had a baby in the Newborn Intensive Care Unit but are not receiving community
nursing visiting under the High Risk Perinatal Program.

Performance Measure 18: Percent of infants born to pregnant women receiving prenatal care
beginning in the first trimester.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

103

Annual Objective and Performance
Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source

2005

2006

2007

2008

2009

78
77.7
74453
95798

78
77.7
79299
102042

79
77.6
79683
102687

79
79.4
78738
99215
AZ Birth
Certificates

80
80.3
74331
92616
AZ Birth
Certificates

2010
81

2011
82

2012
83

Final
2013
84

Final
2014
85

Check this box if you cannot report
the numerator because
1.There are fewer than 5 events over
the last year, and
2.The average number of events over
the last 3 years is fewer than 5 and
therefore a 3-year moving average
cannot be applied.
Is the Data Provisional or Final?
Annual Performance Objective

Notes - 2008
Data for 2008 are not yet available. The estimate for 2008 is provisionally set at the 2007 rate
until data become available in the Fall of 2009.
Notes - 2007
Data for 2007 are not yet available. The estimate for 2007 is provisionally set at the 2006 rate
until data become available in the Fall of 2008.
a. Last Year's Accomplishments
The Health Start Program is a preventative health program that provides case management in
high- risk communities with a focus on early access to prenatal care and improving birth
outcomes. The Health Start Program educated pregnant and postpartum women about prenatal
care, nutrition, the benefits of breastfeeding, danger signs of pregnancy, home safety,
immunizations, insurance and many other health and behavioral health topics during and
between pregnancies. The Program utilized Community Health Workers to identify pregnant
and/or parenting women within their community and facilitate early entry into prenatal care. The
Community Health Workers provided home and/or office visits and follow-up visits with the clients
to verify that they and their children up to age two are attending medical appointments and
receiving needed services. In 2009, Health Start provided educational services to 2,319
unduplicated enrolled clients. The program provided a total of 13,922 home and/or office visits.
The program increased outreach to the most vulnerable populations, Native Americans and
African Americans, in targeted communities to focus on new prenatal enrollments. Approximately
64% of Health Start clients entered the program in their first trimester of pregnancy.
A 2008 Health Start Evaluation concluded that babies of Health Start mothers had higher
gestational ages and/or full term when compared to non-Health Start mothers. Babies of Health
Start mothers also had higher birth weights when compared to babies whose mothers were not in
the program. The proportion of very low birth weight infants born to Health Start clients was
approximately 1%.
The Office of Oral Health (OOH) provided information and materials to educate medical and
dental health professionals on the importance of oral health before, during and after pregnancy
and to increase access to oral care during pregnancy to improve birth outcomes. OOH
encouraged the AHCCCS Dental Director and Health Plans to develop policies regarding oral
care during pregnancy. OOH provides technical assistance and educational materials on oral

104

health and premature, low-birth weight infants for external partners and organizations.
The County Prenatal Block Grant provided pregnant women in all 15 counties with a range of
prenatal services and classes focusing on early prenatal care, smoking, nutrition and exercise,
oral health, labor and delivery, premature births, and basic health issues and its impact on birth
outcome. The program lost all state funding in March 2009.
The ADHS Midwife Licensing Program reviewed data from 695 quarterly reports turned into the
Department by midwifes with notation of any who began care after the first trimester to determine
what the reasons were and why the mother had delayed care. The program reviewed this with the
licensee to see if this is a pattern and review potential corrective action needed. The program
completed enforcement action against the 7 licensed midwives who failed to turn in required
documentation. These individuals were required to complete plans of correction to prevent a
reoccurrence of the deficient practice in the future.
The BWCH Hotlines screened pregnant women for eligibility into Baby Arizona. Baby Arizona is a
presumptive eligibility program consisting of perinatal providers who agree to see pregnant
women while their eligibility into AHCCCS, Arizona's Medicaid, is being determined. These
providers agree to provide a payment plan if the woman does not qualify for AHCCCS. If
prescreening showed a woman was not eligible for AHCCCS, the Hotlines were able to refer
them to other providers in their area who offer prenatal care for a sliding scale fee. The Hotline
took 830 Baby Arizona calls in 2009. The March of Dimes provided the Bureau of Women's &
Children's Health with funding to do new promotion of the Baby Arizona Hotline. Staff worked with
March of Dimes to target organizations in neighborhoods most in need of outreach for early entry
into prenatal care. Hotline partnered with the Nurse Family Partnership project in Maricopa
County to screen for eligibility for the program among callers.
The Arizona WIC program continued to screen pregnant women and refer them to prenatal
services.

Table 4a, National Performance Measures Summary Sheet
Activities
1. Office of Oral Health educates health professionals on the
relationship of oral health and pregnancy risks.
2. Health Start Community Health Workers educate pregnant
and postpartum women.
3. Health Start Community Health Workers ensured clients and
children attended medical appointments.
4. Bilingual Hotline staff prescreened callers for Baby Arizona.
5. Bilingual Hotline staff referred to providers offering sliding
scale rates for prenatal care for pregnant women who would not
qualify for Medicaid.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X
X
X

b. Current Activities
The Office of Oral Health (OOH) is available to provide education and technical assistance to
dentists on treatment protocols during pregnancy and provides information to health care workers
and pregnant women on the importance of oral health during pregnancy.

105

The Health Start Program educates pregnant and postpartum women about prenatal care,
nutrition, the benefits of breastfeeding, danger signs of pregnancy, and home safety. The
program utilizes Community Health Workers to identify pregnant and/or parenting women within
their community and facilitate early entry into prenatal care.
Health Start continues outreach to higher risk populations.
The BWCH Pregnancy and Breastfeeding Hotlines continue to screen pregnant women for
eligibility into Baby Arizona, and to refer women not eligible for Medicaid to prenatal care
providers that serve the uninsured. Hotline continued to partner with the Nurse Family
Partnership project in Maricopa County to screen for eligibility for the program among callers.
Bureau of Nutrition & Physical Activity promotes the benefits of early entry into prenatal care. WIC
participants are referred and tracked, and WIC staff are trained to refer pregnant women for early
prenatal care.

c. Plan for the Coming Year
Office of Oral Health will continue to enhance dental provider knowledge on women's oral health
and pregnancy issues, to increase referrals for dental care and offer technical assistance
regarding dental care during regnancy.
OOH will continue to print and distribute information for pregnant women on the relationship
between periodontal disease and birth outcomes. The OOH will collaborate with Baby Arizona
and Health Start to enhance oral health education in those programs. The OOH will promote
incorporation of dental exams as a routine part of prenatal care.
The Health Start Community Health Workers will continue to provide education and assist clients
in obtaining prenatal care. The Community Health Workers will continue to follow-up with the
clients to verify that they are attending prenatal care medical appointments and are complying
with the physician's instructions. They will make referrals to community resources as appropriate,
such as smoking cessation programs and alcohol/substance abuse prevention and treatment
programs in their community. They will continue to distribute the Arizona Resource Guides in
English and Spanish to enrolled clients.
The Pregnancy and Breastfeeding Hotlines will continue to screen pregnant women for eligibility
into Baby Arizona. The Hotline will continue to maintain and update a database of participating
providers and providers offering reduced rates and sliding scale rates. BWCH staff will continue
to disseminate hotline information to the public. Hotline will continue to screen for eligibility of
callers for Maricopa County's Nurse Family Partnership project.
Arizona WIC participants will continue to be referred and tracked for access to prenatal services,
and new WIC staff will be trained to refer pregnant women for early prenatal care. WIC staff will
continue to regularly meet with AHCCCS coordinators.

D. State Performance Measures
State Performance Measure 1: Proportion of low-income women who receive reproductive
health/family planning services.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

106

Annual Objective and
Performance Data
Annual Performance
Objective
Annual Indicator
Numerator
Denominator
Data Source

2005

2006

2007

2008

2009

11

50

50

51

51

49.2

49.2

49.2

47.4
129616
273417
AZ Family Planning
Council survey
Final

47.4
129616
273417
AZ Family Planning
Council survey
Final

2010
51

2011
51

2012
51

2013
51

2014

Is the Data Provisional or
Final?
Annual Performance
Objective

Notes - 2007
Starting with the 2004 data point, the numerator is women at or below 200% FPL who received
family planning services through Title V, TItle X, Title XIX, or 330/340 Federally Funded
Community Health Centers. The denominator is women at or below 200% FPL who are fertile.
Data for this measure is from the Arizona Family Planning Council's Comprehensive Family
Planning Report, which is usually conducted annually. However, this report was not produced in
2007. Therefore, the 2005-2007 rates are provisionally set at the 2004 rate the new report is
issued in the fall of 2008.
a. Last Year's Accomplishments
Through the Reproductive Health/Family Planning Program (RHFP), 11 out of the 15 County
Health Departments and Maricopa Integrated Health Services received intergovernmental
agreements (IGA's) funded with Title V dollars to provide reproductive health/family planning
services that focused on women at or below 150% of the federal poverty level. Of the 4,866
women who received an initial or annual exam in 2009, 99% were at or below 150% of the
federal poverty level and received services at no charge. The Reproductive Health/Family
Planning Program focused on making services available to sexually active teens in an effort to
reduce teen pregnancy rates. In 2009, 48% of clients served were under 24 years old. The RHFP
collaborated with the Title X and Arizona Family Planning Council (AFPC) to share data and
coordinate services.

Table 4b, State Performance Measures Summary Sheet
Activities
1. The Reproductive Health/Family Planning Program (RHFP)
funds IGA's to sustain and increase the number of low income
women receiving reproductive health services.
2. The RHFP program works with other agencies to integrate
various women’s health issues such as domestic violence,
preconception health, tobacco cessation and prevention, and
STDs .
3.
4.
5.
6.
7.
8.
9.

Pyramid Level of Service
DHC ES
PBS
IB
X

X

107

10.
b. Current Activities
The Reproductive Health/Family Planning Program (RHFP) continues to provide Title V funding
to county health departments and Maricopa Integrated Health Services. The program works with
contractors to improve access for low income clients to preconception care within family planning.
Maricopa Integrated Health Services utilizes the Title V family planning dollars to serve women in
their Internatal Care Project. This project provides interconception health care to women whose
babies were admitted to Maricopa Medical Center's Newborn Intensive Care Unit.
Arizona received a Project Connect grant from the Family Violence Prevention Fund that will
result in improved screening for domestic violence in Title V and Title X family planning clinics
through training and technical support.
The Arizona Coalition Against Domestic Violence is the lead agency, and in partnership with
BWCH and the Arizona Family Planning Council will identify pilot clinic sites to implement grant
activities.
The Arizona Family Planning Council received a grant from the local March of Dimes to provide
preconception health care training to Title X and Title V family planning contractors and promote
the provision of these services in their clinics. The training will also focus on how to develop a
reproductive life plan with their clients.
Children's Rehabilitative Services member handbook includes resources for family planning and
STD and HIV testing.

c. Plan for the Coming Year
This state performance measure will be discontinued in FY2011 due to unavailability of data.
The Reproductive Health/Family Planning Program (RHFP) will continue to provide Title V
funding to county health departments and Maricopa Integrated Health Systems to offer services
to underserved populations. The program will continue to focus on women at or below 150% of
the federal poverty level. The program will continue to seek out locations where underserved
clients can be reached.
In coordination with the Arizona Coalition Against Domestic Violence, ADHS will assist in the
training of family planning providers to screen women for domestic violence in the clinic setting.
BWCH will continue to promote the integration of preconception care into family planning services
and other appropriate venues. BWCH will continue to work in partnership with the Arizona Family
Planning Council and the March of Dimes to identify opportunities to expand preconception care
training of clinical care staff across the state.

State Performance Measure 2: The percent of high school students who are overweight or
at-risk for overweight.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and

2005

2006

2007

2008

2009

108

Performance Data
Annual Performance
Objective
Annual Indicator
Numerator
Denominator
Data Source

25.5

25

25

24.5

24.5

25.5

25.9

25.9

27.7

Arizona Youth Risk
Behavior Survey
Final

Arizona Youth Risk
Behavior Survey
Final

2013
24

2014

Is the Data Provisional or
Final?
Annual Performance
Objective

2010
24

2011
24

2012
24

Notes - 2009
The YRBS report is done every two years. For future reporting periods, the indicator will be
changed to indicate the percentage of high school students who are overweight and obese.
Currently the state performance measure uses the terms overweight and at-risk for overweight.
Notes - 2008
The YRBS report already provides the calculated percentage. The percent at risk was added to
the percent overweight to get the total at-risk +overweight.
The YRBS report is done every two years. The next report available will be for 2009, and the
indicator will be changed to indicate the percentage of high school students who are overweight
and obese.
Notes - 2007
The YRBS report already provides the calculated percentage. The percent at risk was added to
the percent overweight to get the total at-risk +overweight.
The YRBS report is done every two years. The next report available will be for 2009.
a. Last Year's Accomplishments
Title V funds continued to fund Community Health Grantees across the state to address obesity
prevention. One of these grantees, Mountain Park Community Health Center (South Phoenix
Healthy Kids Partnership), took a comprehensive approach to reducing childhood obesity and
overweight. Part of their approach was to develop a local speakers' bureau comprised of
interested community partners. Six speakers were trained and conducted 7 presentations on
childhood obesity and how community organizations can contribute to behavior and policy
change to various local organizations. During 2009, their website had 40,916 hits and a total of
3,450 visitors. Ninety-eight (98) community courses focusing on healthy eating and physical
activity were given to children and their mothers.
Their coalition of community partners was expanded, and has worked to promote healthy policy
changes within the community and local organizations. Coalition partners attended four trainings
on advocacy and local and state policy development related to healthy eating and physical
activity. The contractor is a community health center whose physicians are now utilizing the Care
Model, a structured approach to weight management. Physicians are placing overweight or at risk
of overweight children ages 4 -- 18 in a self management program that includes a plan for diet
and physical activity. The project enrolled 461 children in the pediatric weight management
program for children who are overweight or at risk for overweight. Surveys were implemented to
assess their pediatric management program, followed by strategies to increase the health care
providers' perception of efficacy.

109

A total of 2,967 children and women of childbearing age, including high school students,
participated in educational programs that addressed the issues of nutrition and physical activity
as well as the problems of obesity and overweight for themselves and their families. All of the
multi-week classes contained a physical activity component suitable for each local community.
Over 80% of participants in classes were Hispanic, Native American, and Black women, children
and adolescents. At the end of the class, mothers showed a significant increase in proper
nutrition and had also lost weight; 70% of participants in physical activities increased their activity
levels; fruit and vegetable consumption increased by 37.9%, 71.4 % of participants either
maintained or reduced their BMI and 78.7% of women expressed their ability to manage stress
better.

