Maternal and Child Health Services
Title V Block Grant

State Narrative for
Arizona
Application for 2012
Annual Report for 2010

Document Generation Date: Tuesday, September 13, 2011

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.................................................................................................................... 19
C. Organizational Structure........................................................................................................ 27
D. Other MCH Capacity ............................................................................................................. 29
E. State Agency Coordination.................................................................................................... 33
F. Health Systems Capacity Indicators ...................................................................................... 36
Health Systems Capacity Indicator 01: .................................................................................. 36
Health Systems Capacity Indicator 02: .................................................................................. 37
Health Systems Capacity Indicator 03: .................................................................................. 38
Health Systems Capacity Indicator 04: .................................................................................. 38
Health Systems Capacity Indicator 07A:................................................................................ 39
Health Systems Capacity Indicator 07B:................................................................................ 40
Health Systems Capacity Indicator 08: .................................................................................. 41
Health Systems Capacity Indicator 05A:................................................................................ 42
Health Systems Capacity Indicator 05B:................................................................................ 43
Health Systems Capacity Indicator 05C:................................................................................ 44
Health Systems Capacity Indicator 05D:................................................................................ 44
Health Systems Capacity Indicator 06A:................................................................................ 45
Health Systems Capacity Indicator 06B:................................................................................ 46
Health Systems Capacity Indicator 06C:................................................................................ 46
Health Systems Capacity Indicator 09A:................................................................................ 47
Health Systems Capacity Indicator 09B:................................................................................ 48
IV. Priorities, Performance and Program Activities ....................................................................... 50
A. Background and Overview .................................................................................................... 50
B. State Priorities ....................................................................................................................... 51
C. National Performance Measures........................................................................................... 55
Performance Measure 01:...................................................................................................... 55
Form 6, Number and Percentage of Newborns and Others Screened, Cases Confirmed, and
Treated ................................................................................................................................... 58
Performance Measure 02:...................................................................................................... 59
Performance Measure 03:...................................................................................................... 62
Performance Measure 04:...................................................................................................... 66
Performance Measure 05:...................................................................................................... 69
Performance Measure 06:...................................................................................................... 72
Performance Measure 07:...................................................................................................... 75
Performance Measure 08:...................................................................................................... 79
Performance Measure 09:...................................................................................................... 81
Performance Measure 10:...................................................................................................... 83
Performance Measure 11:...................................................................................................... 87
Performance Measure 12:...................................................................................................... 90
Performance Measure 13:...................................................................................................... 94
Performance Measure 14:...................................................................................................... 97
Performance Measure 15:...................................................................................................... 99
Performance Measure 16:.................................................................................................... 102

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Performance Measure 17:.................................................................................................... 104
Performance Measure 18:.................................................................................................... 107
D. State Performance Measures.............................................................................................. 109
State Performance Measure 1: ............................................................................................ 109
State Performance Measure 2: ............................................................................................ 112
State Performance Measure 3: ............................................................................................ 114
State Performance Measure 4: ............................................................................................ 117
State Performance Measure 5: ............................................................................................ 120
State Performance Measure 6: ............................................................................................ 123
State Performance Measure 7: ............................................................................................ 125
State Performance Measure 8: ............................................................................................ 128
E. Health Status Indicators ...................................................................................................... 130
Health Status Indicators 01A:............................................................................................... 131
Health Status Indicators 01B:............................................................................................... 132
Health Status Indicators 02A:............................................................................................... 133
Health Status Indicators 02B:............................................................................................... 134
Health Status Indicators 03A:............................................................................................... 135
Health Status Indicators 03B:............................................................................................... 136
Health Status Indicators 03C:............................................................................................... 137
Health Status Indicators 04A:............................................................................................... 138
Health Status Indicators 04B:............................................................................................... 139
Health Status Indicators 04C:............................................................................................... 140
Health Status Indicators 05A:............................................................................................... 141
Health Status Indicators 05B:............................................................................................... 142
Health Status Indicators 06A:............................................................................................... 144
Health Status Indicators 06B:............................................................................................... 144
Health Status Indicators 07A:............................................................................................... 145
Health Status Indicators 07B:............................................................................................... 146
Health Status Indicators 08A:............................................................................................... 146
Health Status Indicators 08B:............................................................................................... 148
Health Status Indicators 09A:............................................................................................... 149
Health Status Indicators 09B:............................................................................................... 150
Health Status Indicators 10: ................................................................................................. 152
Health Status Indicators 11: ................................................................................................. 152
Health Status Indicators 12: ................................................................................................. 152
F. Other Program Activities...................................................................................................... 153
G. Technical Assistance .......................................................................................................... 154
V. Budget Narrative ..................................................................................................................... 156
Form 3, State MCH Funding Profile ..................................................................................... 156
Form 4, Budget Details By Types of Individuals Served (I) and Sources of Other Federal
Funds.................................................................................................................................... 156
Form 5, State Title V Program Budget and Expenditures by Types of Services (II)............ 157
A. Expenditures........................................................................................................................ 158
B. Budget ................................................................................................................................. 158
VI. Reporting Forms-General Information ................................................................................... 161
VII. Performance and Outcome Measure Detail Sheets ............................................................. 161
VIII. Glossary ............................................................................................................................... 161
IX. Technical Note ....................................................................................................................... 161
X. Appendices and State Supporting documents........................................................................ 161
A. Needs Assessment.............................................................................................................. 161
B. All Reporting Forms............................................................................................................. 161
C. Organizational Charts and All Other State Supporting Documents .................................... 161
D. Annual Report Data ............................................................................................................. 161

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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. IA - Letter of Transmittal

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.

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
Medical Association, American Academy of Pediatrics, hospitals and other health care providers,

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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.
/2012/ New Title V priorities were announced on the agency website and disseminated
through the BWCH newsletter, with an invitation for further input on implementation of the
priorities. The Bureau of Women's & Children's Health targeted public input this past year
to new funding opportunities. Special community public meetings were held to dscuss
the new federal funding for Abstinence Education, Personal Responsibility and Education
Program, and Maternal, Infant, and Early Childhood Home Visiting. Community input was
critical in the development of these programs. The draft 2012 Title V application and
annual report for 2010 was posted on the ADHS website. Twitter was used as one
mechanism to notify the public about the draft and ask for comments. A family advisor
also reviewed the application and provided comments. //2012//

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II. Needs Assessment
In application year 2012, Section IIC will be used to provide updates to the Needs Assessment if
any updates occurred.

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
group of stakeholders and ADHS staff charged with setting general MCH priorities. This new

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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 /2012/ 6,595,778
//2012//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. /2012/ According to the
2010 Census, the population of Arizona declined to an estimated 6,392,017, or 3.1% lower
than the previous year estimate. The decline is likely due to reduced immigration from
other states and Latin America as a result of the economic recession in Arizona. //2012//
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.

8

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
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. /2012/ In 2010, births declined another 6 percent to
87,053 live deliveries. //2012//
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. /2012/ This pattern continued in
2010 as White non-Hispanic births were 38,777 and Hispanic or Latino births totaled
34,333. The decline ton total births in Arizona is being driven by the reduction in Hispanic
or Latino deliveries. //2012//
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. /2012/ Senate Bill 1070 is currently
under consideration by the federal courts and major components of the law are not
currently in effect in Arizona. //2012//
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. /2012/ The total number of women of
childbearing age in Arizona decreased by 6 percent in 2010 to 1,262,557 //2012//
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). /2012/ According to the 2010 Census,
approximately 30 percent of Arizona's population is Hispanic or Latino of any race. White
(73 percent) made up the largest single race group. //2012//
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.

9

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
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

10

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
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./2012/ In June 2011, the Kaiser State of Health Report
showed Arizona ranked 34th in economic distress. Arizona still ranked high in foreclosure
rates (2nd), but showed ‘improvement' relative to other states in the percent change in
annual unemployment (34th) and food stamp participation (34th). It is important to note
that the actual unemployment rate in Arizona (9.3 percent, April 2011) remained above the
national rate (9.1percent). //2012//
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). /2012/ The 2009 American Community Survey showed 16.5 percent of
Arizonans living in poverty. //2012// 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

11

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. /2012/ The 2009 American Community Survey showed
increases in the rates of poverty among women (17 percent), children under 18 years (23
percent), Black or African Americans (22 percent), American Indian and Alaskan Natives
(37 percent), and Hispanic or Latinos (26 percent). //2012//
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
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:

12

•

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
(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;

13

•

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.
/2012/ State budget reductions in FY11 and FY12 primarily occurred in education, the
Medicaid Program (AHCCCS), and Behavioral Health. No further cuts were made to state
public health programs. The State implemented mandatory furlough days in FY11 and a
pay cut. Furlough days were eliminated for state FY12. //2012//
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
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),

14

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.
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

15

Legislature restored the matching funds for KidsCare with a freeze on new enrollment.
/2012/ KidsCare enrollments totalled 18,646 as of June 1, 2011. Enrollments were over
45,000 in January 2010 when the enrollment freeze took effect. There were over 105,000
applicants on the KidsCare waiting list as of June 15, 2011. //2012//
/2012/ Due to continued budget shortfalls, AHCCCS was required to implement changes to
the benefit package for people age 21 and older. Annual well exams and most dental care
services were eliminated effective October 2010. Certain transplants that had been
eliminated were restored in April 2011. Additional pending changes may result in
substantial reductions to the amount of respite care available to families of children with
special health care needs. //2012//
/2012/ The Arizona Legislature passed a Medicaid Reform Package that will eliminate
AHCCCS coverage for specific categories of people, including childless adults, people on
a Medical Spend-Down Program, and parents earning 75% to 100% of federal poverty level.
In total, an estimated 130,000 to 160,000 are expected to lose medical coverage during the
next 12 months, pending federal approval. //2012//
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.
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

16

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.
/2012/ The CRS program was moved from ADHS to AHCCCS in January 2011. Services for
CRS members remain the same. //2012//
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
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.

17

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
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.
/2012/ In August 2010, HRSA released the first round of funding from the Affordable Care
Act to develop community health centers through new access points. An estimated 20
applications were submitted by Arizona community-based organizations. Awards are
expected to be made for 350 new community health centers throughout the country in the
fall. In October 2010, HRSA released the first round of funding for expanded services to
increase access to care for primary and preventative care. Arizona anticipates benefiting

18

from these grant opportunities. Arizona currently has 16 federally qualified health centers
with over 100 sites. These sites are located in every county except for La Paz and Gila
counties. //2012//
An attachment is included in this section. IIIA - Overview

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

19

law enforcement agencies, prosecutors, medical examiners, health care facilities and social
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.
/2012/ In 2011, the Arizona Legislature revised the state child fatality statute to add
authority to review maternal deaths. Maternal mortality review will be implemented
through a sub-committee of the State Child Fatality Review Team. //2012//
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.

20

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
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

21

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
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

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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.
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.
/2012/ Funds have not been appropriated yet for any of the oral health initiatives included
in the health care reform legislation. //2012//
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.
/2012/ Arizona was awarded a competitive grant from the CDC for core injury prevention.
This will enable Arizona to continue its injury prevention program for the next five years.
//2012//
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.
/2012/ Bureau of Women's & Children's Health received $1.2 million in federal Abstinence

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Education funding that was reauthorized through the Affordable Care Act, as well as $1
million for the new Personal Responsibility and Education Program. Competitive grants
will be awarded to community based projects to begin implementing these programs in
2011. //2012//
/2012/ Home Visiting
Arizona submitted applications and began receiving new federal funding to implement the
Maternal, Infant, and Early Childhood Home Visiting Program. ADHS Bureau of Women's
& Children's Health worked collaboratively with Department of Economic Security,
Department of Education Head Start Office, Behavioral Health, and First Things First to
shape the program. Communities with the high risk ranking on several indicators will be
targeted for implementation of evidence-based home visiting programs. ADHS will
continue to work with partners on development of infrastructure for home visiting in
Arizona. //2012//
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
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.
/2012/ As of January 1, 2011, Arizona's Medicaid Agency, AHCCCS, assumed
responsibility for administration of Children's Rehabilitative Services (CRS). All services
to families enrolled in CRS remain the same. //2012//
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

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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.
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

25

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.
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

26

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.

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
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

27

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 Needs
The Office for Children with Special Health Care Needs has five divisions, plus a medical director
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.

28

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.
/2012/ The Office for Children with Special Health Care Needs was merged with and
became an office within the Bureau of Women's and Children's Health in January 2011.
The Children's with Rehabilitative Services Program was moved to AHCCCS, Arizona's
Medicaid agency, on January 1, 2011. OCSHCN maintains its critical Title V role by
assisting families in accessing appropriate care and services for children and youth with
special health care needs (CYSHCN), providing information and referral services including
SSI applicants under age 21 informing them of potential resources for which they may be
eligible, training to families and professionals on best practices related to medical home,
cultural competence, pediatric to adult transition and family centered care, technical
assistance in the development of best practices for CYSHCN among providers, school
nurses, community partners and other child serving agencies through education and
training and supports telemedicine to provide services in remote areas of the state.
OCSHCN oversees contracts for social services funds, respite and palliative care,
overnight stays that enable families to stay near their hospitalized CYSHCN and to
increase the involvement of families and youth within OCSHCN, other ADHS programs and
other state agencies. OCSHCN currently includes an Office Chief, and Education &
Advocacy Manager, a Title V Outreach Manager, a Program & Project Specialist, and
Administrative Assistant and an on-site Family Advocate. //2012//
An attachment is included in this section. IIIC - Organizational Structure

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.
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.

29

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
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

30

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
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

31

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.
/2012/ Marta Urbina was appointed Office Chief for Children with Special Health Care
Needs in January 2011. Rita Aitken has served as Education & Advocacy Manager since
April 2011. Ralph Figueroa was hired as the Title V Outreach Manager in April 2011. Mr.
Figueroa is a parent of a young adult with learning disabilities. He has worked as an
administrator for the Division of Developmental Disabilities and for Arizona's Parent to
Parent Center, Raising Special Kids. Mr. Figueroa has extensive expertise in the
educational system, social services, and community-based organizations. //2012//

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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

33

Program (AzEIP), AHCCCS, Division of Developmental Disabilities (DDD), Arizona Schools for
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

34

professionals and consumers from Texas, New Mexico, Arizona, Utah, Colorado, Wyoming,
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.

35

/2012/ Additional partnering with tribal and Native American organizations occurred in
2011. The Office of Oral Health assisted with development and implementation of an
Arizona Native American Oral Health Summit in April 2011. The Office for Children with
Special Health Care Needs will join the planning process for the next oral health summit.
BWCH developed a partnership with the White Mountain Apache Tribe to implement a
promising practice as part of the federal home visiting program. OCSHCN engaged the
Salt River Pima-Maricopa Community around youth leadership for youth with special
health care needs. //2012//
/2012/ The Association of Community Health Centers is an active participate in the BWCH
Preconception Health Taskforce and the Women's & Girls' Health Conference Planning
Committee. BWCH also engaged city housing and employment agencies in planning of
the women's health conference. //2012//

F. Health Systems Capacity Indicators
Introduction
/2012/ Asthma admissions per 10,000 youth under 5 years of age increased significantly in
2010. The increase may be caused by an actual increase in the incidence of asthma and/or
an increase in the proportion of repeat admissions by the most at-risk children. Eligibility
levels for enrollment in Arizona Medicaid (AHCCCS) remained the same across all
population groups in 2010. //2012// 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. /2012/ The Arizona Legislature passed a Medicaid Reform Package that
will eliminate AHCCCS coverage for specific categories of people, including childless
adults, people on a Medical Spend-Down Program, and parents earning 75% to 100% of
federal poverty level. In total, an estimated 130,000 to 160,000 are expected to lose
medical coverage during the next 12 months, pending federal approval. //2012//
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
2006
2007
2008
2009
2010
Annual Indicator
27.4
28.1
28.9
26.9
31.2
Numerator
1323
1400
1447
1342
1424
Denominator
482344 499045 501481 498464 455715
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 - 2010
The rate for 2010 was significantly greater than the rate for 2009 (p<0.0001). However, it is
important to note that the 2009 Census Bureau population estimates for Arizona were likely overestimated. This means the 2009 rate of asthma admissions was likely an underestimate.
Notes - 2009

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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.

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.
/2012/ The rate of hospitalization for asthma among this age cohort increased in 2010.
When compared with 2009 (26.9 per 10,000 children) the 2010 rate (31.2 per10,000 children)
was significantly greater Chi-square=15.406 (1), p<0.00008. Although it is yet to be
determined, the increase may be the result of a true increase in the incidence of asthma
and/or an increase in repeat admissions for asthma by an at-risk cohort of children. An
analysis of 2009 Arizona emergency room data showed that 11% of visits by children were
repeat visits in the same calendar year.
In 2009-2010 the Office of Oral collected information on asthma prevalence among third
grade school children across Arizona. Results from the 2009 Arizona Healthy Smiles,
Healthy Bodies Survey estimated current asthma among pre-school and third grade
students at 4.5 percent. //2012//

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
2006
2007
2008
2009
2010
Annual Indicator
97.6
96.4
99.1
100.0 100.0
Numerator
56520 58301 58861 57283 39546
Denominator
57884 60473 59373 57283 39546
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.
/2012/ According to 2010 data provided Arizona Medicaid (Arizona Health Care Cost
Containment System) 100 percent of infants enrolled in health plans that contract with

37

AHCCCS received at least one initial periodic screen. However, the number of enrollees
declined by 31 percent in 2010 compared to 2009. //2012// 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. /2012/ The
state MCH Program (Bureau of Women's and Children's Health) and SSDI have no access
to client level Medicaid data for analysis purposes. //2012//

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
2006 2007 2008 2009 2010
Annual Indicator
78.4 82.5 84.0 82.1 100.0
Numerator
580
721
646
320
21
Denominator
740
874
769
390
21
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 - 2010
Enrollement in Arizona's SCHIP (KidsCare) was indefinitely frozen in 2010 per legislative action.

Narrative:
/2012/ The total number of enrollees in KidsCare (SCHIP) declined nearly 93 percent. As of
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 have
any infants enrolled in this program in 2011 and will not have any data to report on this
measure beyond 2010. //2012//

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
2006
2007
2008
2009
2010
Annual Indicator
69.8
70.3
71.7
72.5
73.7
Numerator
70976
71865
70965 66838 63900
Denominator
101749 102246 98971 92162 86664
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.

38

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. /2012/ The percentage of
Arizonan women aged 15 through 44 who entered prenatal care during the first trimester
increased in 2010 to 82 percent. //2012//
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 by the state /2012/ legislature. //2012//
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
2006
2007
2008
2009
2010
Annual Indicator
74.5
74.7
76.8
78.5
82.0
Numerator
432605 434205 468812 529527 603750
Denominator
580568 581632 610091 674385 736529
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 - 2010
Arizona Medicaid (AHCCCS) provides the estimate for this measures. The ADHS Bureau of
Women's and Children's Health does not have access to Medicaid data and, therefore, is unable
to analyze the data to verify the accuracy of the estimate.

Narrative:
The percent of children enrolled in Medicaid (AHCCCS) who have received a service paid by
AHCCCS increased over each year from 2006 (74.5 percent) to 2010 (82.0 percent). /2012/ This
is particularly impressive considering the growth in the total number of children eligible
for AHCCCS (27% increase over five years). //2012//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

39

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
2006
2007
2008
2009
2010
Annual Indicator
54.1
56.6
59.6
62.9
66.5
Numerator
66522
71063
80349
96768
109672
Denominator
122975 125470 134811 153910 164910
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
The numerator for 2009 has been corrected to reflect the true number of of EPSDT eligible
children aged 6 through 9 years who have received any dental services during the year.

Narrative:
/2012/ The estimate for 2009 was revised up to 62.9 percent. The estimate for percent of
EPSDT eligible children ages 6 to 9 who received any dental service rose to 66.5% in 2010.
Compared to 2009, the percent increased significantly (Chi sq.=459.875(1), p<0.0001) in
2010. //2012//The Office of Oral Health provides referrals to high-risk children to ensure they
receive dental services. /2012/ In 2009-2010 the ADHS school-based sealant program placed
sealants on 2,592 EPSDT eligible children; this is a 60 percent increase from the 2008-2009
school year. During the 2009-2010 school year the program served four of Arizona's
fifteen counties. According to the 2009 oral health survey of third grade children, tooth
decay is still a significant health problem for Arizona children: 75 percent of them have
experienced tooth decay with 42% having untreated decay. These rates are significantly
higher than the Healthy People 2010 targets of 42 percent and 21 percent respectively.
//2012// 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.
/2012/ The Office of Oral Health administers a school-based fluoride mouth rinse program
which serves 24,553 children throughout Arizona. //2012//
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 the HRSA Workforce Grant, the Office is continuing to promote the
development of enhanced dental teams using teledentistry to increase workforce activities in
underserved locations. 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.

40

While the Patient Protection and Affordable Care Act of 2010 included language about improving
oral health infrastructure, including school based dental sealant programs, these initiatives have
not yet been funded.

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
2006
2007
2008
2009
2010
Annual Indicator
43.1
47.4
46.4
100.0 100.0
Numerator
6627
7540
7630
17327 17886
Denominator
15392 15891 16443 17327 17886
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 - 2010
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 - 2009
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.

Narrative:
Previous to 2009, 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 /2012/ 17,886 //2012// SSI beneficiaries who are identified by the
Social Security Administration as applying for SSI services /2012/ in 2010 //2012// are reported in
both the numerator and the denominator for this measure.

41

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

2010

DATA SOURCE

payment source
from birth certificate

POPULATION
MEDICAID NONMEDICAID

ALL

7.5

7.1

6.6

Narrative:
The percent of low birth weight in Arizona remained at 7.1 percent in /2012/ 2010. //2012//
Although the percent of low birth weight infants born to mothers on Medicaid (AHCCS) increased
/2012/ from 7.3 percent in 2009 to 7.5 percent in 2010 //2012//, the increase was not
significant.
The Bureau of Women's & Children's Health (BWCH) enhanced efforts directed toward
preconception health in /2012/ recent years //2012//. Through a HRSA First Time Motherhood
grant, BWCH produced 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 and developed a statewide preconception health plan. BWCH and its partners
selected preconception health as a new state MCH priority for the next five years. /2012/
Starting in 2011, Title V funding has been provided to six county health departments to
implement preconception health strategies. BWCH programs have also continued
integration of //2012//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 has trained 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

42

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
INDICATOR #05
POPULATION
YEAR
DATA SOURCE
Comparison of health
MEDICAID NONALL
system capacity
MEDICAID
indicators for Medicaid,
non-Medicaid, and all
MCH populations in the
State
Infant deaths per 1,000
2010
other
0
0
6
live births
Notes - 2012
The Arizona Death Certificate does not contain information on the insurance status of the infant at
the time of death.

Narrative:
/2012/ The total infant mortality rate per 1,000 live births saw a non-significant increase in
2010. Arizona is meeting the current HP 2020 Goal for infant mortality. Infant death
statistics in Arizona are not available by payer. //2012//
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
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 and developed a statewide preconception health
plan. BWCH and its partners selected preconception health as a new state MCH priority. /2012/
Starting in 2011, Title V funding has been provided to six county health departments to
implement preconception health strategies. //2012// Increased focus and funding on
preconception health is intended to improve multiple birth outcomes, including infant death.
/2012/ In 2010 //2012//, 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, /2012/ improving funding to
the Arizona Poison Center's Pregnancy Riskline to provide information about risks
associated with drug and medication exposures, and improving reporting of suspected
child abuse or neglect. //2012//
/2012/ While state budget cuts to Medicaid could potentially impact the rate of infant death,
some areas of Arizona's public health system are increasing in their capacity to potentially
impact infant death. //2012// Arizona has experienced enhanced funding of home visiting
programs through First Things First and has received 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.