Table 4b, State Performance Measures Summary Sheet
Activities
1. Title V Community Health Grants provide age-appropriate
obesity and overweight education and services specifically
designed for children.
2. ADHS Prevention Services bureaus are working on integrated
messaging and programming for obesity prevention.
3. ADHS Communities Putting Prevention Grant improves school
wellness policies
4.
5.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X

X
X

b. Current Activities
Title V funded Community Health Grants addressing obesity prevention will continue through
2010.
ADHS Bureau of Nutrition & Physical Activity is working with Arizona Department of Education to
implement the federal Coordinated School Health Grant and Communities Putting Prevention to
Work Grant. Activities are targeting school age population, providing technical assistance to
school districts to help them implement their school wellness policies and create model policies.
ADHS and ADE will provide training on completion of the School Health Index followed by
technical assistance on implementing evidence-based nutrition and physical activity policies.
ADHS and ADE will develop interactive video on creation of School Health Advisory Councils that
will guide the development of nutrition and physical activity policies. ADHS is also working with
the Safe Routes of School Program to incorporate an Active School Neighborhood Checklist that
includes health assessment questions as part of the Safe Routes to School application.
ADHS Bureaus of Women's & Children's Health, Nutrition & Physical Activity, Tobacco & Chronic
Disease, and Health Systems Development are working together to integrate obesity prevention
messaging and programming.

c. Plan for the Coming Year

110

Bureau of Women's and Children's Health will work closely with the Bureau of Nutrition &
Physical Activity, Office for Children with Special Health Care Needs (OCSHCN) and other
stakeholders to develop specific strategies for the Title V funds. Strategies under consideration
include: providing community grants for obesity prevention; coordinating revision of state
Nutrition & Physical Activity Plan to reflect national Let's Move initiative and recent
recommendations; convening agencies across the state that are working on obesity prevention
efforts and provide opportunities to share successes, challenges, and improved coordination;
disseminating best practices; developing youth-based coalitions around nutrition, physical
activities and obesity prevention efforts; and developing and providing training on obesity
prevention toolkit for community health workers and other paraprofessionals. The Bureau of
Women's and Children's health will look at comprehensive models that blend multiples areas of
the spectrum of prevention, with an increased focus on policy and organizational practices.
OCSHCN will offer to research models specific to children with special health care needs.
ADHS Bureau of Nutrition & Physical Activity will continue providing assistance to schools to
implement evidence-base nutrition and physical policies, and will continue to work with the
Department of Transportation's Safe Routes to School Program to incorporate the Active School
Neighborhood Checklist as part of the Safe Routes to School application.

State Performance Measure 3: The percent of preventable fetal and infant deaths out of all
fetal and infant deaths.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and
Performance Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source

2005

2006

2007

2008

2009

33.2
251
756

33
25.8
191
739

32.5
25.0
188
753

2010
31

2011
31

2012
31

32
29.0
238
821
AZ Vital Records
data
Final
2013
31

31.5
31.5
256
813
AZ Vital Records
data
Final
2014

Is the Data Provisional or Final?
Annual Performance Objective

Notes - 2009
The 2007 birth cohort was used in this analysis.
Notes - 2008
Data provided is for the 2006 birth cohort, which is the most recent data available.
Notes - 2007
Data provided is for the 2005 birth cohort, which is the most recent data available.
a. Last Year's Accomplishments
The Child Fatality Review Program and the Arizona Unexplained Infant Death Council
collaborated with the Sudden Unexpected Infant Death Investigation Task Force to revise the
current the Infant Death Investigation Checklist to improve data collection and reflect current
recommendations from the CDC. The Infant Death Investigation Checklist is completed by law
enforcement during the investigations of all unexpected infant deaths and submitted to the
Medical Examiners' offices so forensic pathologists can accurately assess cause of death.

111

The new version of the Checklist provides the Medical Examiners with more information for use
during the post mortem examination. These forms are also submitted to the Child Fatality Review
Program and provide critical information regarding circumstances surrounding unexpected infant
deaths. In 2009, Child Fatality Review teams reviewed 100% of deaths for all children in Arizona,
including infant deaths. Recommendations regarding prevention of infant deaths included
implementation of an infant safe sleep message, which was posted on the BWCH website.
The Office of Assessment and Evaluation produced the 5th annual report on the incidence and
reported causes of stillbirths. The Unexplained Infant Death Council recommended the statewide
adoption of the revised 2003 U.S. Standard Fetal Death Certificate, which includes data fields for
BMI, pre-pregnancy weight, and trimester/frequency of cigarette use. If adopted in Arizona, the
revised fetal death certificate would bolster future analyses of the risks for stillbirth.
ADHS continued to promote the use of folic acid through www.takemultivitamins.com, particularly
targeting young Latinas in Arizona. The ADHS Folic Acid Education and Distribution Program
provided a year's supply of multivitamins to low-income women of childbearing age.
The Bureau of Women's & Children's Health used Title V funding to help fund a Community
Health Grant for the Nurse Family Partnership Program in Yavapai County. The project served
149 low-income new moms with 110 babies under the age of two, pregnant women, and pregnant
teens. Each participant received education and support about the importance of prenatal, primary
and infant care; breastfeeding; reducing the incidence of obesity and overweight in themselves
and their children; post partum mood disorders; infant safety; immunizations; and parenting.
Ninety-five percent of the babies born to the Nurse Family Partnership had birth weights greater
than 2500 grams. Women received classroom instruction on preconception health, and received
folic acid supplements.
The BWCH Office of Women's Health developed the Liveitchangeit.com campaign through
funding by HRSA's First Time Motherhood/New Parents Initiative grant. The campaign launched
in October 2009 and targets African American men and women ages 18-30 to increase
awareness about preconception health and the life course perspective. It consists of radio spots,
posters, billboards, a website, monthly e-blasts, a mood piece, a spoken word piece, promotional
items and community based presentations. The BWCH has partnered with Tanner Community
Development Corporation and the Phoenix Chapter of the Black Nurses Association (BNA) to
conduct presentations in Black churches and other service organizations and teach barbers and
beauticians about preconception health. The barbers and beauticians are given stylist drapes
with the name of the campaign on them and provided with a laminated card they can reference
when educating their clients. BWCH is also partnering with the graduate chapters of Black
fraternities and sororities of the local university to staff exhibits and provide education at public
events. The March of Dimes is contracted to provide Grand Round presentations at Level III
hospitals, host a preconception health summit and make presentations on preconception health
at workshops/conferences for health care professionals.
The Office of Women's Health convened a taskforce to review preconception health materials
developed by Every Woman Florida to make them specific to Arizona. The new materials were
shared with the state's Medicaid health plans, posted on the web, and distributed to partners.

Table 4b, State Performance Measures Summary Sheet
Activities
1. Child Fatality Review Program promotes use of the Infant
Death Investigation checklist.
2. Unexplained Infant Death Council and Bureau of Women’s &

Pyramid Level of Service
DHC ES
PBS
IB
X
X

112

Children’s Health produces annual report on stillbirth.
3. Child Fatality Review Program produces annual report on
infant and child deaths, including recommendations for
prevention.
4. ADHS programs promote use of folic acid and multivitamins.
5. BWCH Office of Women’s Health implemented preconception
health LiveItChange It Campaign.
6. BWCH promotes preconception health materials.
7.
8.
9.
10.

X

X
X
X

b. Current Activities
The Arizona Peace Officer Standards and Training Board developed a DVD which explains the
use of the revised Infant Death Investigation Checklist and highlights the importance of
compassionate, professional investigations of all sudden, unexplained infant deaths. This DVD
was sent to all law enforcement agencies in Arizona and will fulfill 25% of an officer's yearly
training requirement. The Child Fatality Review Program continues to disseminate the Infant
Death Checklist to promote consistent investigations throughout the state and comply with
national trends in data reporting.
Office of Women's Health worked with March of Dimes to hold Arizona's first summit on
Preconception Health in April 2010. The Office has put together a taskforce to develop a
statewide strategic plan for preconception health. Plan is scheduled to be completed by fall of
2010. The Black Nurses Association continues to provide community based presentations and
trainings for the LiveitChangeit campaign. The campaign will continue to have a presence at
venues frequented by African Americans. The March of Dimes continues to make Grand Rounds
presentations and make preconception health presentations at other training/education
gatherings for professional health care providers.
BWCH has partnered with WIC to distribute the Every Woman Arizona materials in their clinics,
and continues to identify opportunities to promote the use of the preconception health materials in
a variety of settings.

c. Plan for the Coming Year
Child Fatality Review Program will issue annual report in November 2010, with recommendations
for prevention of infant deaths. The Child Fatality Review Program and Arizona Unexplained
Infant Death Council will continue to promote use of updated Infant Death Investigation Checklist.
Bureau of Women's & Children's Health will focus future activities for prevention of infant deaths
based on the results of the data analysis. Bureau programs will continue to promote infant safe
sleeping strategies.
The new statewide plan for preconception health is expected to be complete by the fall of 2010.
The Bureau of Women's & Children's health will determine which recommended actions it can
implement and whether Title V funding will be needed to do so.

113

State Performance Measure 4: Emergency department visits for unintentional injuries per
100,000 children age 1-14.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and
Performance Data
Annual Performance
Objective
Annual Indicator
Numerator
Denominator
Data Source

2005

2006

2007

2008

2009

7478

7477

7477

7476

7,174.4
90201
1257269

6,902.9
89255
1293014

6,681.6
92588
1385725

6,835.2
90940
1330464
AZ Hospital
Discharge data
Final

7,077.9
95037
1342722
AZ Hospital
Discharge data
Final

2010
7476

2011
7476

2012
7476

2013
7476

2014

Is the Data Provisional
or Final?
Annual Performance
Objective

Notes - 2008
The 2008 data was not available prior to completion of the narrative sections in this grant.
Notes - 2007
Data for 2007 are not yet available. The estimate for 2007 is provisionally set at the 2006 rate
until data become available in the Fall of 2008.
a. Last Year's Accomplishments
The Arizona Department of Health Services was awarded more than $4.5 million to improve child
health and wellness in Phoenix's South Mountain community. The award, received through the
Substance Abuse and Mental Health Services Administration's Project LAUNCH (Linking Actions
for Unmet Needs in Children's Health), will be distributed in increments of $900,000 each year for
five years.
The Safe Kids program manager provided certification child passenger safety training to four
communities in Arizona, two in tribal communities in partnership with local coalitions, Banner
Health or and the Governor's Office of Highway Safety. The program provided support materials
to the 30 Child Passenger Safety Instructors in Arizona. The program hosted a continuing
educational program for child passenger safety technicians. The program provides a data needs
assessment to for each coalition.
In 2008, Arizona's Emergency Medical Services for Children Program began work on establishing
a pediatric designation system for hospital emergency departments. This system will identify
minimum training and equipment a hospital should have to care for a pediatric patient. In addition,
the program is updating treatment guidelines for the paraprofessional caregiver in schools. A
three tiered criteria has been developed and approved by stakeholders with implementation
planned for Fall 2010.
In 2009, the Injury Prevention program provided county specific injury fact sheets and county
child fatality factsheets for county health departments. The program also conducted a survey on
the use of helmets during skiing and snowboarding by children, as injuries from these sports
present a measureable caseload for hospitals in Arizona's colder climates. Injury Prevention staff
coordinated community-based meetings with people interested in reducing injuries and deaths
due to ATV crashes.
The High Risk Perinatal Program (HRPP) Community Health Nurses and the Health Start

114

Community Health Workers conducted environmental risk assessments on every home visit.
These assessments helped to identify potentially hazardous situations in the home. Once
identified, the Community Health Nurse or the Community Health Worker worked with the family
to correct the situation, thereby reducing risk and the potential for preventable emergency room
visits.
The Title V Community Health Grants program also funded "Safe Dates", a co-educational injury
prevention course for adolescents 12 to 18 years of age. The project provided 935 participants
with information about healthy and abusive dating relationships. During 2009, 839 adolescents
participated in at least one class with 586 students completing the entire curriculum. In addition,
1500 teens at Teen Maze were reached with a Healthy Relationships booth.
The Title V funded Community Health Grant to Navajo County is focusing on preventable infant
mortality. In 2009, Navajo County provided five parent trainings on safety for the car, home, and
sun safety, seven CPR classes, and five First Aid classes. Screening for preconception care was
provided to 73 mothers who also attended car seat safety classes and 300 preconception care
kits at the Hopi Health Care Center.
The Title V funded Early Childhood Education/Child Care Health Consultant in Pima County
provided assessment, consultation, and recommendations regarding playground safety in 70
preschools.
The 16th Annual Arizona Child Fatality Review Report highlighted specific areas of concern
related to unintentional injuries. These included poisonings from prescription medications, injuries
among children who were not properly restrained in motor vehicles, and injury deaths involving all
terrain vehicles. The recommendations in the report included enactment of booster seat
legislation, enactment of primary seat belt laws, and increased enforcement of existing laws
regarding children riding or driving all terrain and off-highway vehicles (including helmet use and
licensing).

Table 4b, State Performance Measures Summary Sheet
Activities
1. HRPP Community Health Nurses conduct environmental
assessments.
2. Safe Kids provides certified child passenger safety training.
3. EMSC is establishing and implementing pediatric designation
criteria.
4. Injury Prevention Program provides data analysis and
technical assistance on various injury issues
5. State Child Fatality Review Team makes recommendations for
prevention of unintentional injuries.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X
X
X

b. Current Activities
Project LAUNCH seeks to reduce violence within the home and help to mediate the family and
community conditions in South Phoenix, including economic and family instability, incarceration,
involvement with Child Protective Services, patterns of anti-social behavior and criminality, and

115

educational deficits that put children at extreme risk.
Interventions will improve parenting practices and prevent child abuse and neglect.
Community Health Nurses conduct environmental risk assessments on every home visit. These
assessments help to identify potentially hazardous situations in the home. Once identified, the
Community Health Nurse works with the family to correct the situation, thereby reducing risk and
the potential for injuries.
For 2010, the Emergency Medical Services for Children is completing the school guidelines for
emergency treatment and continue working toward the creation of a pediatric designation system
for emergency departments.
Title V Community Health Grants continue to focus on car seats for newborns, boosters and
education on driving safety and Safe Dates Program, They will be adjusting objectives to increase
the outcomes.
The Title V funded Early Childhood Education Program/Child Care Health Consultant in Pima
County provides assessment, consultation, and recommendations regarding playground safety in
preschools.

c. Plan for the Coming Year
Project LAUNCH will continue to provide training for staff and community providers in evidencebase parenting programs, and a variety of parenting programs to families with children under the
age of nine. The evidence-based Strengthening Multi-Ethnic Families and Communities
(SMEFC) Facilitator training will be offered to project staff and community providers. SMEFC
aims to reduce drug/alcohol abuse, teen suicide, juvenile delinquency, gang involvement, child
abuse and domestic violence. Additional project staff will be trained to deliver the Parents as
Teacher (PAT) home visitation program. PAT increases parent knowledge of early childhood
development, improves parenting practices, provides early detection of developmental delays and
health issues, and prevents child abuse and neglect. PAT is available to families with children
under the age of six residing in the South Phoenix zip codes of 85040 and 85041. Parenting
Wisely, a self-administered, self-paced CD-ROM program, will also be available to parents and
caregivers with children ages six to eight years of age. Parenting Wisely seeks to help families
enhance relationships and decrease conflict through behavioral management and support.
The High Risk Perinatal Program, Community Health Nurses will continue to conduct
environmental risk assessments on every home visit. These assessments help to identify
potentially hazardous situations in the home. The Community Health Nurse will work with the
family to correct the situation, thereby reducing risk and the potential for preventable ER visits.
Health Start Community Health Workers will continue to conduct environmental risk assessments
and educate parents on eliminating potential injury risks.
The HRSA funded EMS Children program will begin implementation of a voluntary pediatric
designation process for hospital emergency departments.
The Injury Prevention Program, in partnership with Indian Health Services, will be conducting
Indian Health Service's Level I and II Injury Prevention Training.
All Terrain Vehicle injuries to children are a concern to ADHS partners and were highlighted as an
area of concern in the last annual Child Fatality Review Report. The Injury Prevention Program
will continue to collaborate with the Arizona Department of Game and Fish to explore
opportunities to increase community education and enforcement of current laws.