43

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

2010

DATA SOURCE

payment source
from birth certificate

POPULATION
MEDICAID NONMEDICAID

ALL

75.6

81.9

89.2

Narrative:
The percentage of Arizonan women aged 15 through 44 who entered prenatal care during the
first trimester increased insignificantly from /2012/ 80 percent in 2009 to 81.9 percent in 2010
//2012//. Medicaid (AHCCCS) enrollees also increased prenatal care at first trimester from /2012/
71.4 percent in 2009 to 75.6 percent in 2010. //2012// However, a significant disparity in the
percent of women initiating first trimester care /2012/ (Chi-square=2710.136 (1), p<0.0001)
//2012//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. /2012/ The AHCCCS data is not available and,
therefore, has not been linked to other MCH data sources by SSDI. //2012//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 sponsored 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
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,

YEAR

DATA SOURCE

POPULATION
MEDICAID NONMEDICAID

ALL

44

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])

2010

payment source
from birth certificate

67.6

80.8

73.7

Narrative:
There was a slight, but insignificant increase in the percentage of pregnant women with adequate
prenatal care according to the Kotelchuck Index. However, a significant disparity exists between
the Medicaid (AHCCCS) and non-Medicaid populations. /2012/ Only 67.6 percent of women on
AHCCCS had at least adequate prenatal care, while 80.8 percent of the non-AHCCCS
population had adequate care according to the Kotelchuck Index (13.2 percent difference).
//2012//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 by SSDI.
The Pregnancy and Breastfeeding Hotline and the Health Start Program continue to encourage
women to access prenatal care.
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)
INDICATOR #06
The percent of poverty level for eligibility in the State's
Medicaid programs for infants (0 to 1), children, Medicaid and
pregnant women.
Infants (0 to 1)
INDICATOR #06
The percent of poverty level for eligibility in the State's SCHIP
programs for infants (0 to 1), children, Medicaid and pregnant
women.
Infants (0 to 1)

YEAR

PERCENT OF
POVERTY LEVEL
Medicaid

2010
YEAR

140
PERCENT OF
POVERTY LEVEL
SCHIP

2010

200

Narrative:
The percent of poverty for eligibility in the state Medicaid (AHCCCS) program and state CHIP
(KidsCare) for infants remained unchanged in /2012/ 2010. //2012// 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

45

increased from 4% of household income to 5% of household income. /2012/ No information was
available in FY2011 on KidsCare premium changes. //2012//

Health Systems Capacity Indicator 06B: The percent of poverty level for eligibility in the
State’s Medicaid and SCHIP programs. - Medicaid Children
INDICATOR #06
The percent of poverty level for eligibility in the State's
Medicaid programs for infants (0 to 1), children, Medicaid and
pregnant women.
Medicaid Children
(Age range 1 to 5)
(Age range 6 to 18)
(Age range to )
INDICATOR #06
The percent of poverty level for eligibility in the State's SCHIP
programs for infants (0 to 1), children, Medicaid and pregnant
women.
Medicaid Children
(Age range 1 to 18)
(Age range to )
(Age range to )

YEAR

PERCENT OF
POVERTY LEVEL
Medicaid

2010
133
100
YEAR

PERCENT OF
POVERTY LEVEL
SCHIP

2010
200

Narrative:
The percent of poverty level for Medicaid programs for infants, children, and pregnant women,
and Arizona SCHIP (KidsCare) remained the same in /2012/ 2010 //2012//. However, KidsCare
enrollment 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. /2012/ Arizona may be the only
state in the U.S. without SCHIP coverage for infants born in 2011. //2012//

Health Systems Capacity Indicator 06C: The percent of poverty level for eligibility in the
State’s Medicaid and SCHIP programs. - Pregnant Women
INDICATOR #06
The percent of poverty level for eligibility in the State's
Medicaid programs for infants (0 to 1), children, Medicaid and
pregnant women.
Pregnant Women
INDICATOR #06
The percent of poverty level for eligibility in the State's SCHIP
programs for infants (0 to 1), children, Medicaid and pregnant
women.
Pregnant Women

YEAR

PERCENT OF
POVERTY LEVEL
Medicaid

2010
YEAR

150
PERCENT OF
POVERTY LEVEL
SCHIP

2010

200

Narrative:
The percent of poverty level for pregnant women in the state Medicaid program and state CHIP
(KidsCare) remained the same in /2012/ 2010 //2012//. 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. /2012/ Arizona may be the only state in the U.S. without SCHIP
coverage for infants born in 2011. //2012//

46

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 3
Yes
Annual linkage of infant
birth and infant death
certificates
1
No
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
Annual linkage of birth
certificates and newborn
screening files
REGISTRIES AND
3
Yes
SURVEYS
Hospital discharge survey
for at least 90% of in-State
discharges
2
No
Annual birth defects
surveillance system
1
No
Survey of recent mothers at
least every two years (like
PRAMS)
Notes - 2012
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.
/2012/ The SSDI position was filled by a Technical IT Consultant in April 2011. Prior to this
date, all SSDI grant funded data linkages were completed by the MCH Epidemiologist and
Chief of the Office of Assessment and Evaluation for the Bureau of Women's and
Children's Health.
The SSDI allowed for the link of infant birth and death certificates to conduct a
retrospective cohort study on the role of interpregnancy interval (see State Performance
Measure) in neonatal infant death.
The SSDI allowed for the link of birth, death, hospital discharge, and fetal death
certificates as part of a Maternal Mortality brief that became the basis of our new Maternal

47

Mortality Review Program. Details about the use of SSDI to support Maternal Mortality
Review may be found in the SSDI Grant Performance Report.
The Bureau of Women's and Children's Health has a data sharing agreement with the
Bureau of Nutrition and Physical Activity (BNP) . The SSDI will work with BNP to link WIC
data to AZ Birth Certificates. Initiating this project has been made more important by the
decision of the CDC to discontinue PedNSS/PNSS data analysis. //2012//

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 - 2012
Narrative:
/2012/ The ADHS Bureau of Women's and Children's Health does not have access to raw
YRBS or Arizona Youth Survey data. However, the proprietors of these data provide either
query systems or annual reports from which estimates for indicators are drawn. //2012//
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
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 networkwas the 2010 Arizona Youth Tobacco Coalition Conference in
June 2010.

48

49

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

50

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

51

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

52

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

53

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.

/2012/ The new Title V priorities were presented to a variety of audiences at multiple
venues, and published and disseminated through the BWCH newsletter. BWCH staff,
including OCSHCN, developed a strategic plan for the Title V priorities. The draft plan was
disseminated for public comment, and final version is posted on BWCH website. New
federal funding from Affordable Care Act will address three priorities: teen pregnancy,
children's preventive health services (through home visiting), and healthy weight. Title V
funds are allocated to support priorities of preconception health, injury prevention,
healthy weight, oral health, and children with special health care needs. Title V also helps
to fund the children's preventive health services of immunization outreach and education,
newborn hearing screening follow-up, High-Risk Perinatal Community Nursing, and
Children's Information Center. BWCH Strategic Plan is attached.//2012//

54

An attachment is included in this section. IVB - State Priorities

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
Annual Indicator
Numerator
Denominator
Data Source

2006

2007

2008

2009

2010

100
100.0
79
79

100
100.0
85
85

100
100.0
93
93
AZ Office of
Newborn
Screening

100
100.0
115
115
AZ Office of
Newborn
Screening

100
100.0
113
113
AZ Office of
Newborn
Screening

2011
100

2012
100

2013
100

Final
2014
100

Final
2015
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 3year moving average cannot be
applied.
Is the Data Provisional or Final?
Annual Performance Objective

a. Last Year's Accomplishments
The Newborn Screening Program (NBS) reported 83,809 initial bloodspot screens. Of those
screened, 113 infants were diagnosed with clinically significant disorders, including 59 cases of
primary congenital hypothyroidism; 14 cases of congenital adrenal hyperplasia; 1 case of classic
galactosemia; 14 cases of sickle cell anemia and 2 cases of hemoglobin SC--both
hemoglobinopathies; 1 case of carnitine uptake deficiency; 2 cases of homocystinuria; 2 cases of
classic Phenylketonuria; 6 cases of medium-chain acyl-CoA dehydrogenase deficiency; 1 case of
propionic acidemia, and 11 cases of cystic fibrosis (CF). In all, 113 primary target disorders were
confirmed. Secondary findings include an additional 849 disorders or traits including 139 CF
carriers and 683 hemoglobinopathy traits. In 2010 there were 86 presumptive positive cases
closed without confirmation. Of them, 67 expired, 12 moved out of state and 7 parents declined
services. The NBS program located 100% of affected infants that had screen results suggestive
of target diseases, provided case management services through to definitive diagnosis, and
ensured the availability of services for clinical management.
Monthly subspecialty meetings with pediatric hematologists, endocrinologists, pulmonologists,
metabolic geneticists, and audiologists occurred. The NBS program completed the NBS Provider
Guidelines, a comprehensive guide to newborn screening in Arizona. The new guidelines reflect a
more current standard of care emphasizing early collection, timely receipt of specimens and
unsatisfactory specimens. Hits to the web site were down markedly from 20,000 hits in 2009 to
4481 unique visitors in 2010, 48 % of whom found us through a search engine.
NBS implemented Microsoft Sharepoint as a secure means of collaborating with the state CF

55

centers to share patient data, test results, and outcomes. For the Phoenix CF Center this resulted
in an increase to their case closure rate from 70% to > 95 %. Days to diagnosis went from 54 to
21 as a result of this shared model. Similar disorder groups were developed with the Phoenix
Children's hospital endocrinology department with similar outcomes.
OCSHCN and 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 readability, family centeredness,
and also provided translation services.
Uninsured and underinsured families received information about health care coverage,
prescription medication resources, testing available at community health centers, and resources
for metabolic formula. OCSHCN collaborated with Arizona Physicians IPA-CRS and the WIC
Program on a contract that provided metabolic formula to 8 uninsured and underinsured children.
The High Risk Perinatal Program Community Health Nurses (CHN) educated families of
newborns about the importance of newborn screening. There were provisions in the CHN
contracts for the CHNs to find children with positive screens who were lost to follow up to ensure
repeat screening. Utilizing the CHNs has been instrumental to timely notification for those
families difficult to reach through traditional methods. By extension, our partnership with Arizona
Perinatal Trust (APT) has provided an effective mechanism to reach hospital administrators with
quality improvement initiatives.
The midwife licensing program provides information on 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 616 reported home deliveries from
January 1 through December 31, 2010. 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. 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.

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 educates parents about the need for
second screens.
5. Newborn Screening continues to offer cystic fibrosis
screening.
6. Midwife Licensing Program provides information to all
midwifes about NBS.
7. The Community Health Nurses & Health Start workers
educate families about the importance of a second newborn
screen.
8. OCSHCN supports family partners to assist in the

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

X

X

56

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.
b. Current Activities
A team comprised of NBS staff and consultants are visiting hospitals, clinical labs, and ENT
offices, targeting the sites with the most critical need for quality improvement first. Most sites are
not aware of current guidelines for collection or shipping of specimens, resulting in unnecessary
delays in testing. The bloodspot collection kit has been revised to collect data more in line with
current best practice recommendations and includes information on neonatologists, is easier to
read, and highlights kit expiration dates. This should result in the collection of fewer unsatisfactory
specimens that cannot be analyzed.
NBS submits yearly laboratory totals and confirmed bloodspot cases to the National Newborn
Screening and Genetic Resource Center for national review. Although the opportunity exists to
partner with Mayo Clinic to analyze and evaluate all tandem mass spectrometry data, we have
been unable to do so due to limitations associated with the budget shortfall. Consequently, cutoffs
need to be evaluated and adjusted, positive predictive values for disorders are unknown, and the
sensitivity and specificity of tests remain unevaluated. With two years of decreasing births, NBS
has experienced decreased fee revenues which, combined with fund sweeps from a previous
year, created a chronic budget shortfall. ADHS made one-time funding transfers, utilized Title V
funding, and reduced operating costs to maintain the program.

c. Plan for the Coming Year
Many decisions for the coming year are guided by factors such as limited resources, hiring
freezes, and the budget shortfall. These factors serve as the impetus for a review of streamlining
services with pediatric specialists to save money and minimize delays in notification and
treatment of affected babies. As the data indicates, there may be up to 5% of newborns who are
not receiving the critical first bloodspot screen within 5 days. Working with licensed midwives we
hope to develop and implement regional trainings to ensure proper provider education among this
community. Developing a coordinated outreach effort is the goal. Included in that is provider
education, utilizing our AZ American Academy of Pediatrics (AAP) Chapter Champion and the
AAP listserv to disseminate programmatic updates and information. As the Secretary's Advisory
Committee has recommended that all sick/preterm newborns receive three bloodspot screens, 1)
upon admission to the neonatal intensive care unit, 2) another screen at 48-72 hours, and 3) at
28 days of life or at discharge, NBS is evaluating the adoption of this protocol by developing state
specific guidelines in partnership with neonatologists throughout the state. Recommendations
from this committee are being prepared for the NBS Advisory Committee.
Newborn screening goals focus on reducing the numbers of unsatisfactory and batched
specimens received, and to refine the positive and negative predictive values of analytes. Using
culturally sensitive materials, the NBS continues to educate parents about the need for a second
screen, timely referrals to specialists, and access to Children's Rehabilitative Services, OCSHCN,
Arizona Early Intervention Program and other resources. Performance measures will be reviewed
to ensure laboratory standards are met. As new disorders are added or analyte cut off values
changed, educational 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.
Community Health Nurses (CHNs) and Health Start workers will continue to find families that
cannot be reached by conventional means. They will educate families about the need for a
second newborn screen and facilitate referral to a medical home for those screens. BWCH will

57

work with hospitals during Arizona Perinatal Trust site visits to resolve issues with NBS
processes.
Infrastructure building, including developing data exchange between vital records and the
bloodspot database, is currently being tested with the hearing screening database. We are
evaluating alternatives to allow the bloodspot database to accommodate web-based
technologies, provide real time results, and improve reporting capabilities.
NBS, BWCH, Immunization Program, and Midwife Licensing will together develop training
opportunities for midwives on newborn screening. Midwife Licensing will provide better web
resources to midwives.

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
Cystic Fibrosis
Homocystinuria
Maple Syrup
Urine Disease
Other
betaketothiolase
deficiency
Tyrosinemia
Type I
Very LongChain Acyl-CoA
Dehydrogenase
Deficiency

88603
2010
(A)
Receiving at
least one
Screen (1)

(B)
No. of Presumptive
Positive Screens

(C)
No. Confirmed
Cases (2)

No.
83881

%
94.7

No.
126

No.
2

(D)
Needing
Treatment
that
Received
Treatment
(3)
No.
%
2
100.0

83881

94.7

528

59

59

100.0

83881

94.7

239

1

1

100.0

83881

94.7

3

2

2

100.0

83881
83881
83881

94.7
94.7
94.7

169
321
182

11
2
0

11
2
0

100.0
100.0

83881
83881

94.7
94.7

141
0

14
0

14
0

100.0

83881

94.7

145

0

0

83881

94.7

7

0

0

58

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
Sickle Cell
Anemia (SSDisease)
Medium-Chain
Acyl-CoA
Dehydrogenase
Deficiency
Long-Chain L-3Hydroxy AcylCoA
Dehydrogenase
Deficiency
3-Hydroxy 3Methyl Glutaric
Aciduria
Methylmalonic
Acidemia
(Mutase
Deficiency)
S-Beta
Thalassemia
Pregnancy
Tests
Pap tests
Hearing

83881

94.7

2

0

0

83881
83881

94.7
94.7

2
33

0
0

0
0

83881

94.7

7

1

1

100.0

83881

94.7

3

1

1

100.0

83881

94.7

12

0

0

83881

94.7

7

0

0

83881

94.7

7

0

0

83881

94.7

0

0

0

83881

94.7

11

0

0

83881

94.7

14

14

14

100.0

83881

94.7

14

6

6

100.0

83881

94.7

0

0

0

83881

94.7

12

0

0

83881

94.7

7

0

0

83881

94.7

4

0

0

15679

4736

0

0

4749
480071

0
11156

0
1398

0
1398

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)

59

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

2006
55
51.4

2011
57.4

2007
56
53.6

2012
57.4

2008
54
53.6

2009
55
53.6

2010
54
53.6

SLAITS

SLAITS

SLAITS

2013
57.4

Final
2014
57.4

Final
2015
57.4

Notes - 2010
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.
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.
a. Last Year's Accomplishments
OCSHCN used a variety of methods to promote family participation in decision-making. OCSHCN
took the lead with managing the ADHS Building Partnerships for Quality Care (BPQC) contract,
which provided for family, consumer, and youth to participate in policy development and decisionmaking with ADHS. Through this contract, families were developed as leaders and trained on
agency processes so that they were prepared to participate in decision-making. BPQC
contractors recruited, trained, and compensated families, consumers and youth who reflected the
diversity of Arizona's population to partner as decision-makers in ADHS specific activities.
Participation extended beyond ADHS as families were made available to other agencies so that
family participation can be incorporated into their activities. OCSHCN worked with the Medicaid
agency by providing training to AHCCCS health plans on incorporating family-centered practices
for CSHCN.
OCSHCN incorporated family involvement in its day-to-day management, including participation
in committees (e.g., management team, cultural competence, quality management, proposal
evaluation), development of contracts, grants, policies, curriculum and other materials. Sixteen
families and youth reviewed the OCSHCN and contractor's websites for family-centeredness,
cultural competence and ease of use, including ADA compliance. Family feedback mechanisms
were built into all programmatic activities, which were regularly analyzed for opportunities to
improve systems of care.

60

OCSHCN provided education and technical assistance on family involvement to other offices
within ADHS, AHCCCS health plans, NICU staff and families, Division of Developmental
Disabilities, community agencies and organizations. Raising Special Kids' Family to Family
Health Information Center (RSK F2F-HIC) contract provided family centered care training to 120
medical and dental students and coordinated resident-in-training home visits with 48 host families
and 6 youth focused on learning about the daily lives of families with CSHCN.
OCSHCN sponsored 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 in decision-making. Consumer
and family input was incorporated into the online training, "Navigating the Systems" created for
families. OCSHCN kept a log of all calls from families and provided 320 families with information,
support or training on navigating the system of care.
OCSHCN encouraged other agencies, organizations and ADHS offices to include family and
youth participation in contract language. Technical assistance was provided on how to develop
mechanisms to support parents and youth, recognizing their time, leadership, travel and
accommodations.

Table 4a, National Performance Measures Summary Sheet
Activities
1. Families and youth develop and review contracts, policies,
curriculum, training, OCSHCN website and resources
2. Building Partnership for Quality Care contractors recruit, train,
compensate and support the development of family, consumer
and youth leaders to partner in all levels of decision making.
3. The OCSHCN webpage includes an email address that
encourages comments and input.
4. Family and youth leadership curriculum and training supports
the development of family, consumer and youth involvement in
decision making.
5. Contracts include a requirement to include families,
consumers and youth in all levels of decision making.
6. Technical assistance is provided on how to develop
mechanisms to support parents and youth, recognizing their
time, leadership, travel and accommodations
7. Families, consumers and youth evaluate curriculum, materials
and OCSHCN website for ease of use, family friendliness and
accessibility.
8. OCSHCN sponsors resident and physician training so they
can learn how to make decisions with families as partners.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X

X
X

X
X

X

X

b. Current Activities
The administration of the Children's Rehabilitative Services Program transferred from ADHS to
the Arizona Health Care Cost Containment System (AHCCCS) on January 1, 2011 and OCSHCN
moved to the Bureau of Women's and Children's Health. An intergovernmental agreement with
AHCCCS supports education, training, technical assistance and resources to AHCCCS staff,
AHCCCS Health Plans and providers related to best practices. OCSHCN supports family and
youth involvement in policies, program and practices that affect the CRS delivery system,

61

telemedicine services and administration of social service funds.
OCSHCN's new RFGA, Building Family and Youth Leadership, promotes families and youth as
decision-makers. The BPQC contract funds families and youth to participate in planning of
Arizona's 20th Anniversary celebration of the Americans with Disabilities Act, the Arizona
Department of Education annual transition conference, focus groups around the state regarding
proposed changes to the AHCCCS system and Family Advisor available on-site to ADHS offices.
OCSHCN works with Arizona's Special Olympics Program to increase participation of children
and youth in the Special Olympics Steps to Better Health Program. OCSHCN develops
curriculum and training to support development of family, youth, and consumer involvement in
decision-making, promotes families as decision-makers in other child-serving agencies, including
education and early intervention and by sharing resources.

c. Plan for the Coming Year
OCSHCN will continue to incorporate family participation in all of its day-to-day management
through the ADHS Building Partnerships for Quality Care (BPQC) contract that recruits, trains and
compensates families, consumers and youth who reflect the diversity of Arizona's population.
Participation will continue to be extended beyond AHDS as families, consumers and youth are
made available to other agencies so that participation can be incorporated into their activities.
OCSHCN's new Request for Grant Application (RFGA), Building Family and Youth Leadership,
will result in new Title V funded community-based projects that promote family, consumer and
youth as decision-makers. OCSHCN will also continue to support family and youth involvement
through the APIPA-CRS contract amendment.
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 continue to
involve consumers and families in development of online trainings. OCSHCN also will 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.
OCSHCN will continue to provide education, training, technical assistance and resources to
AHCCCS staff, AHCCCS Health Plans and providers on cultural competence as it relates to
chronic health conditions, families as decision-makers, medical home and care coordination for
CSHCN, pediatric to adult transition for YSHCN and navigating the system of care. OCSHCN will
provide articles on best practices for CSHCN for member and provider newsletters for inclusion in
AHCCCS Health Plans communication.
OCSHCN will explore new ways to get input from families and youth, including social networking
technologies, such as Facebook and Twitter, in partnership with families, youth and consumers.

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

2006
52
50.5

2007
52.5
40.4

2008
41
40.4

2009
41
40.4

2010
40
40.4

62

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

2011
47.1

2012
47.1

SLAITS

SLAITS

SLAITS

2013
47.1

Final
2014
47.1

Final
2015
47.1

Notes - 2010
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.
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
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.
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 was integrated into contracts,
training, presentations, published materials and new staff orientation.
Through a contract with Raising Special Kids (RSK), 120 physicians, dental students, therapists
and nurses received training on the medical home model of care. Arizona's Medical Home Care
Coordination Manual was converted to a CD that included information on eligibility requirements
of various state programs and information on how to apply for them. Information was revised to
reflect changes due to statewide budget cuts. 318 manuals were distributed to physicians,
providers, families, school nurses, therapist and others. Manuals provided sample questions on
what to ask providers and templates for letters that families and providers could use.
OCSHCN participated in the Arizona School Nurse Consortium annual conference and provided
information on the medical home model of care to 121 RNs, LPNs and other health professionals.
OCSHCN regularly communicated this same information to its community partners through
regular email communications. OCSHCN staff met weekly with therapists and Department of
Economic Security-Division of Developmental Disabilities care coordinators at various state
agencies to coordinate services.
OCSHCN staff provided information and referral to families on understanding their rights and

63

responsibilities regarding their health insurance, importance of partnering with a primary care
provider, how to identify aspects of a medical home, and how to communicate needs and
preferences to their primary care providers.
The Children's Rehabilitative Services (CRS) Program managed a network of pediatric subspecialists who provided multi-specialty interdisciplinary care to Medicaid recipients with special
health care needs. Electronic infrastructure development merged 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 available at the four regional clinics, and at other points
of service. Two hundred and sixty seven CRS members used telemedicine services during the
year for the specialty clinics of orthopedics, neurology and neurosurgery. Telemedicine events
are evaluated through reports filled out by telemedicine providers, telemedicine coordinators and
families. Families reported saving an average of 10 work hours by attending telemedicine events
instead of an in-person visit.

Table 4a, National Performance Measures Summary Sheet
Activities
1. OCSHCN’s information and referral 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 Medical Home Care Coordination Manual is
adapted yearly to reflect 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 funds translation services for written materials and
videos to community partners on behalf of CSHCN.
6. OCSHCN funds the Arizona Telemedicine Program
membership fees that provides a statewide system to conduct
clinical and follow up services for CYSHCN at geographically
separate sites to members living in remote areas without access
to specialists.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X

X

X

X

X

X
X

b. Current Activities
The administration of the Children's Rehabilitative Services Program transferred from ADHS to
the Arizona Health Care Cost Containment System (AHCCCS) on January 1, 2011 and OCSHCN
moved to the Bureau of Women's and Children's Health. An IGA with AHCCCS supports
education, training, technical assistance and resources to AHCCCS staff, AHCCCS Health Plans
and providers related to best practices.
The medical home model is integrated into contracts, published materials, trainings,

64

presentations to other ADHS offices, school nurses, therapists, and others such as the Arizona
Children's Association quarterly CSHCN trainings for foster parents, Arizona Therapy Association
and Coordinated School Health Conference. OCSHCN presented to AHCCCS MCH Health Plan
Coordinators on the technical assistance and resources OCSHCN can provide. OCSHCN
connects families with resources and supports medical home activities that empower families to
develop individual service plans and act as their own advocates. OCSHCN funds resident and
physician training through a contract with RSK on medical home concepts.
OCSHCN works with refugee resettlement programs to develop programs and resources for
families of CSHCN who are new to the US on cultural brokering, understanding Arizona's
complex system of care, how to be a self-advocate, and what questions to ask their health care
providers. OCSHCN also funds translation services for both written materials and videos to
community partners on behalf of CSHCN.

c. Plan for the Coming Year
OCSHCN will continue to offer education, trainings, technical assistance and resources on best
practices for CSHCN to AHCCCS health plans, school nurses, therapists and providers on
cultural competence as it relates to chronic health conditions, families as decision-makers,
medical home and care coordination for CSHCN, pediatric to adult transition for YSHCN and
navigating the system of care.
OCSHCN will continue to partner with Raising Special Kids, Arizona's Family Voices Chapter and
Family to Family Health Information Center to incorporate the integration of physical health and
mental health in the physician residency training curriculum. An evaluation workgroup will be
comprised of family members, health care plans, medical and behavioral health professionals.
OCSHCN will continue collaborating with BHS-Family Involvement Subcommittee and use the
BPQC contract to involve families in physician training evaluation.
In a new partnership with AzEIP, DDD, Southwest Human Development, RSK and private
therapists on a Feeding Workgroup to address transition home of newborns in the NICU,
OCSHCN will engage in additional opportunities to promote the medical home model of best
practice.
OCSHCN will be converting its Breaking the Diagnosis training to video format focusing on how
families and physicians experience being confronted with a diagnosis, and how information is
processed and communicated. The Navigating the Systems of Care online training has been
translated to Spanish and will be made available on the OCSHCN webpage.
OCSHCN will explore partnering opportunities with BWCH oral health program to introduce and
promote the medical home model with dental health providers to improve service delivery for
CSHCN.
OCSHCN will update and further develop their Medical Home webpage, with information and
resources for professionals and families that reflect best practices for CSHCN. OCSHCN will
solicit input from school nurses, social workers and other professionals on improving the content
of the Medical Home Care Coordination Manual and make it available on the OCSHCN webpage.
OCSHCN will continue to work 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 their health care providers. OCSHCN will also fund
translation services for both written materials and videos to community partners on behalf of
CSHCN.