116

The Injury Prevention Program and Advisory Council will update state injury prevention plan, and
provide further direction on future actions the Bureau of Women's & Children's Health can take to
prevent childhood injury.
ADHS will implement new child care rules that better support injury prevention.

State Performance Measure 5: The percent of women entering prenatal care during their
first trimester in underserved primary care areas.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and
Performance Data
Annual Performance Objective
Annual Indicator
Numerator
Denominator
Data Source

2005

2006

2007

2008

2009

47.2
60
127

48
50.0
62
124

48
50.4
63
125

2010
46

2011
46

2012
45

47
51.2
64
125
AZ Birth
Certificates
Final
2013
45

47
52.0
65
125
AZ Birth
Certificates
Final
2014

Is the Data Provisional or Final?
Annual Performance Objective

Notes - 2009
The numerator is the number of Primary Care Area's (PCA's) with less than 74% of women giving
birth receiving prenatal care in the first trimester. The denominator is the total number of PCA's
in Arizona.
Notes - 2008
The 2008 data is not available to complete this measure until 2009.
Notes - 2007
Data for 2007 are not yet available. The estimate for 2007 is provisionally set at the 2006 rate
until data become available in the Fall of 2008. The numerator is the number of Primary Care
Area's (PCA's) with less than 74% of women giving birth receiving prenatal care in the first
trimester. The denominator is the total number of PCA's in Arizona. For 2006 the percent of
women giving birth in a Arizona Medically Underserved Area (AzMUA) who received prenatal
care in the first trimester was 73.8%.
a. Last Year's Accomplishments
Through three fourths of the state fiscal year, women were provided prenatal services in the
rural/medically underserved areas through the County Prenatal Block Grant Program. Rural
counties utilized mobile clinics for women who had no or minimal transportation, provided
immunization clinics to attract women who were at risk of getting pregnant, and contacted high
schools to develop teen pregnancy programs and teen mazes. The County Prenatal Block
Program also provided incentives for women who completed prenatal classes, and provided free
pregnancy tests.
The Health Start program educated pregnant women about prenatal care, nutrition and danger
signs of pregnancy. The Community Health Workers followed-up with the clients to verify that
they were attending prenatal care medical appointments and were complying with the physician's

117

instructions. All contracted agencies serve communities that are designated as primary care
areas. Of those categorized as primary care areas a large portion are also designated as
medically underserved areas. Two Fetal Alcohol Spectrum Disorders screening and brief
intervention trainings were conducted in 2009 to Health Start contractors. Of the 368 women
screened in 2009, 28% screened positive or at risk for alcohol use. Approximately 64% of Health
Start clients entered the program in their first trimester of pregnancy. A Health Start 2008 Report
concluded that babies of Health Start mothers had higher gestational ages and/or full term when
compared to non-Health Start mothers. Babies of Health Start mothers also had higher birth
weights when compared to babies whose mothers were not in the program.
The Pregnancy and Breastfeeding/Baby Arizona Hotline assisted pregnant women throughout the
state in finding a prenatal care provider and helping them apply for Medicaid. Baby Arizona is a
presumptive eligibility program consisting of prenatal providers who agree to see pregnant
women while their eligibility into AHCCCS, Arizona's Medicaid, is being determined. These
providers agree to provide a payment plan if the woman does not qualify for AHCCCS. If
prescreening showed a woman was not eligible for AHCCCS, the Hotlines were able to refer
them to other providers in their area who offer prenatal care for a sliding scale fee. The Hotline
assisted 830 callers with Baby Arizona in 2009. The Bureau of Women's and Children's Health
(BWCH) participated with the March of Dimes Program Services Committee to promote the Baby
Arizona hotline. March of Dimes provided BWCH with a small grant to provide new promotional
materials for Baby Arizona, particularly promoting the new website www.babyarizona.gov.
AHCCCS developed online training for providers to make it easier for providers to sign up to
become a Baby Arizona provider.

Table 4b, State Performance Measures Summary Sheet
Activities
1. Health Start Community Health Workers assists clients to
access prenatal care
2. Health Start educates low-income women about the benefits
of early prenatal care.
3. Pregnancy and Breastfeed/Baby Arizona Hotline links
pregnant women to prenatal care providers throughout Arizona.
4.
5.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X

b. Current Activities
Health Start continues to conduct community outreach to identify pregnancy women early in their
pregnancy and help them access prenatal care. The Health Start Program also provides
education to Community Health Workers on interconception care and provides new Every
Woman Arizona Preconception Health educational materials so that they can convey the
information to clients on the importance of prenatal care and ensure access to prenatal care to
clients.
BWCH is working with partners such as the March of Dimes and AHCCCS, the state's Medicaid
agency, to continue to disseminate information regarding Baby Arizona. BWCH, AHCCCS, and
Department of Economic Security (which conducts Medicaid eligibility) continue to meet regularly

118

to work out any issues related to Baby Arizona.

c. Plan for the Coming Year
This state performance measure is being discontinued in 2011. Activities related to prenatal care
are report under National Performance #18.

State Performance Measure 6: Percent of Medicaid enrollees age 1-18 who received at least
one preventive dental service within the last year.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and
Performance Data
Annual Performance
Objective
Annual Indicator
Numerator
Denominator
Data Source

2005

2006

2007

2008

2009

43

43.5

44

44.5

42.6
255983
600379

30.9
170018
550768

34.0
189423
556516

37.9
224227
592298
AZ Medicaid
(AHCCCS)
Final

41.5
277345
668472
AZ Medicaid
(AHCCCS)
Final

2010
44.5

2011
44.5

2012
44.5

2013
44.5

2014

Is the Data Provisional or
Final?
Annual Performance
Objective

a. Last Year's Accomplishments
Continued support for our partners in addressing access to care issues has been a strategy to
improve oral health. The Office of Oral Health continued the dental trailer loan program for
communities and non-profit organizations in underserved areas. Dental care is provided while the
organizations seek funding and establish permanent dental clinics. Typically, communities lease
the trailers for a period of five years. Dental students are involved in one of the current sites,
providing them with experience in delivering services to underserved and low income populations.
Through this program, nine dental clinics for underserved populations have been established
throughout the state. The Office of Oral Health facilitated and conducted training of approximately
450 staff members of childcare facilities,
Head Start staff, and WIC programs on early childhood oral health and provided education on
early intervention, screening and referral to approximately 100 physician assistants and other
medical providers. The Office of Oral Health maintained Intergovernmental Agreements with
counties to provide school-based dental screenings, referrals and sealants to children in lowincome schools. The Office of Oral Health collaborates with First Things First to promote and
implement prevention programs for children age 0-5 including support for establishing a dental
home by age 1 and providing technical assistance for oral health initiatives. Through a HRSA
Workforce grant, the Office of Oral Health established three pilot teledental sites in rural Arizona
including Northern Arizona University (NAU) School of Dental Hygiene, one tribal site and one
site targeted at Head Start children in rural areas.

Table 4b, State Performance Measures Summary Sheet
Activities
1. The Office of Oral Health provides support to communities in

Pyramid Level of Service
DHC ES
PBS
IB
X

119

addressing access to care issues.
2. The Office of Oral Health provides training for childcare
providers and early childhood teachers.
3. The Office of Oral Health provides education to health care
providers.
4.
5.
6.
7.
8.
9.
10.

X
X

b. Current Activities
The Office of Oral Health continues to monitor AHCCCS Health Plans on policies for dental care
and case management, collaborates with school-based dental clinics, and partners with private
organizations and foundations to enhance prevention activities. Through a HRSA Workforce
Grant, the Office is continuing to collaborate with the established teledentistry sites providing
services to rural areas and training and education to dental providers. The Office continues to
work with the Arizona Dental Association and Arizona Dental Hygiene Association in an effort to
improve the number of providers for the underserved. The Office of Oral Health conducted a
series of regional planning workshops to obtain input in the development of Arizona's Oral Health
Workforce 2020 Plan. The objectives were to review background and specific regional data;
identify and discuss potential strategies to address regional oral health workforce shortages; to
develop short-, mid-, and long-term objectives; and to develop broad action steps to achieve
objectives. The dental sealant program continues to provide oral screenings, referrals and
sealants to underserved children.

c. Plan for the Coming Year
Tracking of AHCCCS utilization for care will continue, as will collaboration with other agencies
and organizations to promote oral health education, early intervention by dental professionals and
early dental referrals by medical professionals. The Office of Oral Health will continue topromote
a dental home by age one by providing training to those who provide services to young children in
childcare, learning and health care environments. The dental sealant program will continue the
current Intergovernmental Agreements with the counties and seek to increase the number of
children served, including children with special health care needs.
Through a new HRSA Workforce Grant and match support provided by First Things First,
teledentistry sites will continue to expand to rural and underserved areas. Additionally regional
coalitions will be formed to support training for both providers and community stakeholders. The
Office of Oral Health will work with other MCH programs in the Bureau of Women's and Children's
Health to enhance integration of oral health strategies into existing programs, such as Health
Start.

State Performance Measure 8: Percent of children and youth with special health care needs
who have access to service.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and
Performance Data
Annual Performance

2005

2006

2007

2008

2009

0.1

0.2

120

Objective
Annual Indicator
Numerator
Denominator
Data Source

14.0
32631
232545

13.5
32738
243314
OCSHCN
program reports
Final

13.6
33188
243314
OCSHCN program
information
Final

2012
0.3

2013
0.2

2014

Is the Data Provisional or
Final?
Annual Performance
Objective

2010
0.2

2011
0.3

Notes - 2009
The 2009 indicator uses the same population estimate as 2008. This number is an estimate of all
residents of Arizona under the age of 21 who meet the functional definition of CSHCN from the
NS-CSHCN.
Notes - 2008
The population estimate for all residents of Arizona under age 21 is 1,946,515. SLAITS
estimates that 12.5 percent of children under age 18 have a special health care need. This
percentage was applied to the population up to age 21, as the best estimate of the proportion for
that population subgroup. The number of children and youth with special health care needs
under age 21 living in Arizona is estimated as 1,946,515 X 0.125 = 243,314.
Notes - 2007
The population estimate for all residents of Arizona under age 21 is 1,860,359. SLAITS
estimates that 12.5 percent of children under age 18 have a special health care need. This
percentage was applied to the population up to age 21, as the best estimate of the proportion for
that population subgroup. The number of children and youth with special health care needs
under age 21 living in Arizona is estimated as 1,860,359 X 0.125 = 232,545.
a. Last Year's Accomplishments
The Office for Children with Special Health Care Needs (OCSHCN) has several systems in place
linking families to services. OCSHCN collaborated with the Arizona Department of Health
Services (ADHS) Newborn Screening Program (NBS) to develop notification letters for families of
newborns identified with sickle cell disease, other hemoglobin traits and abnormal Cystic Fibrosis
test results. OCSHCN and the ADHS Birth Defects Registry developed a letter to send to families
of children born with spina bifida and cleft lip/cleft palate informing them of programs, resources
and possible coverage available through the Children's Rehabilitative Services (CRS) Program
and the Arizona Early Intervention Program (AzEIP). The Birth Defects Registry identified16
children with cleft lip/cleft palate or spina bifida, 12 were enrolled in a public insurance program,
the remainder received a follow up call or letter to inquire about insurance coverage or to provide
information and resources.
The SSI Project reviewed 1665 SSI applications and provided families with information about
insurance, services and programs and helped connect families to other agencies. In FY 08-09
letters were sent to all SSI applicants 0-21 and referral information for the Department of
Education, the Arizona School for the Deaf and Blind, CRS, the Division of Developmental
Disabilities, the Brain Injury and Spinal Cord Injury Associations and Raising Special Kids (RSK)
and Regional and Tribal Behavioral Health Authorities was provided.
OCSHCN reviewed all letters mailed to families for readibility, family centeredness and provided
translation services as needed. The letters instructed families to call OCSHCN for help with any
additional resources or needed information. The Information and Referral Project responded to
627 family and provider calls and directed families to services. Uninsured and underinsured

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families received information about health care coverage, prescription medication resources,
community health centers and testing available for CSHCN.
OCSHCN funded the Bureau of Women's and Children's Health (BWCH) Children's Information
Services (CIS) Hotline and the Community Nurse Program to educate families on CRS,
AHCCCS, insurance information, and other services for CYSHCN. Community Nursing visited
173 families of CSHCN. OCSHCN provided training to Hot Line staff on services and programs
for CYSHCN and participated in annual school nurse conference planning committees, events
and exhibited at conferences. Information on services for CYSHCN was provided to 91 nurses
and 25 other health personnel at the annual school nurse conference.
OCSHCN and RSK developed e-learning training modules for families and providers on
navigating the systems of care for CYSHCN. OCSHCN revised the training to reflect budget cuts
that created changes to eligibility and program requirements for several of the systems of care.
OCSHCN and RSK revamped parent youth leadership training to meet the needs of RSK
volunteers.
OCSHCN participates in meetings with intra-agency bureaus and offices, other state agencies
and community partners. Staff provided education, offered information about OCSHCN programs
and best practices for CYSHCN and identified opportunities to partner on projects and initiatives.
Outreach was provided to AzEIP, the Division of Developmental Disabilities (DDD), Arizona
Developmental Disabilities Planning Council, and the Family Assistance Administration. Outreach
activities also included sharing resources with First Things First (FTF), the Arizona Association of
Community Health Centers, the Arizona School for the Deaf and Blind, the Interagency
Coordinating Council for Infants and Toddlers, Mountain Park Community Health Center, Native
Health, the Arizona Bridge to Independent Living, Raising Special Kids, the Spina Bifida
Association, the Foundation for Blind Children, Ryan House and United Cerebral Palsy.

Table 4b, State Performance Measures Summary Sheet
Activities
1. OCSHCN partners with intra-agency bureaus, other offices,
other state agencies and multiple community partners to identify
opportunities for collaboration on projects and to share resources
and information on CYSHCN.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X

b. Current Activities
The Information and Referral Project refers callers to services and provides an overview of
systems of care, information on eligibility and guides families through the application processes,
financial aid and behavioral health services. The SSI Project reviews application information,
sends letters to applicants informing them of insurance options, services and programs and
responds to calls generated by the letters.

122

OCSHCN supports the Community Nursing Program and the CIS Hot Line, provides information
about CYSHCN and educates staff about services. OCSHCN and the Birth Defects Registry
inform families of children with Spina Bifida and Cleft Lip/Cleft Palate about CRS eligibility and
other insurance programs. OCSHCN works with NBS to educate families and specialists about
services for CSHCN.
Through outreach activities, OCSHCN and United Cerebral Palsy and Special Olympics are
partnering to identify families of CYSHCN who are interested in participating in family involvement
activities. OCSHCN, the AHDS Office of Nutrition and Physical Activity, and the ADHS Bureau of
Licensing and Assurance are partnering to produce educational materials for use by licensed
childcare providers around the state that include and promote healthy lifestyles for CSHCN.
OCSHCN provides training to RSK staff regarding eligibility requirements for health care services.
OCSHCN works with state school nursing organizations and AzEIP to provide information on how
to access care and services for CYSHCN.

c. Plan for the Coming Year
OCSHCN is retiring State Performance Measure 8 and has integrated all current activities and
future plans related to this measure into the National Performance Measures for Children with
Special Health Care Needs.