65

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

2006
61
60.8

2011
62

2007
61
58.1

2012
62

2008
59
58.1

2009
59
58.1

2010
58
58.1

SLAITS

SLAITS

SLAITS

2013
62

Final
2014
62

Final
2015
62

Notes - 2010
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.
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.
a. Last Year's Accomplishments
OCSHCN administered the Children's Rehabilitative Services (CRS) Program for over 23,000
Medicaid recipients under age 21 with special health care needs as a service carve out,
managing a statewide network of pediatric physician sub-specialists to provide access to needed
specialty services throughout.
320 callers received information on how to use public or private health plan member and provider
services, member handbooks, and offer guidance on negotiating rates with doctors. OCSHCN
assisted families who were uninsured and underinsured to identify potential resources for needed
services. 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
Supplemental Security Income (SSI), AHCCCS and early intervention services. Families,
providers, community organizations and advocacy groups were educated about eligibility
requirements, how to apply for services, appeal rights, filing grievances and requesting state fair

66

hearings when denied services to which they thought they were entitled.
1,384 letters were sent to SSI applicants under age 21 informing them of potential resources for
which they might be eligible, and giving them family resource contact information that includes
and 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 and the ADHS Birth
Defects Registry (ABDR) sent 25 letters to families of newborns with spina bifida and cleft lip/cleft
palate to provide information about resources and health care.
OCSHCN worked with the Children's Information Center (CIC) Hotline, Community Health
Nursing (CHN) Program, school nurses, and other ADHS programs, to educate families about
potential sources of health care coverage. OCSHCN funds supported the Community Health
Nursing Program, which served over 300 families of CSHCN. OCSHCN converted the online
training on navigating Arizona's health care systems to an online interactive class to reflect
changes to enrollment and eligibility requirements caused by budget cuts.
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. 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.
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.

Table 4a, National Performance Measures Summary Sheet
Activities
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. OCSHCN assists and encourages families and youth to apply
for the AHCCCS programs.
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 provides information and technical assistance to
help families understand eligibility requirements, learn how to
apply for services and understand their rights and
responsibilities.
5. OCSHCN refers CSHCN to the EAR Foundation for hearing
aids, cochlear implant batteries, repairs and ‘audiology testing.
6. OCSHCN works with the CIC Hotline, CHN Program, school
nurses and others to educate families on potential sources of
health care coverage.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X

X
X

X

X
X

67

b. Current Activities
The administration of the Children's Rehabilitative Services Program transferred from ADHS to
the Arizona Health Care Cost Containment System (AHCCCS) on January 1, 2011 and OCSHCN
moved to the Bureau of Women's and Children's Health.
OCSHCN works with families and providers to find coverage for medical care and services.
Families are educated to use their private or public health plan's member and provider services,
member handbook, negotiate with their doctor about rates for services and navigate the system
of care. Families receive information about SSI, AHCCCS, and early intervention services. Letters
are mailed to families identified by NBS, ABDR and SSI to inform them about medical coverage
and programs for which they may be eligible.
OCSHCN educates school nurses, providers, and other community partners on eligibility
requirements and services available to CSHCN. OCSHCN supports the CIC Hotline and CHN
through funding and training about public and private health insurance options, services and
programs for CYSHCN. OCSHCN identifies charitable funds, such as the UnitedHealthcare
Children's Foundation, to help families offset medical costs. Telephone call log data tracks
barriers identified by families in accessing services and health insurance.
OCSHCN converted its training on navigating Arizona's system of care into an online interactive
class with updated information on changing 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 Newborn Screening
Program, the Arizona 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 CIC
Hotline and the Community Health Nursing Programs through funding and training about public
and private health insurance options, services and programs for CYSHCN. OCSHCN will
continue to identify charitable funds, such as the UnitedHealthcare Children's Foundation, to help
families offset for 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 continue to 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.

68

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

2006
74
70.9

2011
89.1

2007
75
86.5

2012
89.1

2008
87
86.5

2009
87
86.5

2010
86
86.5

SLAITS

SLAITS

SLAITS

2013
89.1

Final
2014
89.1

Final
2015
89.1

Notes - 2010
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.
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 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.
a. Last Year's Accomplishments
OCSHCN staff responded to over 300 family calls for information and referral that identified
services for which CSHCN may be eligible, and guided families on application processes, and
helped them understand their rights in school, healthcare and community settings including
grievance procedures and appeal rights. 1,384 letters were sent to families of SSI applicants
informing them of services for which they might be eligible in their community. The Newborn
Screening (NBS) Program directed families to OCSHCN for assistance in its follow up
correspondence to families.
Training was provided to 120 medical and dental students on family centered care practices and
promoted family home visits with 48 faculty families and 6 youth that hosted the 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

69

communicating with physicians, school IEP teams, child-serving agencies, families, and their role
in helping students become self advocates. Nurses were trained on how to 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.
OCSHCN funded Ronald McDonald House (RMH) Charities, Phoenix that enabled families to
stay near their hospitalized CSHCN. OCSHCN's partnership with RMH provided 98 visits
averaging 12-15 days.
The Arizona Telemedicine program made specialty services available to 266 CYSHCN in remote
areas of the state and works to expand both the number of locations for specialty clinics in
orthopedics, neurology and neurosurgery. Two hundred and sixty seven CRS members used
telemedicine services during the year for the specialty clinics of orthopedics, neurology and
neurosurgery. Telemedicine events are evaluated through reports filled out by telemedicine
providers, telemedicine coordinators and families. Families reported saving an average of 10
work hours by attending telemedicine events instead of an in-person visit.
OCSHCN took advantage of an another 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 group homes. New Rules were crafted recognizing CSHCN concerns
regarding transportation, physical environment, and nutrition. Training materials were posted on
the ADHS website that included a series of videos that specifically addressed CSHCN in
childcare settings and routines.
OCSHCN staff represented ADHS on the AzEIP Interagency Coordinating Council (ICC), and
kept them informed on changing aspects of the system of care for CSHCN. OCSHCN also
participated in the Pediatric Advisory Council for Emergency Services, ensuring that issues
related to CSHCN were addressed including car seat safety, TBI/SCI, and training for first
responders on CSHCN.
OCSHCN worked with other ADHS programs to influence that policies be inclusive of CSHCN in
areas that focused on wellness, injury prevention, and childcare; and with First Things First,
Arizona Department of Education, Arizona Developmental Disabilities Planning Council,
Department of Economic Security- Division of Developmental Disabilities, and Vocational
Rehabilitation. OCSHCN staff serves on the AzEIP ICC keeping participants informed on
changing aspects of the system of care for CSHCN. OCSHCN supported Community Health
Nursing (CHN) Programs and the Children's Information Center (CIC) Hotline and trained staff to
help callers access systems of care for CYSHCN.

Table 4a, National Performance Measures Summary Sheet
Activities
1. OCSHCN staff identifies services for which CYSHCN 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. OCSHCN represents ADHS on the AzEIP ICC, and keeps
them informed on changing aspects of the system of care for
CSHCN.

Pyramid Level of Service
DHC ES
PBS
IB
X

X

X

70

4. OCSHCN funds Ronald McDonald House to enable families to
stay near their hospitalized CSHCN.
5. OCSHCN partners with Arizona Special Olympics (SOAZ) and
others to promote inclusion of CSHCN of all ages in wellness
activities such as nutrition, physical activity and injury prevention.
6. OCSHCN funds the Arizona Telemedicine Program
membership fees that provides a statewide system to conduct
clinical and follow up services for CYSHCN 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 funds the Ryan House to provide respite and
pediatric palliative care in a home-like setting for CYSHCN and
their families.
9. OCSHCN supports Community Health Nursing Program and
Children’s Information Center Hotline and trains staff to help
callers access systems of care for CYSHCN.
10.

X
X

X

X

X

X

X

b. Current Activities
Responsibility for the oversight of the CRS Program transferred from ADHS to AHCCCS on
January 1, 2011 and OCSHCN moved to the Bureau of Women's and Children's Health.
OCSHCN offers information and referral services to identify services, provide guidance on
application processes, and assist with understanding CSHCN rights in school, healthcare and
community settings. SSI letters are mailed to applicants to inform them of community services.
OCSHCN works with NBS to develop resources for families and providers that lists OCSHCN as
a resource in the letters mailed.
OCSHCN trains medical and dental students on family centered care practices and promotes
family home visits. School nurses receive training so that CSHCN can stay in school and
participate in the most inclusive school environment. Training focuses on strategies for
communicating with physicians, school IEP teams, child-serving agencies, families, and nurses'
roles in helping students become self advocates, navigating the changing systems of care,
information on eligibility rules application processes, available community resources and an
overview of public and private insurance.
OCSHCN works with other ADHS programs to influence that policies be inclusive of CSHCN in
areas focused on wellness, injury prevention, and childcare.
OCSHCN partners with SOAZ to promote wellness for CSHCN of all ages and encourages
inclusion of CSHCN in wellness activities, childcare, behavioral health services, and injury
prevention.

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 on developing
processes and resources for families and providers, and the NBS will continue to direct families to
OCSHCN for assistance.

71

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 communicating with physicians, school IEP teams, childserving agencies, and families, and nurses' roles in helping students become self advocates, and
supporting families in navigating the changing systems of care, including information on eligibility
rules and application processes and available community resources as well as an overview of
public and private insurance. Training plans will continue to include therapists and OCSHCN will
educate its partners on the benefits of using telehealth videoconferencing capabilities for training.
OCSHCN will also continue to fund the Ryan House to provide inpatient respite and pediatric
palliative care in a home-like setting and RMH as well as explore expanding to more locations
that will enable more families to stay near their hospitalized CSHCN. OCSHCN will collaborate
with partners to ensure that the needs of CYSHCN and barriers to their participation are
understood and addressed.
OCSHCN will continue to partner with Special Olympics of Arizona and others 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 University
Centers of Excellence on Developmental Disabilities and Arizona's Developmental Disabilities
Planning Council to increase opportunities and services for CSHCN. OCSHCN will continue to
represent ADHS on the AzEIP ICC, and keep them informed on changing aspects of the system
of care for CSHCN. OCSHCN will continue to participate in the Pediatric Advisory Council for
Emergency Services, ensuring that issues related to CSHCN are addressed 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

2006
6
5.8

2011
41.2

2007
6
39.4

2012
41.2

2008
39
39.4

2009
40
39.4

2010
39
39.4

SLAITS

SLAITS

SLAITS

2013
41.2

Final
2014
41.2

Final
2015
41.2

Notes - 2010
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

72

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.
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.
a. Last Year's Accomplishments
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. Transition resources were provided at
community fairs and conferences.
Contractors were monitored to ensure that appropriate transition services were provided. The
Building Partnerships for Quality Care (BPQC) contract included the youth component. CRS
contractors began transition plans for members before they reach age 15. Plans were age
appropriate, addressed member needs, identified an adult health care provider. Youth
participated on the OCSCHN Family Centered Cultural Competency Committee and the CRS
Quality Management Committee.
OCSHCN and the Governor's Council on Spinal and Head Injuries partnered on the Arizona TBI
Transitions Project helping youth transition to adult health care and support systems. OCSHCN
and Behavioral Health Services explored ways to provide information, resources and services to
youth with TBI. OCSHCN shared information and transition resources with behavioral health
contractors at the Behavioral Health Services, Arizona's Children's Executive Committee
meetings and with the Catholic Charities Refugee Relocation Program.
Best practices on transition were promoted through sharing resources that included 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.
Over 120 school nurses received training that promoted best practice information related to
health care transitions, what the role of the school nurse can be in ensuring that CYSHCN are
healthy enough to participate in inclusive activities, to ensure that CYSHCN learn to be as
responsible and knowledgeable about managing their own health care to the greatest extent

73

possible and that CYSHCN are prepared to direct their own healthcare as adults. Health care is
stressed as an important aspect of self determination.

Table 4a, National Performance Measures Summary Sheet
Activities
1. Young adults with SHCN review contracts, policies,
curriculum, training, resources and OCSHCN website and are
members of the cultural competence committee.
2. Health care is stressed as an important aspect of selfdetermination.
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. 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.
5. OCSHCN offers transition resources and training to other
ADHS programs and state agencies, including AHCCCS
programs.
6. OCSHCN is a member of the AzCoPT team and offers training
to inform students, parents, educators, and others about state
agency processes.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X

X

X
X

X

X

X

X

b. Current Activities
Responsibility for the oversight of the CRS Program transferred from ADHS to AHCCCS on
January 1, 2011 and OCSHCN moved to the Bureau of Women's and Children's Health. An IGA
with AHCCCS was developed that supports education, training, technical assistance related to
best practices on transition to adulthood and resources to AHCCCS staff, AHCCCS Health Plans
and providers.
OCSHCN completed a Request for Grant Application, Building Family and Youth Leadership, to
fund practices, activities and projects to address Title V priorities including transition to adulthood
statewide. The BPQC contract recruits, trains, and supports leadership development of youth,
and compensates them to participate with OCSHCN and other ADHS programs.
OCSHCN partners 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 is
partnering with staff and Youth Leader with SWI to fund the youth strand ADE annual transition
conference packets and other youth oriented resources. As an AzCoPT member, OCSHCN is
presenting at the annual ADE Transition Conference and funding scholarships for youth and
families to attend. OCSHCN is translating the AzCoPT training to Spanish that is used to inform
students, parents, educators and others about state agency transition processes.

74

c. Plan for the Coming Year
OCSHCN will use the new Building Family and Youth Leadership contractor(s) to provide
leadership development of YSCHCN and their families. OCSHCN will continue to use the BPQC
contract to recruit, support, train, and provide leadership development for youth, and develop an
OCSHCN youth council to participate in management.
OCSHCN will partner with Southwest Autism Resource and Research Center on 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 SWI and ADE on exploring a standalone Youth
Summit directed by youth for youth.
OCSHCN will continue partnering with the Governor's Council on Spinal and Head Injuries on
providing best practice information on transition for CYSHCN, presenting at their annual
conference and developing new family and youth events for the TBI transition grant.
OCSHCN will also explore ways to incorporate youth transition practices into Medicaid health
plan training. OCSHCN will make available the learning management system for educational
trainings and materials.
OCSHCN and Bureau of Nutrition & Physical Activity will be working on the development of a
training video promoting an employment opportunity for youth and adults with developmental
disabilities and/or intellectual disabilities.

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

2006

2007

2008

2009

2010

79

79.5

80

80

80

79.2

76.2

76.7

76

71.9

National
Immunization
Survey

National
Immunization
Survey

National
Immunization
Survey

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

75

average cannot be applied.
Is the Data Provisional or
Final?
Annual Performance
Objective

2011
80

2012
80

2013
80

Final

Final

2014
80

2015
80

Notes - 2010
Data source is http://www.cdc.gov/vaccines/stats-surv/nis/data/tables_2009.htm The confidence
interval is + or - 5.9%. Although the point estimate for 2009 is lower than 2008, the estimates are
not significantly different.
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
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

76

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.
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 was completely updated to reflect the needs of the community
and to include a comprehensive provider education page. 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 2010 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) posters and flyers on Pertussis vaccine information for parents and
caregivers; 4) flyers for childcare centers on the importance of tracking immunization records
using ASIIS; and 5) teen parent education flyers and post 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 2010.
TAPI conducted nine regional immunization programs with the Vaccines for Children Program
and the Arizona State Immunization Information System for providers statewide. Five 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 and the Arizona Immunization Program
Office (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 with ADHS and ASU
created a web based training program for provider offices on common immunization questions
and best practices for outstanding immunization delivery.
In cooperation with AIPO, TAPI designed and mailed a Vaccines for Children user satisfaction
survey to 840 provider sites. Thirty six percent (36%) of the surveys were completed and
returned by the December 31, 2010. Survey data indicated 90% of respondents are
overwhelmingly very satisfied/satisfied with the program; 98% strongly agreed/agreed VFC
representatives are knowledgeable and helpful.
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 and worked with a large
Medicaid plan to increase childhood immunization rates by developing outreach and training.
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

77

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
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.

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

X

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, medics, 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

78

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 continue to distribute the most current immunization schedule to
contractors. The immunization checklist is now 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
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 and caregivers 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 on disseminating educational materials
that are specific to children with special health care needs.
The ADHS Office of Immunization will work with midwife licensing to tailor educational materials
for home deliveries. The Immunization Program will work with other ADHS programs to highlight
importance of immunizations for caregivers of small children, and will reach out to OB/GYNs and
other providers to educate about cocooning effect.

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

2006

2007

2008

2009

2010

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

23.5
24.4
3374
138280
AZ Birth
Certificates

2011

2012

2013

Final
2014

Provisional
2015

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 3year moving average cannot be
applied.
Is the Data Provisional or Final?

79

Annual Performance Objective

23

22.5

22

21.5

20

Notes - 2010
The 2010 estimate is provisional until the 2010 Census releases total counts of 15-17 year old
females in Arizona.
Notes - 2008
The 2008 data was not available prior to completion of the narrative sections in this grant.
a. Last Year's Accomplishments
In 2010, 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 four other tribes (Tohono O'odham San Lucy District, Fort
McDowell, and Colorado River Indian Tribe, Hopi) were funded through a contract with the InterTribal Council of Arizona. A total of 12,943 youth and 1,510 parents received services in 2010.
Many funded programs implemented a youth development/service learning focus and/or provided
parent education related to talking with their teens about responsible sexual health and risk
factors leading to teen pregnancy 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 and to youth on probation through the
juvenile court system.
Seven abstinence programs were 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 2009 through June 2010, 14,902 young people and 747 parents
received services.
ADHS provided technical assistance to community organizations that applied for federal
comprehensive teen pregnancy prevention grants (Tier I - Replication of Evidence-Based
Program and Tier II - Promising Practices. ADHS coordinated with all funded agencies to best
maximize our funding.

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.

Pyramid Level of Service
DHC ES
PBS
IB
X

X

X
X

80

10.
b. Current Activities
In 2011, the Patient Protection and Affordable Care Act authorized funding for a new
comprehensive sex education initiative titled, the Personal Responsibility Program (PREP) and
renewed funding for the Title V State Abstinence Program. Arizona's award is approximately $1
million for PREP and $1.2 million for Abstinence.
ADHS will target high risk populations such as youth in foster care, Latinos, and African
Americans using PREP funds. ADHS has issued Request for Grant Applicants and will have new
contracts established by July 1, 2011. The Program continues to use lottery dollars to fund the 13
county health department projects and four tribal projects as described above, as well as the
seven abstinence programs. The Program is working on adding one more tribal program through
the Inter-Tribal Council of Arizona to provide comprehensive education. ADHS continues to
coordinate with all federally funded Tier I and II 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 and the Arizona Department of Education for coordination of teen pregnancy
prevention curricula trainings.

c. Plan for the Coming Year
Lottery revenue is expected to continue and ADHS will continue to fund the existing county health
departments and tribal programs. Lottery funds will also continue to be used to fund the seven
abstinence programs, and serves as match for the federal Abstinence Education Program. ADHS
will begin programs utilizing the federal Abstinence Education funding made available through
health care reform, as well as the new Personal Responsibility Education Program (PREP).
ADHS will target high risk populations such as youth in foster care, Latinos, and African
Americans using PREP funds. To ensure fidelity of programs, ADHS will be providing curricula
trainings for program health educators, incorporating a fidelity scale to provide indications that
curricula are being implemented as intended, and adding another program manager to assist with
the monitoring of programs.
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. Existing
curricula will be reviewed to assess appropriateness for youth with special health care needs, and
curricula will be modified or developed.

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

2006

2007

2008

2009

2010

36.5
36.2

36.5
36.2

36.5
36.2

36.5
47.1

47.1
47.1

AZ Office of
Oral Health
survey

AZ Office of
Oral Health
survey

AZ Office
of Oral
Health

Check this box if you cannot report the

81

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

2011
47.1

2012
47.1

2013
47.1

Final
2014
47.1

Final
2015
47.1

Notes - 2010
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 - 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.
a. Last Year's Accomplishments
The Arizona Dental Sealant Program provided dental screenings and referrals to 8,830 children
attending eligible public schools; 6,479 children received 23,997 dental sealants. Two counties
have had difficulties locating dental providers to participate in program activities due to lack of
dental providers and contracting difficulties. Lack of dental providers in rural areas is a barrier to
expansion for underserved populations. In an effort to increase school and student participation,
the Office of Oral Health engaged the Arizona Department of Education and the school nurse
associations for participation in program implementation. 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 was reduced to 50% beginning in the 2010-11 school year, this
helped to expand the program to schools not previously qualified to participate. Students, who
attend eligible schools, are in 2nd or 6th grade and have informed parental consent received oral
health screenings and referrals for treatment needs. Uninsured children, Medicaid and SCHIP
beneficiaries, those covered by Indian Health Services or by state-funded tobacco tax health care
programs were eligible to receive sealants. After 20 years of fairly steady growth, the program
had 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 and has begun
sharing findings with partners. Findings from the Healthy Smiles Healthy Bodies Survey
indicated that 47% of Arizona third-graders had dental sealants on at least one permanent molar,

82

nearly reaching the Healthy People 2010 target of 50%. Oral health findings were submitted to
the Centers for Disease Control and Prevention and are available on the National Oral Health
Surveillance System: http://www.cdc.gov/nohss/.

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.
5.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X

b. Current Activities
The Office of Oral Health continues to provide a school-based sealant program in five Arizona
counties. New teledentistry sites being established through the HRSA grant have expanded
throughout the state with increased interest from other state agencies, the Inter Tribal Council of
Arizona and the Indian Health Services. These teledentistry sites will be instrumental in
increasing outreach to rural populations currently underserved by the Arizona School-based
Sealant Program. The Office of Oral Health has expanded its capacity in supporting the
development of regional oral health coalitions. The Office is currently working with five regional
coalitions to provide information and support development of evidenced based preventive
methods including school-based sealant programs.

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
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. The program is seeking to increase expansion to an additional county for the 20112012 school year. In an effort to increase the proportion of public schools served by the program,
the current school eligibility requirement of 50% National School Meal Program enrollment will
remain in effect for the 2011-2012 school year. The Office of Oral Health will review the
efficiency of the dental sealant program by engaging partners and stakeholders in
recommendations for improvement. New teledentistry sites being established through the HRSA
grant will increase to four active sites in 2011. The teledentistry models will develop education
materials for the training of healthcare providers and administrators.
The Office for Children with Special Health Care Needs will work with the Office of Oral Health to
identify opportunities to provide dental sealants to children with special health care needs.

Performance Measure 10: The rate of deaths to children aged 14 years and younger caused
by motor vehicle crashes per 100,000 children.