State Performance Measure 9: Percentage of state MCH programs that formally incorporate
screening for behavioral health issues.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and
Performance Data
Annual Performance
Objective
Annual Indicator
Numerator
Denominator
Data Source

2005

2006

2007

2008

2009

40

40

33.3
6
18

36.8
7
19
BWCH and
OCSHCN data.
Final

33.3
6
18
BWCH and
OCSHCN data.
Final

2012
50

2013
50

2014

Is the Data Provisional or
Final?
Annual Performance
Objective

2010
45

2011
45

Notes - 2009
The programs included in this measure were; the Health Start Program, High Risk Perinatal
Program, Teen Pregnancy Prevention program, Family Planning Program, Project Launch,
Sexual Violence Prevention and Education Program, Community Health Services Grant, Early
Childhood Health Consultation, Rural Safe Home Network, Office of Children with Special Health
Care Needs programs, and Dental Sealant and Early Childhood Carries programs (Office of Oral
Health).
Notes - 2008
The programs included in this measure were; the Health Start Program, High Risk Perinatal
Program, Teen Pregnancy Prevention program, Family Planning Program, Project Launch,

123

Sexual Violence Prevention and Education Program, County Prenatal Block Grant program,
Community Health Services Grant, Early Childhood Health Consultation, Rural Safe Home
Network, Office of Children with Special Health Care Needs programs, and Dental Sealant and
Early Childhood Carries programs (Office of Oral Health).
Notes - 2007
The programs included in this measure were; the Health Start Program, High Risk Perinatal
Program, Teen Pregnancy Prevention program, Family Planning Program, Sexual Violence
Prevention and Education Program, County Prenatal Block Grant program, Community Health
Services Grant, early childhood health consultation, Rural Safe Home Network, Office of Children
with Special Health Care Needs programs, and Dental Sealant and Early Childhood Carries
programs (Office of Oral Health).
a. Last Year's Accomplishments
The High Risk Perinatal Program (HRPP) Community Health Nurses screened all mothers of
infants enrolled in the Newborn Intensive Care Program for postpartum depression using the
Edinburgh Postnatal Depression Scale.
The Bureau of Women's and Children's Health continued implementation of a Fetal Alcohol
Spectrum Disorders Subcontract. The prevention project integrates alcohol screening, brief
intervention, and referrals for treatment into the existing Health Start Program. During state fiscal
year 2010, the project screened 455 pregnant women for alcohol use. Out of those, 124 women
screened positive for alcohol use and were provided a brief intervention. The Health Start
Program has also encouraged contractors to screen for post-partum depression utilizing the
Edinburgh Screening Tool.
The Project LAUNCH grant is being achieved through the creation of a family-centered system of
care for young children and their families; expansion of system capacity and coordination at the
State and local level; implementation of five evidence-based programs at the local level, including
Healthy Steps; access to appropriate mental health and wellness services; integration of routine
developmental screening across a range of settings; and parent education, referral and support.
Six Title V Community Health Grant contractors conducted community activities to decrease
stress. Women and children of childbearing age participated in educational programs that
addressed healthy eating and physical activity. Many of the classes conducted pre and post tests
which included questions related to stress levels and offered stress management techniques.
Many classes served women of color including Hispanic, Native American, and Black women.
Children's Rehabilitative Services (CRS) covers some behavioral health needs, including
therapeutic trials of medications, for conditions that relate to a member's CRS condition. When
needs are identified that go beyond the CRS covered scope of services, members are referred to
and care is coordinated with appropriate other agencies or providers.

Table 4b, State Performance Measures Summary Sheet
Activities
1. Community Health Nurses screens for post-partum
depression.
2. Health Start integrates screening, brief intervention, and
referrals for alcohol abuse into the program.
3. Project LAUNCH implements evidence-based,
comprehensive programs to families with young children in

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X

124

neighborhood of south Phoenix.
4.
5.
6.
7.
8.
9.
10.
b. Current Activities
Project LAUNCH is implementing an evidence-based intervention, Healthy Steps, for children
birth to age three and their families. Project LAUNCH has partnered with Phoenix Children's
Hospital to implement the Healthy Steps program in South Phoenix (zip codes 85040 and 85041).
The addition of a Healthy Steps Specialist to the pediatric team will lead to enhanced well-child
visits and more time to explore salient developmental, behavioral, or psychological issues. Family
health check-ups will also attempt to identify parental depression, family violence, and drug and
alcohol use.
Six Title V Community Health Grant contractors are conducting community activities to decrease
stress. All of the contractors include physical activity that is suitable for their local community.
Many classes are conducing pre post assessments which include questions related to stress
levels and offer stress management techniques.
Health Start continues to build infrastructure to expand integration of screening, brief intervention,
and referrals for alcohol abuse into additional sites. A total of eight sites are currently providing
screening and brief intervention to enrolled pregnant women in Health Start.
Community Health Nurses continue to provide post-partum depression screening during home
visits to moms who have a baby in the newborn intensive care unit for five days or more.

c. Plan for the Coming Year
This particular state performance measure is being discontinued in 2011 and replaced with a
measure from the Behavioral Risk Factor Surveillance System that assesses mental distress
among adult women. Bureau of Women's & Children Health plans to continue integration of
behavioral health activities into existing maternal and child health programs, including Health
Start and the High Risk Perinatal Program. In addition, the bureau plans to enhance promotion of
mental wellness in conjunction with promotion of preconception health.

E. Health Status Indicators
Introduction
Most birth indicators showed no significant change between 2005 and 2009. Health Status
Indicators reflecting motor vehicle injury and mortality improved significantly for adolescents.
Dramatic declines in 2009 are likely the effect of the economic recession on per capita mileage
driven by this age cohort. Increases were noted in non-fatal injury for children 14 years and
younger during 2009. Rates of Chlamydia among female adolescents and adults continued to
rise. This in part may be due to increased access to and promotion of testing for Chlamydia rather
than a true rate increase among the populations at-risk. Population data is reflecting the effects of
the current economic recession. Total births fell over 6.5 percent in 2009, and among Hispanic or
Latinos, significantly fewer infants were estimated to be living in Arizona in 2009 compared to

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2008. The 2010 Census will further illuminate the rapidly changing composition of Arizona's
maternal and child health population.

Health Status Indicators 01A: The percent of live births weighing less than 2,500 grams.
Health Status Indicators Forms for HSI 01 through 05 - Multi-Year Data
Annual Objective and Performance Data
2005
2006
2007
2008
Annual Indicator
6.9
7.1
7.1
7.1
Numerator
6640
7266
7285
7026
Denominator
95798 102042 102687 99215
Check this box if you cannot report the numerator
because
1.There are fewer than 5 events over the last year,
and
2.The average number of events over the last 3
years is fewer than 5 and therefore a 3-year
moving average cannot be applied.
Is the Data Provisional or Final?
Final
Notes - 2008
The 2008 data was not available prior to completion of the narrative sections in this grant.

2009
7.1
6573
92616

Final

Notes - 2007
Data for 2007 is not yet available. The estimate for 2007 is provisionally set at the 2006 rate until
the data becomes available in the Fall of 2008.

Narrative:
The data show no significant change in the proportion of low birth weight infants from 2004-2009.
The percent of infants born at low birth weight in Arizona remained above the Healthy People
2010 goal of 5.0 percent. There has been an ongoing disparity in the incidence low birth weight
for Black or African American infants in Arizona. Although Hispanic/Latina and American
Indian/Alaskan Native infants had lower incidence of low birth weight infants than White nonHispanics (6.6 percent compared to 6.9 percent) in 2009, the incidence of low birth weight among
Black or African American infants (12.8 percent) was significantly higher than for White nonHispanics. The only racial/ethnic group to witness an increase in the percentage of low birth
weight since 2004 was Black or African American. All data for low birth weight infants were
obtained through the Arizona Vital Statistics Birth Certificate Database.
Preconception, prenatal and interconception care are embedded in multiple Arizona Department
of Health Services' (ADHS) programs that serve women at-risk for delivering a low birth weight
infant. MCH programs refer women to smoking cessation programs within the ADHS Tobacco
Prevention and Education Program. According to the Arizona Behavioral Risk Factor Survey
(BRFS) the smoking rate among adults improved from 19.7 percent in 2007 to 15.8 percent in
2008. In addition to the positive effect of ADHS smoking cessation programs, legislation banning
smoking in most public places and a substantial increase in the tobacco tax also had a positive
effect on the prevalence of smoking. The reduction in smoking prevalence may have a long term
positive influence on the proportion of low birth weight in Arizona.
The Health Start Program integrated the Alcohol Screening and Brief Intervention Services
program to identify and support pregnant women at risk of using alcohol. An evaluation of Health
Start participants found that those who participated in Health Start were less likely to have a low
birth weight delivery or premature birth when compared to similar women not participating in
Health Start.

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BWCH produced the "Live it Change it" campaign targeting preconception health of African
Americans in Arizona. "Every Woman Arizona" preconception health materials were produced
and disseminated. In 2010, Arizona held its first preconception health summit in conjunction with
the March of Dimes. BWCH established a Preconception Health Taskforce to develop a
statewide preconception health plan. The ADHS Bureaus of Physical Activity & Nutrition,
Tobacco and Chronic Disease, Health Systems Development, and Women's & Children's Health
have chosen tobacco prevention & cessation, physical activity, and nutrition as special areas of
focus for integration of programming and messaging. With multiple programs promoting these
healthy behaviors, it is hoped that this will also have a positive impact on birth outcomes in the
future.

Health Status Indicators 01B: The percent of live singleton births weighing less than 2,500
grams.
Health Status Indicators Forms for HSI 01 through 05 - Multi-Year Data
Annual Objective and Performance Data
2005
2006
2007
2008
2009
Annual Indicator
5.5
5.7
5.6
5.6
5.7
Numerator
5162
5632
5599
5392
5123
Denominator
93173 99216 99889 96347 90032
Check this box if you cannot report the numerator
because
1.There are fewer than 5 events over the last year,
and
2.The average number of events over the last 3 years
is fewer than 5 and therefore a 3-year moving
average cannot be applied.
Is the Data Provisional or Final?
Final
Final
Notes - 2008
The data for 2008 were not available when descriptive analyses and program narratives were
completed.
Notes - 2007
The data for 2007 is not yet available. The estimate for 2007 is provisionally set at the 2006 rate
until data becomes available in the Fall of 2008.

Narrative:
The data show no significant change in the proportion of low birth weight singleton infants from
2004-2009. Reduction in total births in Arizona means that the crude number of low birth weight
infants is in decline. The percentage of singleton births weighing less than 2,500 grams in Arizona
remained 14 percent higher than the Healthy People 2010 goal of 5.0 percent for all deliveries. If
Arizona had met the Healthy People 2010 goal with the 2009 singleton birth cohort,
approximately 621 fewer singleton infants would have been born at low birth weight. All data for
low birth weight infants were obtained through the Arizona Vital Statistics Birth Certificate
Database.
Preconception, prenatal and interconception care are embedded in multiple Arizona Department
of Health Services' (ADHS) programs that serve women at-risk for delivering a low birth weight
infant. MCH programs refer women to smoking cessation programs within the ADHS Tobacco
Prevention and Education Program. According to the Arizona Behavioral Risk Factor Survey
(BRFS) the smoking rate among adults improved from 19.7 percent in 2007 to 15.8 percent in
2008. In addition to the positive effect of ADHS smoking cessation programs, legislation banning
smoking in most public places and a substantial increase in the tobacco tax also had a positive

127

effect on the prevalence of smoking. The reduction in smoking prevalence may have a long term
positive influence on the proportion of low birth weight in Arizona.
The Health Start Program integrated the Alcohol Screening and Brief Intervention Services
program to identify and support pregnant women at risk of using alcohol. An evaluation of Health
Start participants found that those who participated in Health Start were less likely to have a low
birth weight delivery or premature birth when compared to similar women not participating in
Health Start.
BWCH produced the "Live it Change it" campaign targeting preconception health of African
Americans in Arizona. "Every Woman Arizona" preconception health materials were produced
and disseminated. In 2010, Arizona held its first preconception health summit in conjunction with
the March of Dimes. BWCH established a Preconception Health Taskforce to develop a
statewide preconception health plan. The ADHS Bureaus of Physical Activity & Nutrition,
Tobacco and Chronic Disease, Health Systems Development, and Women's & Children's Health
have chosen tobacco prevention & cessation, physical activity, and nutrition as special areas of
focus for integration of programming and messaging. With multiple programs promoting these
healthy behaviors, it is hoped that this will also have a positive impact on birth outcomes in the
future.

Health Status Indicators 02A: The percent of live births weighing less than 1,500 grams.
Health Status Indicators Forms for HSI 01 through 05 - Multi-Year Data
Annual Objective and Performance Data
2005
2006
2007
2008
2009
Annual Indicator
1.2
1.2
1.2
1.2
1.2
Numerator
1119
1229
1223
1156
1106
Denominator
95798 102042 102687 99215 92616
Check this box if you cannot report the numerator
because
1.There are fewer than 5 events over the last year,
and
2.The average number of events over the last 3
years is fewer than 5 and therefore a 3-year
moving average cannot be applied.
Is the Data Provisional or Final?
Final
Final
Notes - 2008
The data for 2008 were not available when descriptive analyses and program narratives were
completed.
Notes - 2007
The data for 2007 is not yet available. The estimate for 2007 is provisionally set at the 2006 rate
until data becomes available in the Fall of 2008.

Narrative:
The data show no significant change in the proportion of very low birth weight infants from 20042009. The percent of infants born at very low birth weight in Arizona remains above the Healthy
People 2010 goal of 0.9 percent. If Arizona had met the Healthy People 2010 goal with the 2009
birth cohort, approximately 272 fewer infants would have been born at very low birth weight.
There has been an ongoing disparity in the percentage of very low birth weight for Black or
African American infants in Arizona. Although Hispanic/Latina and American Indian/Alaskan
Native infants had similar proportions of very low birth weight infants than White non-Hispanics
(1.0 percent and 1.1 percent compared to 1.1 percent), the percentage of very low birth weight

128

among Black or African American infants (2.8 percent) was higher than for White non-Hispanics.
All data for very low birth weight infants were obtained through the Arizona Vital Statistics Birth
Certificate Database.
Preconception, prenatal and interconception care are embedded in multiple Arizona Department
of Health Services' (ADHS) programs that serve women at-risk for delivering a low birth weight
infant. MCH programs refer women to smoking cessation programs within the ADHS Tobacco
Prevention and Education Program. According to the Arizona Behavioral Risk Factor Survey
(BRFS) the smoking rate among adults improved from 19.7 percent in 2007 to 15.8 percent in
2008. In addition to the positive effect of ADHS smoking cessation programs, legislation banning
smoking in most public places and a substantial increase in the tobacco tax also had a positive
effect on the prevalence of smoking. The reduction in smoking prevalence may have a long term
positive influence on the proportion of low birth weight in Arizona.
The Health Start Program integrated the Alcohol Screening and Brief Intervention Services
program to identify and support pregnant women at risk of using alcohol. An evaluation of Health
Start participants found that those who participated in Health Start were less likely to have a low
birth weight delivery or premature birth when compared to similar women not participating in
Health Start.
BWCH produced the "Live it Change it" campaign targeting preconception health of African
Americans in Arizona. "Every Woman Arizona" preconception health materials were produced
and disseminated. In 2010, Arizona held its first preconception health summit in conjunction with
the March of Dimes. BWCH established a Preconception Health Taskforce to develop a
statewide preconception health plan. The ADHS Bureaus of Physical Activity & Nutrition,
Tobacco and Chronic Disease, Health Systems Development, and Women's & Children's Health
have chosen tobacco prevention & cessation, physical activity, and nutrition as special areas of
focus for integration of programming and messaging. With multiple programs promoting these
healthy behaviors, it is hoped that this will also have a positive impact on birth outcomes.