83

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

2006

2007

2008

2009

2010

4.2

4

4

3.8

3.5

4.0
55
1390127

4.0
57
1412725

2.7
39
1429459
AZ Death
Certificates

3.5
50
1434985
AZ Death
Certificates

2.7
36
1358059
AZ Death
Certificate

Final

Final

2014
2.5

2015
2.5

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

2011
2.5

2012
2.5

2013
2.5

Notes - 2010
Census 2010 population estimates show a significant decline (5.3%) in the total number of
children 14 years or younger living in Arizona between 2009 and 2010. This decline influenced
the estimated rate of MVC mortality in 2010.
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.
a. Last Year's Accomplishments
The rate of motor vehicle fatalities declined from 9.9 deaths per 100,000 children in 2006 to 4.7
deaths per 100,000 children in 2009, but the rate remained stable between 2008 and 2009.
Motor vehicle crashes claimed 82 children's lives in 2009, the same number of deaths as in 2008.
Six children died in off-highway vehicle (OHV) crashes in 2009. Ninety-three percent of motor
vehicle-related deaths were determined to have been preventable (n=76). Lack of vehicle
restraints was identified as a preventable factor for 41 percent of motor vehicle crash fatalities
(n=34).
Through Title V funding, Navajo County Public Health reached both Apache and Navajo counties
providing car seat and seat belt education. Navajo County targeted Native American Women to
complete the car seat safety program, and subcontracted with the Navajo Nation to conduct car
seat safety check events and car seat safety courses including alcohol awareness. During 2010,

84

152 Native Americans completed a course on alcohol awareness and not operating a motor
vehicle while under the influence. Navajo County conducted safety events and provided
education on driving under the influence, CPR, and water safety to 1,771 adolescents. Navajo
County also partnered with Arizona Game and Fish to educate 984 people about helmet use
while operating an ATV. One hundred seventy two Native Americans received car seats
including a 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.
Apache County provided 198 car seats for children. Classes on car seats and seat belt restraint
use were attended by 202 individuals. Assessments for booster seat use was conducted on 354
preschool and kindergarten; a total of 330 fourth and sixth graders received injury prevention
classes related to seat belts, skateboards, bus, bike, sports and gun safety; 789 high school
students received classes on seat belt safety, crash dynamics, and dangers from alcohol and
drug use while operating a motor vehicle.
Through Title V funding, Maricopa County Department of Public Health educated 4,379
individuals about transportation injuries and child passenger safety. In addition, 1,223 car seats
were distributed along with coaching and observation of correct installation techniques. Eleven
NHTSA certification classes, four CEU classes, and two renewal classes were instructed by,
staffed by or lead by Maricopa County Department of Public Health. Sixty seven medical
residents completed a child passenger safety education module during clinical rotations to
educate families in the emergency room and at birth. Four hundred seventy two youth received
wheeled sports safety education and were fitted for helmets. Three hundred twenty four students
under the age of 18 were educated on the importance of seat belt use.
Through Title V funding, Coconino County Public Health Services District provided education and
distributed 425 car seats. They sponsored two Child Passenger Safety training courses, resulting
in 31 newly certified NHTSA certified technicians and 10 renewed technicians. In 2010, over
4,000 elementary students attended presentations on seat belt use, distracted driving, fire
prevention, helmet use, and calling 911. Coconino County partnered to conduct five
presentations through various agencies to reach 3,050 teens on the dangers of drinking and
driving.
The Injury Prevention Program continued to build capacity for child passenger safety through
providing certified car seat training, particularly in tribal communities. The program worked with
Indian Health Services by providing car seat check up events, training, 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. The Arizona Game and Fish Department increased
enforcement of existing laws regarding children riding or driving all terrain/off-highway vehicles
including helmet use, double riding, and licensing.
The Arizona Injury Prevention Advisory Council in partnership with the Arizona Game and Fish
Department convened two statewide stakeholders' meetings to raise awareness of the various
entities promoting safe all terrain/off-highway vehicle use among Arizona residents.

Table 4a, National Performance Measures Summary Sheet
Activities
1. Child Fatality Review Program reports on motor vehicle
crashes among children.
2. Title V County Health Prevention contracts build local
infrastructure on injury prevention.
3. Injury Prevention Program provides car seat safety technician

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X

85

training.
4.
5.
6.
7.
8.
9.
10.
b. Current Activities
In 2011, The Bureau of Women's and Children's Health issued new Interagency Service
Agreements with five county health departments to support local injury prevention infrastructure.
The new contracts will increase activities around building coalitions, changing organizational
practices, and developing policies. Apache and Navajo Counties are partnering to provide
NHTSA child passenger certification and recertification classes. Apache and Navajo County are
also partnering with Arizona Game and Fish to educate people about helmet use while operating
an ATV. Apache and Navajo Counties are developing a Safe Kids chapter. Coconino County is
sponsoring NHTSA Child Passenger Safety training courses. Coconino County is collaborating
with various agencies to conduct presentations on the dangers of drinking and driving and
distracted driving.
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 Injury Prevention Program collaborates with AZ Dept of
Transportation in conducting Road Safety Audits.
BWCH is using Title V funds to purchase car seats and to establish a new special needs car seat
program for the state. The Injury Prevention 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.

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 18th annual report will be produced in 2011 and will include
information on the deaths that occurred in Arizona during 2010. The Child Fatality Review
Program will continue to analyze 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
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 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.

86

The Title V County Health Prevention contracts will continue to grow through the levels of the
Spectrum of Prevention. These contracts will increase activities around building coalitions,
changing organizational practices, and developing policies. The Injury Prevention Program will
provide technical assistance to county injury prevention staff, and provide collaborative learning
opportunities.

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

2006

2007

2008

2009

2010

38

38

50

50

53

46.5

43.7

48.2

45.3

49.6

CDC National
Immunization
Survey

CDC National
Immunization
Program

CDC National
Immunization
Program

Final

Final

2014
57

2015
60

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

2011
51

2012
53

2013
55

Notes - 2010
The CDC National Immunization Survey data for 2010 (2007 birth cohort) uses a small sample
size, thus the confidience intervals for the 2009 estimate are wide (+/- 6.9) . The estimate is not a
statisitcally significant difference from 2008, nor is it significantly different from the U.S. rate of
43.0. The HP 2020 Goal is 60.6%.
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

87

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.
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. Five Community Health Workers became Certified
Lactation Educators and one became a Certified Lactation Specialist. 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 2010.
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 regarding
concerns about breastfeeding. BWCH and WIC worked together to ensure the Arizona
Breastfeeding Hotline continues to provide access to International Board Certified Lactation
Consultants for lactation help 24 hours a day, seven days a week. Approximately 320 mothers
per month have reached out during evening, weekend, and holiday hours to the Hotline for
answers about positioning and latch, medications, managing work and school, and infant
behavior. The after-hours aspect of the hotline is especially useful for mothers unable to reach
their health care providers.
The Arizona WIC program had a breastfeeding rate of 65.5% for ‘ever breastfed' (CDC PedNSS
2009) and a target rate of 69.5% as a result of expanded breastfeeding outreach activities,
training, and access to services. In October, 2010, six Arizona WIC staff earned certification as
new International Board Certified Lactation Consultants (IBCLCs). This raises the total number of
WIC IBCLCs to 32 in Arizona.
Evergreen Perinatal Education delivered their "Certified Lactation Educator" training course to
WIC staff and community partners, including physicians, nurses, midwives, lactation consultants,
and lay health workers. Additionally, 16 State and Local Agency staff attended Arizona State
University's 45-hour Certified Lactation Educator course.
Arizona continued to offer professional education in breastfeeding at LATCH-AZ (LActation
support To Collaborate for Health - AZ) meetings. These meetings are open to the public at no
charge. They provide an opportunity for WIC staff to network with community partners interested
in lactation.
The Arizona WIC Program expanded its Peer Counselor Program to 12 of its Local Agencies,
including Cochise, Coconino, Gila, Marana, Maricopa, Mariposa, Mohave, Mountain Park, Pima,
Pinal, Yavapai, and Yuma. Each month, the program helps over 6,000 pregnant and
breastfeeding mothers overcome their personal barriers to breastfeeding through the use of
mother-to-mother support.

88

A television commercial about the importance of family support in the success of breastfeeding
initiation and duration was produced and aired throughout the state. It will continue to be
included in healthcare sites and clinic waiting rooms as well as in the WIC Local Agency sites.
As part of Arizona's Communities Putting Prevention to Work (CPPW) grant, 5,000 nurses were
trained on how changes in maternity care practices and policies have a direct relationship to both
the initiation and duration of breastfeeding. This training also included WIC staff presenting on
how the WIC program and the WIC Peer Counselor program support the breastfeeding dyad
before and after delivery.
Also, as part of the Communities Putting Prevention to Work (CPPW) grant, workplace
accommodation postcards were distributed to worksites and to pregnant and breastfeeding
employees regarding the new Patient Protection and Affordable Care Act breastfeeding
accommodation laws. The postcards served as "conversation starters" for participants to
approach their worksites with upon returning to work.

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 Hotlines are staffed by two bilingual Certified Lactation Consultants who answer calls
regarding breastfeeding. A bilingual 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.
Through the Communities Putting Prevention to Work Grant, the Bureau of Nutrition and Physical
Activity (BNPA) is in year two of implementation of the Arizona Baby Steps to Breastfeeding
Success initiative. BNPA is completing policy trainings with 30 hospitals impacting 90% of the
births in Arizona with the implementation of five of the ten Baby Friendly Hospital Initiative (BFHI)
maternity care practices that have the greatest impact on breastfeeding duration. Arizona Baby
Steps for Breastfeeding Success is inclusive of both a policy, environmental, and social marketing
initiative that focuses on maternity policies, peer support, professional support, and maternal
education.
The breastfeeding physician toolkit is in distribution and includes information for breastfeedingfriendly physician's offices. A physicians' conference around the Baby Steps initiative will take
place the summer of 2011 and include both an OB and pediatric component.

89

Free, quarterly lactation education continues to be provided to urban and rural health
professionals and paraprofessionals through LATCH-AZ.

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
clients to commit to breastfeeding. The Program will increase the number of Community Health
Workers that are certified breastfeeding counselors, certified lactation counselors, certified
breastfeeding educators and specialists.
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.
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 regarding 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 new Maternal, Infant and Early Childhood Home Visiting Program will fund the
implementation of evidence based early childhood home visiting. The models selected, Nurse
Family Partnership, Healthy Families and Family Spirit will encourage and support breastfeeding
among their clients.
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. The Bureau of Women's and Children's Health will continue to support this program by
asking for information about how a hospital is implementing the program during Arizona Perinatal
Trust site visits to the hospitals.
Bureau of Nutrition & Physical Activity and Office for Children with Special Health Care Needs are
working together to produce a training video that promotes an employment opportunity for youth
and adults with developmental disabilities.
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.

Performance Measure 12: Percentage of newborns who have been screened for hearing
before hospital discharge.

90

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

2006

2007

2008

2009

2010

98.8

97

97

98

100

96.3
98363
102095

95.4
97986
102687

98.3
97496
99215
AZ Early
Hearing
Detection and
Intervention
Prog.

98.4
91824
93314
AZ Early
Hearing
Detection and
Intervention
Prog.

97.5
86424
88603
AZ Early
Hearing
Detection and
Intervention
Progra

Final

Final

2014
100

2015
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

2011
100

2012
100

2013
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.
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 97.7 % (86,424) of babies born in Arizona in 2010 received a hearing
screen prior to discharge. All 47 birthing hospitals, plus one children's hospital, 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, 58% returned for outpatient screens, most
within 30 days.
One of the biggest accomplishments last year was the development and implementation of a
hospital scorecard. Distributed quarterly, this quality indicator measurement tool reports numbers
of infants screened before discharge, pass and refer rates, outpatient return rates, and
completeness of demographic data on the mother. Included in the scorecard is a statewide
average of each indicator as well as an overall score, allowing the hospitals to compare their
score to the state's overall average. Outcomes include an overall improvement from 71.6% to
88.7% compliance with the quality indicators.
Three important components of the MCHB grant awarded in 2009 were important to this
performance measure. First, Arizona participated with several other state EHDI programs to
develop an 8 minute video and public service announcements in English and Spanish targeted to

91

encourage parents to obtain the follow-up needed after the initial fail of the newborn hearing
screen. More than 200 copies have been distributed throughout Arizona including hospital
screening programs, parent groups, inter-agency partners and others. The second was the
introduction of the Arizona Hands & Voices, Guide By Your Side (GBYS) Follow-Through
program. The program coordinator works closely with the NBS program, sharing information on
the status of infants who failed the initial screen. In addition to site visits with the High Risk
Coordinator, GBYS visited four birthing hospitals in western AZ, and two in northeastern AZ.
Bilingual brochures describing GBYS Follow-Through services for families are distributed at
participating hospitals. The program pairs a trained Parent Guide with a hospital screening
program. Each hospital customizes at what point they have the guides interact with their
screening program.
The third component is a follow-up coordinator dedicated to tracking of high-risk infants (NICU
stay for greater than 5 days and failing the hearing screen) in order to reduce the loss to follow up
to 10% or less. The role of the coordinator is to foster communications between hospital
discharge managers and the NBS program. The high-risk coordinator accomplished the following
in the first year:
Identified 12 hospitals to implement high-risk follow up, determine the loss to follow-up rate
between inpatient and outpatient screenings and between outpatient and diagnostic evaluation;
Implemented program at 5 of the target hospitals and worked with GBYS to implement program
at 6 hospitals;
Established site through SharePoint where hospitals can submit NICU census information and
identify families needing GBYS parent guide;
Determined baseline rate for target hospitals for NICU infants failing inpatient screen;
Established liaison with discharge coordinator/case manager to track high-risk infants;
Initiated follow-up with providers and parents of high-risk infants who fail the hearing screening;
Updated brochures and resource lists provided to families at the time of screening (in English and
Spanish);
Worked with EAR Foundation of Arizona and GBYS to educate audiologists and encourage
parents to schedule follow up appointments.
Given that there were approximately 600 infants lost to follow-up between screening and
diagnosis in 2009, the goals of this coordinated effort is to significantly reduce that number.
ADHS reviewed with licensed midwifes regarding who is completing the hearing screening
following the infant's birth. One midwife is completing the hearing screening tests. Midwives have
been provided information regarding where to obtain the newborn hearing testing and they are
referring the families to a pediatrician or hospital facilities for review of the newborns ability to
hear.