Health Status Indicators 02B: The percent of live singleton births weighing less than 1,500
grams.
Health Status Indicators Forms for HSI 01 through 05 - Multi-Year Data
Annual Objective and Performance Data
2005
2006
2007
2008
2009
Annual Indicator
0.9
0.9
0.9
0.9
1.0
Numerator
856
882
902
850
856
Denominator
93173 99216 99889 96347 90032
Check this box if you cannot report the numerator
because
1.There are fewer than 5 events over the last year,
and
2.The average number of events over the last 3 years
is fewer than 5 and therefore a 3-year moving
average cannot be applied.
Is the Data Provisional or Final?
Final
Final
Notes - 2008
Data for 2008 were not available when the descriptive analyses and program narratives were
completed.
Notes - 2007
Data for 2007 not yet available. Estimates for 2007 are provisionally set at the 2006 rate until
data becomes available in the Fall of 2008.

129

Narrative:
The percentage of very low birth weight singletons increased but not significantly in 2009 (0.95
percent). The data show no significant change in the percentage of very low birth weight singleton
infants from 2004-2009. The percentage of singleton births weighing less than 1,500 grams in
Arizona nearly meets the Healthy People 2010 goal of 0.9 percent for all deliveries. All data for
very low birth weight infants were obtained through the Arizona Vital Statistics Birth Certificate
Database.
Preconception, prenatal and interconception care are embedded in multiple Arizona Department
of Health Services' (ADHS) programs that serve women at-risk for delivering a low birth weight
infant. MCH programs refer women to smoking cessation programs within the ADHS Tobacco
Prevention and Education Program. According to the Arizona Behavioral Risk Factor Survey
(BRFS) the smoking rate among adults improved from 19.7 percent in 2007 to 15.8 percent in
2008. In addition to the positive effect of ADHS smoking cessation programs, legislation banning
smoking in most public places and a substantial increase in the tobacco tax also had a positive
effect on the prevalence of smoking. The reduction in smoking prevalence may have a long term
positive influence on the proportion of low birth weight in Arizona.
The Health Start Program integrated the Alcohol Screening and Brief Intervention Services
program to identify and support pregnant women at risk of using alcohol. An evaluation of Health
Start participants found that those who participated in Health Start were less likely to have a low
birth weight delivery or premature birth when compared to similar women not participating in
Health Start.
BWCH produced the "Live it Change it" campaign targeting preconception health of African
Americans in Arizona. "Every Woman Arizona" preconception health materials were produced
and disseminated. In 2010, Arizona held its first preconception health summit in conjunction with
the March of Dimes. BWCH established a Preconception Health Taskforce to develop a
statewide preconception health plan. The ADHS Bureaus of Physical Activity & Nutrition,
Tobacco and Chronic Disease, Health Systems Development, and Women's & Children's Health
have chosen tobacco prevention & cessation, physical activity, and nutrition as special areas of
focus for integration of programming and messaging. With multiple programs promoting these
healthy behaviors, it is hoped that this will also have a positive impact on birth outcomes in the
future.

Health Status Indicators 03A: The death rate per 100,000 due to unintentional injuries
among children aged 14 years and younger.
Health Status Indicators Forms for HSI 01 through 05 - Multi-Year Data
Annual Objective and Performance
2005
2006
2007
Data
Annual Indicator
10.1
8.6
8.9
Numerator
136
119
126
Denominator
1347557 1390127 1412725
Check this box if you cannot report the
numerator because
1.There are fewer than 5 events over
the last year, and
2.The average number of events over
the last 3 years is fewer than 5 and
therefore a 3-year moving average
cannot be applied.

2008

2009

7.8
108
1379172

7.6
109
1434985

130

Is the Data Provisional or Final?
Final
Final
Notes - 2008
Data for 2008 not yet available. Estimates for 2008 are provisionally set at the 2007 rate until
data becomes available in the Fall of 2009.
Notes - 2007
Data for 2007 not yet available. Estimates for 2007 are provisionally set at the 2006 rate until
data becomes available in the Fall of 2008.

Narrative:
The death rate declined slightly from 7.8 to 7.6 per 100,000 children 14 years and younger, but
this was not a significant decline. Between 2005 and 2009 there was a significant decline in the
rate of deaths for this cohort from 10.1 to 7.6 [Chi-square=4.919 (1), p<0.027].
According to the 16th annual report by the Arizona Child Fatality Review Program, 16 percent of
all child deaths (17 years and younger) during 2008 were due to unintentional injuries. This is a
decline from 2007, when 20 percent of child deaths were unintentional. In 2008, almost half of all
deaths among children ages one through 14 years could have been prevented (46 percent,
n=123), but only 18 percent of deaths among infants were preventable (n=115).
Emergency Medical Services for Children (EMSC) addresses this measure at the infrastructure
level. In 2008, the Emergency Medical Services for Children began working on establishing a
pediatric designation system for hospital emergency departments. This system will identify
minimum training and equipment a hospital should have to care for a pediatric patient. The
system is scheduled to begin in fall of 2010. In addition, the program is updating treatment
guidelines for the paraprofessional care giver in schools.
In 2009, the Arizona Substance Abuse Partnership developed goals, objectives, and action steps
to address prescription drug abuse among children and underage drinking. This group, which is
part of the Governor's Office of Children, Youth, and Families, is enlisting parents, communities,
and pharmaceutical retailers to develop strategies to educate the public about the consequences
of prescription drug abuse. The Division for Substance Abuse Policy is working with partner
agencies to develop and implement a public awareness campaign regarding the proper disposal
of prescription drugs. The Substance Abuse Partnership is also working to build capacity at the
state level to enhance enforcement strategies to reduce underage drinking.
During 2009, several communities throughout Arizona have held ‘Dump the Drugs' events where
residents drop off unneeded medications to be properly destroyed. Among many others, these
included the cities of Cottonwood, Prescott, Show Low, Sierra Vista, White River, and Williams.
In September 2009, the City of Flagstaff enacted a city ordinance requiring children to wear
helmets while riding bicycles within city limits. This ordinance went into effect in January 2010.
In 2009, First Things First Regional Councils began providing grants to community organizations
to target injury prevention among children five years of age and younger. A lack of funding
available at the local level to implement injury prevention programs has been a barrier to
implementation of all injury prevention programs in Arizona.

Health Status Indicators 03B: The death rate per 100,000 for unintentional injuries among
children aged 14 years and younger due to motor vehicle crashes.
Health Status Indicators Forms for HSI 01 through 05 - Multi-Year Data
Annual Objective and Performance
2005
2006
2007

2008

2009

131

Data
Annual Indicator
4.3
4.0
4.0
2.7
3.5
Numerator
58
56
57
39
50
Denominator
1347557 1390127 1412725 1429459 1434985
Check this box if you cannot report the
numerator because
1.There are fewer than 5 events over
the last year, and
2.The average number of events over
the last 3 years is fewer than 5 and
therefore a 3-year moving average
cannot be applied.
Is the Data Provisional or Final?
Final
Final
Notes - 2008
Estimates for 2001 on reflect motor vehicle death rates for all children ages 0-14. Prior to 2001,
estimates were based on ages 1-14. Data for 2006 not yet available.
The 2008 data were not available prior to completion of the descriptive analyses and program
narratives.
Notes - 2007
Estimates for 2001 on reflect motor vehicle death rates for all children ages 0-14. Prior to 2001,
estimates were based on ages 1-14. Data for 2006 not yet available. Data for 2007 not yet
available. Estimates for 2007 are provisionally set at the 2006 rate until data becomes available
in the Fall of 2008.

Narrative:
The rate increased from 2.7 to 3.5 per 100,000 children between 2008 and 2009. Arizona's rate
of unintentional MVC deaths for children remains below the Healthy People 2010 goal of 4.4 per
100,000 children aged 14 years and younger. Mortality data was obtained from the Arizona Vital
Statistics Death Certificate Database.
The BWCH has multiple programs that attempt to reduce the mortality rate from motor vehicle
crashes among children. The Title V Community Health Grant (CHG) program has funded
community organizations to train car and booster seat technicians as well as purchase and
distribute those safety seats. For premature infants, the High Risk Perinatal Program Community
Health Nurses monitored car seat usage with every home visit and continued to educate the
families on the importance of car seat usage.
Arizona Safe Kids is a state-wide program dedicated to the prevention of unintentional injury for
Arizona's children under 15 years of age. Arizona Safe Kids is a member of Safe Kids Worldwide.
Local Safe Kids Coalitions throughout Arizona receive leadership and technical assistance from
Arizona Safe Kids. There are five local Safe Kids Coalitions, one local chapter, and the Arizona
State Coalition. Educational materials, assistance in creating new coalitions, and other injury
prevention strategies for communities are available from the Arizona Safe Kids Coalition. Local
Coalition accomplishments include regular car seat testing events, a permanent car seat testing
site, child passenger safety (CPS) technician certification and development of resource materials
for public education. During the past year Safe Kids established a coalition in southern Apache
and Navajo counties to address the safety needs of rural Arizonans.
The Navajo Nation enacted legislation in 2009 which requires children less than four feet, nine
inches in height to be restrained in booster seats while riding in vehicles. The Arizona legislature
has not passed booster seat or primary seat belt legislation that could safeguard the lives of older
children and teens.

132

Health Status Indicators 03C: The death rate per 100,000 from unintentional injuries due to
motor vehicle crashes among youth aged 15 through 24 years.
Health Status Indicators Forms for HSI 01 through 05 - Multi-Year Data
Annual Objective and Performance Data
2005
2006
2007
2008
Annual Indicator
29.8
32.4
26.7
22.1
Numerator
256
287
237
200
Denominator
859454 885751 889177 903796
Check this box if you cannot report the
numerator because
1.There are fewer than 5 events over the last
year, and
2.The average number of events over the last 3
years is fewer than 5 and therefore a 3-year
moving average cannot be applied.
Is the Data Provisional or Final?
Final
Notes - 2008
The 2008 data was not available prior to completion of the narrative sections in this grant.

2009
16.8
153
912687

Final

Notes - 2007
Data for 2007 not yet available. Estimates for 2007 are provisionally set at the 2006 rate until
data becomes available in the Fall of 2008.

Narrative:
The rate declined significantly from 22.1 to 16.8 per 100,000 youth [Chi-square=6.728 (1),
p<0.01]. The rate remains nearly two --times greater than the overall Healthy People 2010
population goal of 9.2 per 100,000 people of all ages. Mortality data was obtained from the
Arizona Vital Statistics Death Certificate Database.
The Arizona legislature approved a graduated driver license law that requires teens aged 15
years and 6 months old to have an adult at least 21 years of age seated in the front seat at all
times, a driving curfew and supervised training for youth 16 years of age, and limits on the
number of passengers under 18 years of age. This is a best-practice infrastructure building model
that will positively affect the rate of MVC deaths for youth in Arizona. The Child Fatality Review
Program will analyze any trends observed due to the enactment of graduated driving license
restrictions for teen drivers.
The Arizona Injury Prevention Advisory Council, in conjunction with Arizona Automobile
Association implemented a two-year trial safety belt educational program for Arizona high schools
called Battle of the Belt. The schools participated in a year long program to increase safety belt
usage among students, thereby saving lives. Students observed seat belt usage and developed
appropriate intervention strategies to improve student seat belt use at their schools. The
Automobile Association of America provided monetary prizes to schools with the highest overall
safety belt use and most improved safety belt use rates. The tool kit for implementing a Battle of
the Belt program is being made available to high schools throughout Arizona in 2009-2010.
Arizona has not passed state legislation to make the use of seatbelts a primary enforcement law.
Such a measure would aid in the reduction of incidence in fatal and non-fatal injuries among this
age cohort due to motor vehicle crashes.

133

Health Status Indicators 04A: The rate per 100,000 of all nonfatal injuries among children
aged 14 years and younger.
Health Status Indicators Forms for HSI 01 through 05 - Multi-Year Data
Annual Objective and Performance
2005
2006
2007
2008
2009
Data
Annual Indicator
251.6
190.0
177.2
163.6
235.9
Numerator
3391
2641
2504
2338
3385
Denominator
1347557 1390127 1412725 1429459 1434985
Check this box if you cannot report the
numerator because
1.There are fewer than 5 events over
the last year, and
2.The average number of events over
the last 3 years is fewer than 5 and
therefore a 3-year moving average
cannot be applied.
Is the Data Provisional or Final?
Final
Final
Notes - 2008
The 2008 data was not available prior to completion of the narrative sections in this grant.
Notes - 2007
Data for 2007 not yet available. Estimates for 2007 are provisionally set at the 2006 rate until
data becomes available in the Fall of 2008.

Narrative:
The rate increased significantly from 163.6 to 235.9 per 100,000 youth 14 years and younger
[Chi-square=187.902 (1), p<0.0001]. Falls were the largest contributing cause of non-fatal injury
among this age cohort. The data was obtained through analysis of appropriate e-codes in the
Arizona Hospital Discharge Database.
The Injury Prevention Program will be facilitating an update to the 2006-2010 Arizona Injury and
Surveillance Plan. The purpose of the Injury Plan is to expand and improve efforts to control
injury through coordination, communication, and cooperation among the various programs in
ADHS and outside agencies. Data-based surveillance guides the process for determining which
actions and strategies will be most effective in reducing injury.
Safety in the home has been a focus of multiple BWCH programs. As part of Health Start,
Community Health Workers receive training in conducting safe home inspections for children of
all clients. The High Risk Perinatal Program (HRPP) Community Health Nurses also conduct
environmental risk assessments during every home visit in order to reduce the risk of infant injury
and death.
Proper helmet use during pedal bike riding can reduce injury rates among this cohort. The Title V
Community Health Grant program funding has been used to purchase bicycle helmets and
implement bicycle riding education programs throughout Arizona. A large Bike Rodeo was held in
Navajo County. The rodeo focused on gun safety, sun safety, bicycle and helmet safety, car seat
safety, and other safety and health related education.
Arizona Safe Kids is a state-wide program dedicated to the prevention of unintentional injury for
Arizona's children under 15 years of age. Arizona Safe Kids is a member of the National Safe
Kids Campaign. Local Safe Kids Coalitions throughout Arizona receive leadership and technical
assistance from Arizona Safe Kids. There are five local Safe Kids Coalitions, one local chapter,
and the Arizona State Coalition. Educational materials, assistance in creating new coalitions, and

134

other injury prevention strategies for communities are available from the Arizona Safe Kids
Coalition.
Capacity to address injuries among young children 0 -5 years old has been increasing as a result
of funding through the First Things First initiative. Several regional councils have chosen to fund
injury prevention strategies at the local level.
ADHS is updating rules for licensed child care that will strengthen safety requirements, including
adding requirements related to usage of wheelchairs in a motor vehicle, and requiring that infants
are placed on their backs to sleep.

Health Status Indicators 04B: The rate per 100,000 of nonfatal injuries due to motor vehicle
crashes among children aged 14 years and younger.
Health Status Indicators Forms for HSI 01 through 05 - Multi-Year Data
Annual Objective and Performance
2005
2006
2007
2008
2009
Data
Annual Indicator
56.5
50.7
45.3
34.3
38.6
Numerator
762
705
640
491
554
Denominator
1347557 1390127 1412725 1429459 1434985
Check this box if you cannot report the
numerator because
1.There are fewer than 5 events over
the last year, and
2.The average number of events over
the last 3 years is fewer than 5 and
therefore a 3-year moving average
cannot be applied.
Is the Data Provisional or Final?
Final
Final
Notes - 2008
The 2008 data was not available prior to completion of the narrative sections in this grant.
Notes - 2007
Data for 2007 not yet available. Estimates for 2007 are provisionally set at the 2006 rate until
data becomes available in the Fall of 2008.

Narrative:
The rate increased, but not significantly, from 34.3 to 38.6 per 100,000 youth 14 years and
younger. Compared to 2005 (56.5) the 2009 rate is significantly less [Chi-square=47.314 (1),
p<0.0001]. The data was obtained through analysis of appropriate e-codes in the Arizona
Hospital Discharge Database.
The accomplishments of local Safe Kids Coalitions in Arizona include regular car seat testing
events, a permanent car seat testing site, child passenger safety (CPS) technician certification
and development of resource materials for public education. During the past year Safe Kids
established a coalition in southern Apache and Navajo counties to address the safety needs of
rural Arizonans.
In 2009, the Title V Community Health Grants funded four car seat safety projects throughout the
state. Through these programs, car safety seats were installed with accompanying education
including self-installation of the child car seat by the caregiver/parent. Also, car seats were
checked for proper installation, wear, damage, or product recalls.

135

For premature infants, the HRPP Community Health Nurses monitored car seat usage with every
home visit and continued to educate the families on the importance of car seat usage.
Barriers to improving Arizona's performance across this measure include cuts in state funding to
the County Prenatal Block Grant that provided funding through county health departments, some
of which used the funding for car seat distribution and installation training for new parents. The
Child Fatality Review annual report was used to support state legislation introduced in past
sessions including a proposed enactment of booster seat legislation for children who are between
five and nine years of age and are less than four feet, nine inches in height. However, the
Arizona legislature has not passed booster seat legislation. In addition, the legislature has not
passed legislation to make the use of seatbelts a primary enforcement law. Both measures would
reduce the incidence of fatal and non-fatal injuries among older children due to MVC.

Health Status Indicators 04C: The rate per 100,000 of nonfatal injuries due to motor vehicle
crashes among youth aged 15 through 24 years.
Health Status Indicators Forms for HSI 01 through 05 - Multi-Year Data
Annual Objective and Performance Data
2005
2006
2007
2008
Annual Indicator
232.2
211.2
206.6
165.2
Numerator
1996
1871
1837
1493
Denominator
859454 885751 889177 903796
Check this box if you cannot report the
numerator because
1.There are fewer than 5 events over the last
year, and
2.The average number of events over the last 3
years is fewer than 5 and therefore a 3-year
moving average cannot be applied.
Is the Data Provisional or Final?
Final
Notes - 2008
The 2008 data was not available prior to completion of the narrative sections in this grant.

2009
161.1
1471
912887

Final

Notes - 2007
Data for 2007 not yet available. Estimates for 2007 are provisionally set at the 2006 rate until
data becomes available in the Fall of 2008.

Narrative:
The rate declined, but not significantly, from 165.2 in 2008 to 161.1 in 2009. Compared to 2005
(232.2) the rate declined significantly in 2009 [Chi-square=114.635 (1), p<0.0001]. Although
there is no age specific rate goal for this age group in Healthy People 2010, the rate in Arizona is
nearly six-times lower than the goal of 933 motor vehicle injuries per 100,000 people of all ages.
The data was obtained through analysis of appropriate e-codes in the Arizona Hospital Discharge
Database.
The Arizona legislature approved a graduated driver license law that requires teens aged 15
years and 6 months old to have an adult at least 21 years of age seated in the front seat at all
times, a driving curfew and supervised training for youth 16 years of age, and limits on the
number of passengers under 18 years of age. This is a best-practice infrastructure building model
that will positively affect the rate of MVC injuries for youth in Arizona. The Child Fatality Review
Program will analyze any trends observed due to the enactment of graduated driving license
restrictions for teen drivers.

136

The Arizona Injury Prevention Advisory Council, in conjunction with Arizona Automobile
Association implemented a two-year trial safety belt educational program for Arizona high schools
called Battle of the Belt. The schools participated in a year long program to increase safety belt
usage among students, thereby saving lives. Students observed seat belt usage and developed
appropriate intervention strategies to improve student seat belt use at their schools. The
Automobile Association of America provided monetary prizes to schools with the highest overall
safety belt use and most improved safety belt use rates. The tool kit for implementing a Battle of
the Belt program is being made available to high schools throughout Arizona in 2009-2010.
The Arizona Legislature has not passed legislation to make the use of seatbelts a primary
enforcement law. Such a measure would reduce the incidence of fatal and non-fatal injuries
among this age cohort due to MVC.

Health Status Indicators 05A: The rate per 1,000 women aged 15 through 19 years with a
reported case of chlamydia.
Health Status Indicators Forms for HSI 01 through 05 - Multi-Year Data
Annual Objective and Performance Data
2005
2006
2007
2008
Annual Indicator
26.2
29.0
30.7
30.2
Numerator
5451
6188
6600
6595
Denominator
208105 213698 215079 218545
Check this box if you cannot report the
numerator because
1.There are fewer than 5 events over the last
year, and
2.The average number of events over the last 3
years is fewer than 5 and therefore a 3-year
moving average cannot be applied.
Is the Data Provisional or Final?
Final
Notes - 2008
Data for 2008 were not available when descriptive analyses and program narratives were
completed.

2009
30.7
6771
220555

Final

Notes - 2007
Data for 2007 not yet available. Estimates for 2007 are provisionally set at the 2006 rate until
data becomes available in the Fall of 2008.

Narrative:
Since 2007, the reported Chlamydia rate among adolescent females in Arizona has remained
stable. The 2009 rate among females aged 15-19 was again 30.7 per 1,000 population. In
Arizona, reported Chlamydia rates from 2004-2009 ranged between 2.8 and 3.3 times higher in
females than in males. Over the period 2002 to 2009, race-specific rates were generally much
lower among non-Hispanic whites when compared to other racial/ethnic groups. The Chlamydia
case rate among Asians for this time period remained similar to or below the rate for whites. The
rate among Native Americans represented the highest race-specific rate in the state through
2006. This may have been in part due to the aggressive and comprehensive Chlamydia testing
conducted by Indian Health Services in the state. The rising rate of Chlamydia among African
Americans through 2009, however, probably suggested a true increase in morbidity, especially
since expanded screening efforts were not identified. African Americans in Arizona continue to
have the highest rates of reported Chlamydia with rates nearly 6 times higher than non-Hispanic
whites.

137

The Arizona STD Program collaborated with the Arizona Family Planning Council, the Maricopa
County Public Health Laboratory, and the state health laboratories to facilitate Chlamydia
screening activities in Arizona. Due in part to this collaboration, Chlamydia screening efforts have
expanded in family planning clinics, STD clinics, and correctional health facilities through the
Infertility Prevention Project (IPP). Arizona law permits minors to seek treatment for sexually
transmitted diseases without parental or guardian consent.
As of September 2008 new statutory language makes legal the practice of Expedited Partner
Therapy (EPT) for STDs. Specifically, medical providers can dispense an extra dose(s) or write
an extra prescription(s)of an antibiotic medication to their patient to deliver to their partner. This
practice is currently supported for the treatment of partners of patients with Chlamydia and/or
gonorrhea.
Due to state budget cuts, the Arizona state laboratory located in Flagstaff was closed in 2008,
followed by the closure of the Tucson lab in 2009. The only remaining state laboratory located in
Phoenix announced that it would no longer be testing Chlamydia and gonorrhea. As a result, all
state run Chlamydia and gonorrhea tests are being completed via contract with a private lab in
San Antonio, Texas.
The Office of Women's Health is leading a work group that is examining STD prevention
strategies for Black women. The largest newspaper serving the African American community in
Arizona is sponsoring a new section on health issues of concern, which ADHS is contributing
articles.

Health Status Indicators 05B: The rate per 1,000 women aged 20 through 44 years with a
reported case of chlamydia.
Health Status Indicators Forms for HSI 01 through 05 - Multi-Year Data
Annual Objective and Performance
2005
2006
2007
2008
2009
Data
Annual Indicator
9.6
11.2
10.7
8.5
10.5
Numerator
10329
11849
11652
11265
11855
Denominator
1075048 1061924 1085698 1326554 1124281
Check this box if you cannot report the
numerator because
1.There are fewer than 5 events over
the last year, and
2.The average number of events over
the last 3 years is fewer than 5 and
therefore a 3-year moving average
cannot be applied.
Is the Data Provisional or Final?
Final
Final
Notes - 2008
Data for 2008 were not available when the descriptive analyses and program narratives were
completed.
Notes - 2007
Data for 2007 not yet available. Estimates for 2007 are provisionally set at the 2006 rate until
data becomes available in the Fall of 2008.

Narrative:

138

The 2009 rate per 1,000 of reported Chlamydia cases among women aged 20-44 years
increased significantly from 8.5 to 10.5 [Chi-square=274.367 (1), p<0.0001]. In Arizona, reported
Chlamydia rates from 2004-2009 ranged between 2.8 and 3.3 times higher in females than in
males. Over the period 2002 to 2009, race-specific rates were generally much lower among nonHispanic whites when compared to other racial/ethnic groups. The Chlamydia case rate among
Asians for this time period remained similar to or below the rate for whites. The rate among
Native Americans represented the highest race-specific rate in the state through 2006. This may
have been in part due to the aggressive and comprehensive Chlamydia testing conducted by
Indian Health Services in the state. The rising rate of Chlamydia among African Americans
through 2009, however, probably suggested a true increase in morbidity, especially since
expanded screening efforts were not identified. African Americans in Arizona continue to have
the highest rates of reported Chlamydia with rates nearly 6 times higher than non-Hispanic
whites.
The Arizona STD Program collaborated with the Arizona Family Planning Council, the Maricopa
County Public Health Laboratory, and the state health laboratories to facilitate Chlamydia
screening activities in Arizona. Chlamydia screening efforts have expanded in family planning
clinics, STD clinics, and correctional health facilities through the CDC's Infertility Prevention
Project (IPP). Screening occurs in 40 Title X sites (which includes 2 juvenile detention facilities),
16 Title V sites, two Maricopa County Juvenile Detention Centers and one Maricopa County Jail.
As of September 2008, new statutory language makes legal the practice of Expedited Partner
Therapy (EPT) for STDs in Arizona. Specifically, medical providers can dispense an extra
dose(s) or write an extra prescription(s) for an antibiotic medication to their patient to deliver to
their partner. This practice is currently supported for the treatment of partners of patients with
Chlamydia and/or gonorrhea.
The Office of Women's Health and the Office of HIV is leading a work group called Pathways that
is examining STD prevention strategies for Black women. Pathways consists of ADHS staff and
representatives from the Arizona Family Planning Council, the Black AIDS Task Force and the
Maricopa County Health Department. The largest newspaper serving the African American
community in Arizona is sponsoring a new section on health issues that features articles written
by the members of Pathways.
The Black AIDS Taskforce is developing leadership summits in rural areas such as Casa Grande
and Sierra Vista to identify leaders in the community and churches and provide leadership
training so they can be advocates in their communities. BWCH will participate in the planning
and implementation of the Sierra Vista leadership session to promote preconception health and
provide maternal and child health info.

Health Status Indicators 06A: Infants and children aged 0 through 24 years enumerated by
sub-populations of age group and race. (Demographics)
HSI #06A - Demographics (TOTAL POPULATION)
White
Black or
American
CATEGORY
Total
African
Indian or
All
TOTAL
American Native
POPULATION Races
Alaskan
BY RACE
Infants 0 to 1
92263
78130
4339
6333
Children 1
406201
351731
19094
24248
through 4
Children 5
469372
402791
23575
30790
through 9
Children 10
467149
397027
24055
34432

Asian

Native
Hawaiian
or Other
Pacific
Islander

More
than
one
race
reported

Other
and
Unknown

3461

0

0

0

11128

0

0

0

12216

0

0

0

11635

0

0

0

139

through 14
Children 15
through 19
Children 20
through 24
Children 0
through 24

456079

385402

22379

37034

11264

0

0

0

456808

391941

20568

31888

12411

0

0

0

2347872

2007022

114010

164725

62115

0

0

0

Notes - 2011
Narrative:
The estimated total population of Arizona in 2009 (6,595,778) agrees with the U.S. Census
Bureau estimate released in December 2009 (Table 1. Annual Estimates of the Resident
Population for the United States, Regions, States, and Puerto Rico: April 1, 2000 to July 1, 2009;
NST-EST2009-01; available online at http://www.census.gov/popest/states/tables/NST-EST200901.xls).
The percentages of population breakdowns by age, race/ethnicity, gender, and county of
residence were derived from our own population denominator database for 2008. These
percentages were than applied to the estimated total state population for 2009 from the U.S.
Census Bureau. The size of the population <1 year of age was adjusted down, to correspond with
a substantial decrease in the number of resident births in 2009. In 2009 resident births declined
by 6.7 percent compared to 2008. The majority of the decline took place among the Hispanic or
Latino population.
ADHS programs (described in detail elsewhere in the grant application) utilize culturally and
linguistically appropriate interventions to meet the health needs of Arizona's diverse maternal and
child population.

Health Status Indicators 06B: Infants and children aged 0 through 24 years enumerated by
sub-populations of age group and Hispanic ethnicity. (Demographics)
HSI #06B - Demographics (TOTAL POPULATION)
CATEGORY
Total NOT Hispanic
or Latino
TOTAL POPULATION BY
HISPANIC ETHNICITY
Infants 0 to 1
53749
Children 1 through 4
230945
Children 5 through 9
280692
Children 10 through 14
293179
Children 15 through 19
303415
Children 20 through 24
305874
Children 0 through 24
1467854

Total Hispanic
or Latino
38514
175256
188680
173970
152664
150934
880018

Ethnicity Not
Reported
0
0
0
0
0
0
0

Notes - 2011
Narrative:
The estimated total population of Arizona in 2009 (6,595,778) agrees with the U.S. Census
Bureau estimate released in December 2009 (Table 1. Annual Estimates of the Resident
Population for the United States, Regions, States, and Puerto Rico: April 1, 2000 to July 1, 2009;
NST-EST2009-01; available online at http://www.census.gov/popest/states/tables/NST-EST200901.xls).

140

The percentages of population breakdowns by age, race/ethnicity, gender, and county of
residence were derived from our own population denominator database for 2008. These
percentages were than applied to the estimated total state population for 2009 from the U.S.
Census Bureau. The size of the population <1 year of age was adjusted down, to correspond with
a substantial decrease in the number of resident births in 2009. In 2009 resident births declined
by 6.7 percent compared to 2008. The majority of the decline took place among the Hispanic or
Latino population.
ADHS programs (described in detail elsewhere in the grant application) utilize culturally and
linguistically appropriate interventions to meet the health needs of Arizona's diverse maternal and
child population.

Health Status Indicators 07A: Live births to women (of all ages) enumerated by maternal
age and race. (Demographics)
HSI #07A - Demographics (Total live births)
White
Black or
CATEGORY Total
African
All
Total live
American
Races
births
Women < 15
Women 15
through 17
Women 18
through 19
Women 20
through 34
Women 35
or older
Women of all
ages

American
Indian or
Native
Alaskan

Asian

Native
Hawaiian
or Other
Pacific
Islander

More
than one
race
reported

Other and
Unknown

132

107

6

17

2

0

0

0

3519

2920

181

394

18

0

0

6

7319

6047

416

759

68

0

0

29

70044

59410

3292

4427

2577

0

0

338

11602

9677

483

573

731

0

0

138

92616

78161

4378

6170

3396

0

0

511

Notes - 2011
An attachment is included in this section.
Narrative:
Total live births to women in Arizona declined 6.7 percent in 2009 compared to 2008. This
change was driven by reductions in the number of live births to; Hispanic or Latinas (-10%), White
non-Hispanics (-5%), and American Indians (-3%). The effects of the continuing economic
recession and the loss of employment may be driving a reduction in fertility and also a reduction
in the overall number of reproductive age women in Arizona. In addition, the effects of new
employer sanction laws and immigration restrictions may account for the significant disparity in
the reduction of births to Hispanic or Latinas in Arizona.
The rate of births to females aged 15-19 fell from 54.9 in 2008 to 49.1 per 1,000 in 2009, a 10.5
percent reduction. This siginificant reduction was driven again by the reduction in the rate among
Hispanic or Latinas from 96.7 to 85.0 per 1,000, a 12 percent reduction in one calendar year.
All data were obtained through Arizona Vital Statistics, 2009.

141

Health Status Indicators 07B: Live births to women (of all ages) enumerated by maternal
age and Hispanic ethnicity. (Demographics)
HSI #07B - Demographics (Total live births)
CATEGORY
Total NOT Hispanic or
Latino
Total live births
Women < 15
45
Women 15 through
1248
17
Women 18 through
3318
19
Women 20 through
41656
34
Women 35 or older
7476
Women of all ages
53743

Total Hispanic or
Latino
87

Ethnicity Not
Reported
0

2253

6

4001

29

28028

338

3993
38362

138
511

Notes - 2011
Narrative:
Total live births to women in Arizona declined 6.7 percent in 2009 compared to 2008. This
change was driven by reductions in the number of live births to; Hispanic or Latinas (-10%), White
non-Hispanics (-5%), and American Indians (-3%). The effects of the continuing economic
recession and the loss of employment may be driving a reduction in fertility and also a reduction
in the overall number of reproductive age women in Arizona. In addition, the effects of new
employer sanction laws and immigration restrictions may account for the significant disparity in
the reduction of births to Hispanic or Latinas in Arizona.
The rate of births to females aged 15-19 fell from 54.9 in 2008 to 49.1 per 1,000 in 2009, a 10.5
percent reduction. This siginificant reduction was driven again by the reduction in the rate among
Hispanic or Latinas from 96.7 to 85.0 per 1,000, a 12 percent reduction in one calendar year.
All data were obtained through Arizona Vital Statistics, 2009.

Health Status Indicators 08A: Deaths of infants and children aged 0 through 24 years
enumerated by age subgroup and race. (Demographics)
HSI #08A - Demographics (Total deaths)
White Black or
CATEGORY Total
African
All
Total deaths
American
Races
Infants 0 to 1
Children 1
through 4
Children 5
through 9
Children 10
through 14
Children 15
through 19
Children 20
through 24
Children 0

American
Indian or
Native
Alaskan

Asian

Native
Hawaiian
or Other
Pacific
Islander

More than
one race
reported

Other and
Unknown

547

407

75

52

13

0

0

0

127

100

7

15

4

0

0

1

69

57

5

4

3

0

0

0

75

60

5

9

0

0

0

1

262

205

10

34

6

6

0

1

401

308

24

61

6

0

0

2

1481

1137

126

175

32

6

0

5

142

through 24

Notes - 2011
Narrative:
Total infant deaths declined by n=51 in 2009 compared to 2008. Even with the substantial
changes in the total population of infants, the infant mortality rate declined from 6.3 in per 1,000
live births 2008 to 5.9 in 2009 per 1,000 live births. The data for infant mortality is found in
advanced analysis of 2008 Arizona Vital Health and Statistics.
Racial disparities in infant and youth mortality remain persistent in Arizona. Although Whites
(Hispanic and non-Hispanic) had the most total infant deaths, Black or African American infant
mortality (17.1 per 1,000 live born infants) was more than three times as great at the rate for
White non-Hispanics (4.3 per 1,000 live born infants), two-and-a-half times as great as for
Hispanic or Latinos (6.2 per 1,000 live births), and more than two-times as great as the rate found
in American Indian infants (8.4 per 1,000 live born infants).
Among older youth aged 15 through 19, there was a 11 percent decrease in the total number of
deaths in 2009 (262) compared to 2008 (297). Racial disparities were less apparent in the
mortality rates for older youth. The mortality rates for White non-Hispanic youth (0.4 per 1,000
residents aged 15 through 19), Hispanic or Latino youth (0.7), Black or African American youth
(0.5), and American Indian or Alaskan Native youth (0.9) were lower than in 2008. The population
denominator was based on population projections that are less precise than birth certificates.
Thus, the rates are estimates of mortality across this age cohort.
The Arizona legislature approved a graduated driver license law that requires teens aged 15
years and 6 months old to have an adult at least 21 years of age seated in the front seat at all
times, a driving curfew and supervised training for youth 16 years of age, and limits on the
number of passengers under 18 years of age. This is a best-practice infrastructure building model
that will positively affect the rate of MVC deaths for youth in Arizona. The Child Fatality Review
Program will analyze any trends observed due to the enactment of graduated driving license
restrictions for teen drivers.

Health Status Indicators 08B: Deaths of infants and children aged 0 through 24 years
enumerated by age subgroup and Hispanic ethnicity. (Demographics)
HSI #08B - Demographics (Total deaths)
CATEGORY
Total NOT Hispanic or
Latino
Total deaths
Infants 0 to 1
311
Children 1 through 4
72
Children 5 through 9
38
Children 10 through
34
14
Children 15 through
160
19
Children 20 through
273
24
Children 0 through
888
24

Total Hispanic or
Latino
236
54
31

Ethnicity Not
Reported
0
1
0

40

1

101

1

126

2

588

5

143

Notes - 2011
Narrative:
Total infant deaths declined by n=51 in 2009 compared to 2008. Even with the substantial
changes in the total population of infants, the infant mortality rate declined from 6.3 in per 1,000
live births 2008 to 5.9 in 2009 per 1,000 live births. The data for infant mortality is found in
advanced analysis of 2008 Arizona Vital Health and Statistics.
Racial disparities in infant and youth mortality remain persistent in Arizona. Although Whites
(Hispanic and non-Hispanic) had the most total infant deaths, Black or African American infant
mortality (17.1 per 1,000 live born infants) was more than three times as great at the rate for
White non-Hispanics (4.3 per 1,000 live born infants), two-and-a-half times as great as for
Hispanic or Latinos (6.2 per 1,000 live births), and more than two-times as great as the rate found
in American Indian infants (8.4 per 1,000 live born infants).Population counts of
Hispanic or Latino youth are estimates and therefore, mortality rates for this cohort are less
precise than for infants which rely on counts of annual birth certificates. In addition the population
counts are of residents which do not take into account for the substantial number of non-resident
Hispanic or Latinos in Arizona.
Among older youth aged 15 through 19, there was a 11 percent decrease in the total number of
deaths in 2009 (262) compared to 2008 (297). Racial disparities were less apparent in the
mortality rates for older youth. The mortality rates for White non-Hispanic youth (0.4 per 1,000
residents aged 15 through 19), Hispanic or Latino youth (0.7), Black or African American youth
(0.5), and American Indian or Alaskan Native youth (0.9) were lower than in 2008. The population
denominator was based on population projections that are less precise than birth certificates.
Thus, the rates are estimates of mortality across this age cohort.
The Arizona legislature approved a graduated driver license law that requires teens aged 15
years and 6 months old to have an adult at least 21 years of age seated in the front seat at all
times, a driving curfew and supervised training for youth 16 years of age, and limits on the
number of passengers under 18 years of age. This is a best-practice infrastructure building model
that will positively affect the rate of MVC deaths for youth in Arizona. The Child Fatality Review
Program will analyze any trends observed due to the enactment of graduated driving license
restrictions for teen drivers.

Health Status Indicators 09A: Infants and children aged 0 through 19 years in miscellaneous
situations or enrolled in various State programs enumerated by race. (Demographics)
HSI #09A - Demographics (Miscellaneous Data)
CATEGORY
Misc Data
BY RACE

All children
0 through 19
Percent in
household
headed by
single
parent
Percent in
TANF
(Grant)
families
Number
enrolled in
Medicaid

Black or
African
American

American
Indian or
Native
Alaskan

Asian

Native
Hawaiian
or Other
Pacific
Islander

More
than
one
race
reported

Other
and
Unknown

Specific
Reporting
Year

1615081

93442

132837

49704

0

0

0

2009

23.1

21.1

42.8

31.0

13.3

24.0

27.3

25.2

2009

3.5

3.1

8.6

5.6

1.2

0.0

0.0

0.0

2009

821408

644324

56218

88467

13969

0

0

18430

2009

Total
All
Races

White

1891064

144

Number
enrolled in
SCHIP
Number
living in
foster home
care
Number
enrolled in
food stamp
program
Number
enrolled in
WIC
Rate (per
100,000) of
juvenile
crime
arrests
Percentage
of high
school dropouts (grade
9 through
12)

36107

29650

1036

2826

847

0

0

1748

2009

20516

15499

2831

1431

169

0

0

586

2009

454602

358643

36143

50934

3564

1492

0

3826

2009

267162

241369

15988

5365

3146

1294

0

0

2009

4923.6

4909.1

8205.2

3354.1

1432.0

0.0

0.0

0.0

2009

4.8

5.3

5.6

11.3

2.2

0.0

0.0

0.0

2008

Notes - 2011
Narrative:
The estimated number of children aged 0-19 residing in Arizona increased by 0.5 percent from
2008 to 2009. Counts for "White" are imprecise as the total population of Hispanic or Latino 0-19
year olds probably declined in 2009 even though official estimates do not account for the
reduction.
The economic recession in Arizona had a dramatic effect on the percentage of youth enrolled in
Medicaid and food stamps. The number of 0-19 year olds enrolled in Medicaid increased 25
percent in 2009, far more than accounted for by population growth. The following increases were
experienced in enrolled Medicaid children by race; White non-Hispanic (+ 32.2%), Black or
African American (+27.6%), American Indian (+18.1%), and Hispanic or Latino (+16.4). The
aforementioned freeze on new enrollment in the SCHIP resulted in a -43.3% reduction in the total
number of 0-19 year olds served. Food stamp enrollment for 2008 was revised to 318,312. In
2009 enrollment increased significantly (+43%) to 454,602.
Although the Arizona MCH Title V program does not fund most of these programs, Title V funding
is used to support the maternal and child health needs of populations that utilize these programs.
For instance, the Office of Oral Health continues to maintain dental trailers on loan to
communities or non-profit organizations to provide care in underserved areas. The Dental Sealant
program reaches children in underserved and low-income areas and through a HRSA Work
Force grant piloted tele-dental sites in rural Arizona.
The Teen Pregnancy Prevention Program (TPP) actively works with juvenile detention facilities
and the Department of Economic Security to provide education on teen pregnancy prevention to
incarcerated youth and those in foster care. Inter-agency collaboration has enabled a Title V
funded program such as the TPP to reach a cohort of youth that would otherwise be missed with
traditional outreach in public schools.
Many of the various state programs listed above continue to experience substantial cuts in
service capacity due to the economic recession. Particularly hard hit is the Department of
Economic Security which supports TANF, food stamps, foster care programs, and child abuse

145

prevention.

Health Status Indicators 09B: Infants and children aged 0 through 19 years in miscellaneous
situations or enrolled in various State programs enumerated by Hispanic ethnicity.
(Demographics)
HSI #09B - Demographics (Miscellaneous Data)
CATEGORY
Total NOT
Total
Hispanic or
Hispanic or
Miscellaneous Data BY
Latino
Latino
HISPANIC ETHNICITY
All children 0 through 19
Percent in household headed
by single parent
Percent in TANF (Grant)
families
Number enrolled in Medicaid
Number enrolled in SCHIP
Number living in foster home
care
Number enrolled in food stamp
program
Number enrolled in WIC
Rate (per 100,000) of juvenile
crime arrests
Percentage of high school dropouts (grade 9 through 12)

Ethnicity Not
Reported

Specific
Reporting
Year

1161980

729084

0

2009

24.8

23.5

0.0

2009

2.7

4.8

0.0

2009

424969
16098

396439
20009

18430
1748

2009
2009

12170

7760

586

2009

194731

256018

3826

2009

73545

171407

0

2009

4616.2

5456.7

0.0

2009

4.6

7.3

0.0

2008

Notes - 2011
Narrative:
The estimated number of children aged 0-19 residing in Arizona increased by 0.5 percent from
2008 to 2009. Counts for "White" are imprecise as the total population of Hispanic or Latino 0-19
year olds probably declined in 2009 even though official estimates do not account for the
reduction.
The economic recession in Arizona had a dramatic effect on the percentage of youth enrolled in
Medicaid and food stamps. The number of 0-19 year olds enrolled in Medicaid increased 25
percent in 2009, far more than accounted for by population growth. The following increases were
experienced in enrolled Medicaid children by race; White non-Hispanic (+ 32.2%), Black or
African American (+27.6%), American Indian (+18.1%), and Hispanic or Latino (+16.4). The
aforementioned freeze on new enrollment in the SCHIP resulted in a -43.3% reduction in the total
number of 0-19 year olds served. Food stamp enrollment for 2008 was revised to 318,312. In
2009 enrollment increased significantly (+43%) to 454,602.
Although the Arizona MCH Title V program does not fund most of these programs, Title V funding
is used to support the maternal and child health needs of populations that utilize these programs.
For instance, the Office of Oral Health continues to maintain dental trailers on loan to
communities or non-profit organizations to provide care in underserved areas. The Dental Sealant
program reaches children in underserved and low-income areas and through a HRSA Work
Force grant piloted tele-dental sites in rural Arizona.
The Teen Pregnancy Prevention Program (TPP) actively works with juvenile detention facilities
and the Department of Economic Security to provide education on teen pregnancy prevention to
incarcerated youth and those in foster care. Inter-agency collaboration has enabled a Title V
funded program such as the TPP to reach a cohort of youth that would otherwise be missed with

146

traditional outreach in public schools.
Many of the various state programs listed above continue to experience substantial cuts in
service capacity due to the economic recession. Particularly hard hit is the Department of
Economic Security which supports TANF, food stamps, foster care programs, and child abuse
prevention.

Health Status Indicators 10: Geographic living area for all children aged 0 through 19 years.
HSI #10 - Demographics (Geographic Living Area)
Geographic Living Area
Living in metropolitan areas
Living in urban areas
Living in rural areas
Living in frontier areas
Total - all children 0 through 19

Total
1874757
1429900
429547
31617
1891064

Notes - 2011
Narrative:
The percentage of children aged 0 through 19 years living in all areas was estimated to have
increased 0.5 percent in 2009. This is a provisional figure until the Fall of 2009. Revisions in the
methodology used to estimate the number of children reported living in rural and frontier areas in
2008 made comparisons with previous years data unreliable.

Health Status Indicators 11: Percent of the State population at various levels of the federal
poverty level.
HSI #11 - Demographics (Poverty Levels)
Poverty Levels
Total Population
Percent Below: 50% of poverty
100% of poverty
200% of poverty

Total
6595778.0
6.9
18.0
37.1

Notes - 2011
Narrative:
The total population of Arizona was estimated to have increased by 1.4 percent according to U.S.
Census Current Population Survey. The effects of the economic recession and job losses in
Arizona caused all poverty categories increased in 2009. Nearly 7 percent of Arizonans were
classified as severely poor, 18 percent were living below 100 percent of the federal poverty level,
and 37.1 percent were below 200 percent of the federal poverty level. These poverty estimates
are likely reflected in the large increases in the percentages of Arizonans on food stamps and
temporary assistance for needy families.

147

Health Status Indicators 12: Percent of the State population aged 0 through 19 years at
various levels of the federal poverty level.
HSI #12 - Demographics (Poverty Levels)
Poverty Levels
Children 0 through 19 years old
Percent Below: 50% of poverty
100% of poverty
200% of poverty

Total
1891064.0
9.2
25.3
48.2

Notes - 2011
Narrative:
According to the 2009 U.S. Census Current Population Survey (data collected in 2008), an
estimated one-in-four children under 20 years old were living at or below the federal poverty line
and nearly half were below 200 percent of the federal poverty level. The only decrease in poverty
was found among the severely poor as that estimate declined insignificantly to 9.2 percent.

F. Other Program Activities
Arizona Telemedicine Program
OCSHCN is part of the Arizona Telemedicine Program and has an established CSHCN
telemedicine network at four regional sites throughout the state. Telemedicine has increased
access to care for CSHCN in remote areas of the state and allowed for more efficient utilization of
rare pediatric subspecialty providers in the areas of neurology and orthopedics. OCSHCN is
developing a more extensive CSHCN telemedicine network to include an Indian Reservation
based health center and outreach clinic sites. The expansion will also increase the types of
specialty care offered through telemedicine visits to include hearing screening, cardiology,
metabolic nutrition and genetic testing follow up at multiple sites throughout the state, especially
in areas without or with limited access to pediatric specialty providers.
Family Violence Prevention & Services Grant
The Family Violence Prevention and Services Act provides funding to prevent family violence and
to provide immediate shelter and related assistance for victims of family violence and their
dependents. In Arizona, funds are provided to safe homes in rural areas, known as the Rural
Safe Home Network. Between October 1, 2008 and September 30, 2009 the Rural Safe Home
Network provided 14,567 shelter nights to 466 women, 515 children and 3 men.
Sexual Violence Prevention & Education Grant
Arizona's Sexual Violence Prevention and Education Program is funded through Centers for
Disease Control and Prevention. Between November 1, 2008 and October 31, 2009, the
program reached 25,719 Arizonans with primary prevention of sexual violence and education. In
2009 BWCH expanded its scope beyond primary prevention of sexual violence and was awarded
a Department of Justice grant for direct services of survivors of sexual assault. These funds are
unique with respect to providing services to those collaterally affected by the victimization,
including but not limited to, friends, coworkers, and classmates.
Toll-Free Hotlines

148

BWCH operates three toll-free hotlines: the Children's Information Center (CIC), the Pregnancy
and Breastfeeding Hotline, and the WIC Hotline. The CIC is a statewide, bilingual/bicultural tollfree number that provides information, referral, support, education and advocacy to family care
givers and health care professionals throughout Arizona. The Pregnancy and Breastfeeding
Hotline facilitates entry of pregnant women into prenatal care services and provides breastfeeding
support. The Hotline serves as the state's Baby Arizona Hotline, in partnership with Arizona's
Medicaid agency, AHCCCS. Baby Arizona is a presumptive eligibility process which enables
pregnant women to access prenatal care before Medicaid eligibility is determined. The Hotline is
staffed by two bilingual Certified Lactation Consultants. An International Board Certified Lactation
Counselor is available to answer all breastfeeding questions after normal business hours and to
answer technical questions 24 hours a day, seven days a week.
EMPOWER
In 2010, ADHS implemented s new program known as the Empower Program. The program
promotes 10 standards on nutrition, physical activity and tobacco prevention designed to create a
healthy environment for children in child care settings. Child care providers that adopt the
standards receive a reduction in licensing fees, training and technical assistance, and a logo that
identifies them as an "Empower Center." ADHS blended three funding streams, including Title
V, to help off-set the licensing fees for providers that participate in the program. The
development of Empower helped to facilitate proposed changes in licensing requirements that
support the standards.
HRSA's State Early Childhood Comprehensive Systems Grant (SECCS)
Arizona's SECCS grant is administered by and integrated into the work of Arizona's Early
Childhood Development and Education Board, known as First Things First. BWCH receives
some funding from the grant to enhance integration of early childhood at ADHS and among other
state agencies. BWCH convenes an ADHS bimonthly 0-5 workgroup to foster coordination of
maternal and child health services within ADHS.
HRSA's Emergency Medical Services for Children (EMSC)
The EMSC program utilized its Pediatric Advisory Committee for Emergency Services, along with
additional stakeholders, to begin working on establishing a voluntary pediatric designation system
for hospital emergency departments. This system will identify minimum training and equipment a
hospital should have to care for a pediatric patient, and is scheduled to begin in fall of 2010.
State Systems Development Initiative (SSDI)
The overarching goal of the Arizona State Systems Development Initiative (SSDI) is to enhance
the epidemiological structure of the Bureau of Women's and Children's Health (BWCH) to
facilitate linking and reporting of data that will be used to improve women's and children's health.
Data systems involved in the SSDI project include birth and death records, WIC, birth defects
registry, community nursing, hospital discharge, behavioral health, and newborn screening.

G. Technical Assistance
The ADHS Office of Oral Health requests additional training assistance to create and enhance
coordination between ADHS and other state and non-state agencies to promote oral health
priorities. There is a need for enhance integration of oral health interventions into other health
programs.

149

V. Budget Narrative
Budget and expenditure data from Forms 3, 4, and 5 are provided for the application year, interim
year, and reporting year to assist the reviewer in analysis of the budget and expenditure
narrative. For complete financial data, refer to all the financial data reported on Forms 2-5,
especially when reviewing the federal allocation on Form 2 for the 30%/30%/10% breakdown for
the budgets planned for primary and preventive care for children, children with special health care
needs, and administrative costs.

Form 3, State MCH Funding Profile

1. Federal
Allocation
(Line1, Form 2)
2. Unobligated
Balance
(Line2, Form 2)
3. State Funds
(Line3, Form 2)
4. Local MCH
Funds
(Line4, Form 2)
5. Other Funds
(Line5, Form 2)
6. Program
Income
(Line6, Form 2)
7. Subtotal
8. Other
Federal Funds
(Line10, Form 2)
9. Total
(Line11, Form 2)

FY 2009
Budgeted Expended
7028756
5653715

FY 2010
Budgeted Expended
7035771

FY 2011
Budgeted Expended
7090511

394791

474628

1166773

612223

17892553

12603084

6063683

7734184

0

0

0

0

34243753

22932949

6790456

31969534

0

0

0

0

59559853

41664376

21056683

47406452

159137459

161256851

70982759

74092038

218697312

202921227

92039442

121498490

Form 4, Budget Details By Types of Individuals Served (I) and Sources of Other
Federal Funds
I. Federal-State
MCH Block Grant
Partnership
a. Pregnant
Women
b. Infants < 1 year
old
c. Children 1 to
22 years old
d. Children with

FY 2009
Budgeted Expended

FY 2010
Budgeted Expended

FY 2011
Budgeted Expended

1610053

1403115

2079462

1819821

10572144

3748192

1765108

3739081

9457947

7271800

9202688

6097680

35698324

27484665

6419851

33794776

150

Special
Healthcare Needs
e. Others
1518510
1313096
885997
1499676
f. Administration
702875
443508
703577
455418
g. SUBTOTAL
59559853 41664376 21056683
47406452
II. Other Federal Funds (under the control of the person responsible for administration of
the Title V program).
a. SPRANS
0
0
0
b. SSDI
94644
94644
93713
c. CISS
140000
0
0
d. Abstinence
0
0
0
Education
e. Healthy Start
0
0
0
f. EMSC
115000
130000
130000
g. WIC
86373163
0
0
h. AIDS
0
0
0
i. CDC
0
0
0
j. Education
0
0
0
k. Other
1ST TIME
0
497213
500000
MOTHERHOOD
CRS
61143652
59610387
68937712
FAMILY
1730552
1700000
1868628
VIOLENCE
NGIT FASD252778
264199
227669
SAMHSA
ORAL HEALTH
0
0
384092
WORKFORC
PROJECT
0
900946
900000
LAUNCH
RAPE PREV ED
671551
651448
640456
SEXUAL
0
0
282410
ASSAULT SVCS
STATE INJURY
116700
116748
127358
SURVEIL
KIDS CARE
6717174
6717174
0
SPINAL HEAD
300000
300000
0
INJURY
CHILD FATALITY
148000
0
0
PHBG
1184314
0
0
UNIVERSAL NB
149931
0
0
HEARING

Form 5, State Title V Program Budget and Expenditures by Types of Services (II)

I. Direct Health
Care Services
II. Enabling
Services
III. PopulationBased Services

FY 2009
Budgeted Expended
37594218 29955895

FY 2010
Budgeted Expended
5305578

FY 2011
Budgeted Expended
35021005

2379095

1872983

3241647

2306163

12497718

5153458

6039920

4748460

151

IV. Infrastructure
Building Services
V. Federal-State
Title V Block
Grant Partnership
Total

7088822

4682040

6469538

5330824

59559853

41664376

21056683

47406452

A. Expenditures
Over the past three years, ADHS has been required to dramatically reduce spending and staffing
levels in an effort to bring state spending in line with substantially reduced state revenues. State
general funding for Health Start, Abstinence Education, County Prenatal Service, Children's
Rehabilitative Services, and Pregnancy Services were completely eliminated. The budget for the
High Risk Perinatal Program was reduced by nearly 60 percent. In spite of the state general fund
reductions, the state's match and overmatch continues to exceed the 1989 maintenance of effort.

B. Budget
The estimated Title V allocation for Arizona, FFY2011, is $7,090,511. For FFY 2010, 33.12%
($2,348,502) of the Title V Block grant will be allocated for preventative and primary care needs
for children and adolescents; 30.71% ($2,117,202) will be allocated to children with special health
care needs; 29.75% ($2,009,389) will be allocated for women, mothers, and infants and 6.42%
($455,418) will be budgeted for administrative costs.
It is projected that there will be $612,223 unobligated funds from our FY2010 block grant. The
Office for Children with Special Health Care Needs expends their funds on a state fiscal year (7/1
- 6/30) and does not begin using the funds awarded 10/1 until 7/1 the following year.
For FFY 2010, the state's match and maintenance of effort includes State General, Lottery,
Dental Sealant, and donation funds. The $30,903,383 in State General funds include High Risk
Perinatal Services, Children's Rehabilitation Services (CRS), Child Fatality Review Program, and
operating funds allocated to the Public Health Prevention Division and, supports some of the
personnel located in the Bureau of the Women's and Children Health, and the Office of Oral
Health. The $5,222,260 in Lottery funds includes the Teen Pregnancy Prevention and Prenatal
Outreach (Health Start) Programs. The $101,968 in donation funds are for the Children's
Rehabilitation Services Program and $250,000 is from fees generated by the Dental Sealant
Program. Arizona's FY2010 match and overmatch of $39,703,718 continues to exceed the
maintenance of effort amount of FY1989's $12,056,360.
Other federal funds administered by the MCH Chief and CSHCN Chief besides the MCH Title V
Block Grant Program include matching funds from Title XIX and Title XXI for Children's
Rehabilitative Services, Rape Prevention and Education, Sexual Assault Services, Oral Health
Workforce Activities, Family Violence Prevention, Core State Injury Surveillance and Program
Development, Emergency Medical Service for Children, State Systems Development Initiative,
NGIT Fetal Alcohol Spectrum Disorders, 1st Time Motherhood, and Project Launch.
Core Public Health Infrastructure - $3,564,141: Bureau of Women's and Children's Health (Part A
& B): $1,573,939 will support the Department's birth defect registry, management service,
information technology automation, assessment, evaluation and epidemiologic analysis, Child
Fatality services, and the Midwife Licensing Program. Strategic planning is currently in progress
to finalize how best to utilize Title V funds to support new priorities of preconception health,
obesity/overweight, injury prevention, and behavioral health. Infrastructure strategies to address
these priorities may include policy initiatives, coalition building, and provider education. Title V
funds may be used to support the Empower program, which promotes health standards for child
care providers, if alternative resources are not secured to support Empower.

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Office of Children with Special Health Care Needs (Part C): $1,990,202 will support administrative
initiatives, CRS Direct Services, Service Coordination, Early Intervention, Education, Training,
Support Services and Advocacy, Outreach and Member Services.
Population-Based Services: $1,194,559 is budgeted for initiatives that include the Sensory
Program, Pregnancy and Breastfeeding Hotline, Breastfeeding Consultation, Immunizations,
Early Childhood, and Oral Health services for children. Strategic planning is currently in progress
to finalize how best to utilize Title V funds to support new priorities of preconception health,
obesity/overweight, injury prevention, and behavioral health. Population-based services to
address these priorities may include community education and social marketing.
Enabling and Non-Health Support: $210,154 will support the Medical Home Project and the
Pregnancy and Breastfeeding Hotline.
Direct Health Care Service: $1,666,239 will support community nursing services for high-risk
infants, and Reproductive Health services for women.
Indirect Administrative Costs: $455,418

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VI. Reporting Forms-General Information
Please refer to Forms 2-21, completed by the state as part of its online application.

VII. Performance and Outcome Measure Detail Sheets
For the National Performance Measures, detail sheets are provided as a part of the Guidance.
States create one detail sheet for each state performance measure; to view these detail sheets
please refer to Form 16 in the Forms section of the online application.
For the detail sheets and objectives for the state performance measures developed from the 2010
needs assessment, refer to TVIS Forms, Form 11 and Form 16 under the section “New State
Performance Measure Detail Sheets and Data.

VIII. Glossary
A standard glossary is provided as a part of the Guidance; if the state has also provided a statespecific glossary, it will appear as an attachment to this section.

IX. Technical Note
Please refer to Section IX of the Guidance.

X. Appendices and State Supporting documents
A. Needs Assessment
Please refer to Section II attachments, if provided.

B. All Reporting Forms
Please refer to Forms 2-21 completed as part of the online application.

C. Organizational Charts and All Other State Supporting Documents
Please refer to Section III, C "Organizational Structure".

D. Annual Report Data
This requirement is fulfilled by the completion of the online narrative and forms; please refer to
those sections.

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