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

Pyramid Level of Service
DHC ES
PBS
IB
X
X

92

stakeholders.
3. Newborn screening protocols have been revised by the NBS
Advisory Committee.
4. Newborn Screening educates parents about the need for
second screens.
5. Newborn Screening continues to offer cystic fibrosis
screening.
6. Midwife Licensing Program provides information to all
midwifes about NBS.
7. The Community Health Nurses & Health Start workers
educate 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.

X
X
X
X
X

X

X

b. Current Activities
The Newborn Screening team continues work to determine how to impact the number of families
who meet the 1-3-6 goals. Changes in the program that have been 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. 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.
The parent hearing screening brochure was updated to include Joint Committee on Infant
Hearing best practice recommendations. A new provider pocket guide was distributed to all care
providers and includes a workflow for patients who are navigating the system of care.
OCSHCN and AzEHDI are offering online training for hospital-based hearing screeners. Ear
Foundation of Arizona has developed a new screening training module that incorporates the
ECHO training into the state system of Train the Trainer (T3).

c. Plan for the Coming Year
Following State Priority 8, and alongside OCSHCN, NBS plans to expand coordination efforts to
reach the families of infants, 0-3 who are lost to follow-up. Stakeholders involved in these efforts
include Early Head Start, Head Start, First Things First, T3, medical home providers and others.
Activities will include data integration, parent outreach efforts and surveys, ensuring that families
have family-centered and culturally sensitive access to information about where to get screened,
including mechanisms to reach those underserved in the current EHDI system. Included in this
partnership will be technology enhancements, such as data sharing and infrastructure building,
data exchange, and training to include broader use of the eLearning platform.
The hearing screening database has been upgraded and will be expanded to include access by
all hospitals, audiologists and other providers in a two-way role based secure environment. This
expansion, paid for under the CDC Data integration grant, will result is a significant reduction in

93

loss to documentation. Ongoing on-site training to audiologists and ENT practices, including rules
for reporting data, will be expanded to include best practices as well as technology education.
The Sensory Program will continue to utilize Title V funding to train hearing and vision screening
trainers, post newsletters on the Sensory Program web page, and continue to provide technical
assistance to school health offices. The Sensory Program will work with stakeholders to develop
vision and hearing resources and continue implementation of recommendations to improve vision
screening in Arizona. The Sensory Program will work with Midwife Licensing to make hearing
screening equipment and training available to midwives.
NBS, BWCH, Immunization Program, and Midwife Licensing will together develop training
opportunities for midwives on newborn screening. Midwife Licensing will provide better web
resources to midwives.
OCSHCN will continue to work with hospitals, the AZ EHDI program, and providers to establish a
telemedicine connection for hearing screening follow-up. OCSHCN will partner with NBS on
hearing results from screening sites participating in the T3 OAE programs.
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.
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 continue to work on getting midwives the Arizona Parent
Kit to provide to parents who do home birth.

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

2006
14.5
17

2007
16.5
17

2008
16.3
13.8

2009
16
16

2010
15.8
13.4

US
Census

US
Census

U.S.
Census

2013
12.5

Final
2014
12.2

Final
2015
12

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

2011
13.1

2012
12.8

Notes - 2010
The estimate is available at http://www.census.gov/hhes/www/hlthins/data/historical/index.html
(Table HIA-5)
Notes - 2009

94

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.
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. In addition, prescription medications, diagnostic laboratory services, eyeglasses, and
dental services are provided as necessary to qualifying children. 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. In 2010, the Medical Services
Project served 165 individual children.
In 2010, the Medical Services Project developed collaborative partnerships with the following
organizations: Kidzzaam Dentistry in Prescott Valley, Westside Headstart which serves Glendale
and Avondale, Patient 1st, Magic Smiles Dental, and North Valley Native Health. 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 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 16,352 callers with
accessing Arizona's Medicaid health plan and linked them to needed services including Baby
Arizona, oral health, pregnancy, breastfeeding, family planning, traumatic brain injury, WIC,
pregnancy testing, immunizations, farmers market, and car seats.

Table 4a, National Performance Measures Summary Sheet

95

Activities
1. Medical Services Project provides uninsured children with
health care services.
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 insurance.
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 83 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 dental).
The Medical Services Project has coordinated mapping of all health care clinics that provide
services to low income children and is targeting those 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
The Medical Services Project will continue to foster collaborative partnerships and link acute care
services to uninsured children.
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

96

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

2006

2007

2008

2009

2010

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

34.5
35.8
42255
117927
AZ WIC
Program

2011
34

2012
33.5

2013
33

Final
2014
32.5

Final
2015
32

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
ADHS implemented 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 also revised its administrative rules for child care centers to
incorporate many of the standards. Bureau of Nutrition and Physical Activity developed and
posted on the website special training videos for child care providers related to the nutrition and
physical activity Empower standards. One video highlighted children with special health care
needs.
In 2010, all Bureau of Nutrition and Physical Activity programs have expanded use of common
nutrition messages using the theme of "Champions for Change" to empower mothers in making
healthy choices for their families. Based on the Health Belief Model, "Champions for Change" has
been introduced in Arizona Nutrition Network efforts and has been expanded to programs and
initiatives through ADHS. In FY2011, Arizona WIC branded its Participant Centered Services
(PCS) initiative. The branding campaign was initiated in response to the pilot study finding that
terminology was confusing and not relatable to WIC staff and families. ‘Together We Can' was
chosen to brand the PCS initiative. Together We Can symbolizes that WIC is a partnership in all
areas and that only by listening to and supporting one another and by working together can the
Arizona WIC Program accomplish its goals in reducing obesity and improving health in Arizona.
As part of Together We Can, taglines were created to describe the various elements of PCS that
Arizona has been implementing. For all PCS activities related to staff training, nutrition
promotion, and clinic environment, the tagline is: Together We Can: Influence Change.
The WIC Farmers' Market Nutrition Program (FMNP) has fully incorporated the WIC Cash Value

97

Voucher into all authorized farmers markets throughout the state. Every grower authorized to
participate in the FMNP is able to accept WIC FMNP checks, Senior FMNP checks, and WIC
Cash Value Vouchers. FMNP and CVV's provide WIC families with access to fresh fruits and
vegetables throughout the state. A new coordinated effort between Arizona FMNP, a local
Community Health Agency, and United Health Care has resulted in a bi-weekly market event at
one of Arizona's FMNP Approved Markets. Activities include a physical activity station for WIC
children, cooking demonstrations, health information booths, and stipends for local growers who
redeem vouchers for fresh, locally grown fruits and vegetables. The partnership will expand to a
second market in October 2011.
The Bureau of Nutrition and Physical Activity Community Programs Team continued 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.

Table 4a, National Performance Measures Summary Sheet
Activities
1. Empower Program sets standards related to obesity
prevention for child care providers.
2. WIC outreach focuses on promoting healthy lifestyles.
3. ADHS programs are working together to implement integrated
approaches to addressing childhood obesity.
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 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, and ADHS is evaluating the results. ADHS leadership and staff are working to
disseminate information about Empower nationally. The ADHS nutrition and physical activity
video series is featured on the Let's Move Childcare webpage at
http://www.healthykidshealthyfuture.org/nutrition.html under tools and resources, helpful videos.
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" and Champions for Change campaign in providing consistent nutrition and
physical activity messaging to WIC families. The integrated marketing campaign includes AZNN,
Arizona WIC, and Nutrition and Physical Activity Program (NUPA). Other campaigns include
"Fruits and Veggies -- More Matters", Physical Activity, and "Go Low".
Arizona WIC is continuing the distribution of the emotion-based education materials for obesity
prevention for WIC families.

98

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. Nutrition curriculum 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.
Bureau of Women's & Children's Health, Bureau of Nutrition & Physical Activity, and Bureau of
Tobacco and Chronic Disease will collaborate to devise a Worksite Wellness program for
Community Health Workers and Community Nutrition Workers to implement in WIC and Health
Start sites in 2012.
ADHS will be working on department-wide strategies to reduce and prevent obesity throughout
Arizona. Promoting physical activity and nutrition has been selected as a department-wide
priority. Bureau of Women's and Children's Health will work in partnership with rest of
Department in achieving strategic actions that are in process of being identified.
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.
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

2006

2007

2008

2009

2010

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

4
4.7
4063
87053
AZ Birth
Certificates

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

99

events over the last 3 years is
fewer than 5 and therefore a 3year moving average cannot be
applied.
Is the Data Provisional or Final?
Annual Performance Objective

2011
4

2012
3.4

2013
2.8

Final
2014
2.1

Final
2015
1.4

Notes - 2010
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.
The HP 2020 Goal for abstaining from cigarettes during pregnancy is 98.6% (1.4% using tobacco
during pregnancy).
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.
a. Last Year's Accomplishments
For calendar year 2010, 6,792 women utilized Arizona Smokers' Helpline (ASHLine) services. Of
these, 121 (or 1.7% of women using ASHLine) reported being pregnant and using tobacco.
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 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 Women Together for Health (WTFH) program in Maricopa County was funded through a Title
V Community Health Grant. The WTFH program provides women of childbearing age with limited
education, family income, and employment opportunities with education and support on tobacco
use and stress management. Seven hundred and seventy one women participated in the WTFH

100

program. Eighty three percent of these women were from minority populations. Mariposa
Community Health Center in Nogales Arizona provided culturally appropriate and linguistically
relevant interventions tobacco cessation among Hispanic women and adolescents.
Approximately 150 women participated in this program.
The Health Start Program continued to provide 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
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 provided materials to the
midwifery community regarding tobacco prevention programs.
2. BWCH bilingual Hotline staff refer pregnant women to ADHS
tobacco education and cessation programs.
3. Health Start and Family Planning Programs provided 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 Pregnancy & Breastfeeding 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. ASHLine participated in two trainings
for Community Lactation Consultants (CLC's) which were organized by the ADHS Bureau of

101

Nutrition & Physical Activity. The training held in Phoenix was attended by approximately 100
CLC's and the meeting in Tucson was attended by approximately 80 CLC's. The Tucson meeting
was also available for video-streaming to CLC's statewide. The ASHLine portion of the training
covered the Ask, Advise, Refer model for brief tobacco interventions as well as an introduction to
ASHLine services.
ASHLine developed and piloted a brief tobacco intervention training program especially for
Women, Infants, and Children (WIC) program staff. This program was piloted in Pima County in
October 2010 and was made available to all other county WIC programs into 2011. To date,
twenty-seven WIC clinics have been trained.
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.

c. Plan for the Coming Year
Bilingual Pregnancy & Breastfeeding 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 2012. 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 Midwife Licensing Program will work with BWCH and the ADHS Bureau of
Tobacco and Chronic Disease (BTCD) to implement tobacco education and cessation training
with the midwives.
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

2006

2007

2008

2009

2010

11.5

13.5

13

12

10

102

Annual Indicator
Numerator
Denominator
Data Source

13.0
57
439190

8.5
38
444825

12.4
56
451910
AZ Health
Status and
Vital
Statistics

10.7
49
456079
AZ Health
Status and
Vital
Statistics

8.4
39
461582
AZ
Health
Status

2011
8.2

2012
8

2013
7.8

Final
2014
7.7

Final
2015
7.5

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.
a. Last Year's Accomplishments
In 2010, the 16th Annual Child Fatality Report was produced, summarizing reviews of child
deaths that occurred in Arizona during 2009. This marks the fifth year that the Child Fatality
Review Program has reviewed 100 percent of child deaths that occurred in Arizona. During
2010, Child Fatality Review Teams reviewed the circumstances surrounding the suicides of 27
children that occurred during 2009. Twenty-four (89 percent) of the suicides were among children
15 through 17 years, and three children (11 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 in
developing web based training for emergency departments that would include depression
screening in emergency departments.
The Division of Behavioral Health Services provided information to BWCH program managers
regarding behavioral health resources for women and children.

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. Title V County Health Prevention projects address injury
prevention.
4.
5.

Pyramid Level of Service
DHC ES
PBS
IB
X
X

X

X

103

6.
7.
8.
9.
10.
b. Current Activities
For 2009, recommendations in the annual Child Fatality Review Report related to child suicides is
focused on outreach to hospitals and emergency departments across the state in efforts to
incorporate screening and brief intervention into policy and protocols and educate on availability
of the Substance Abuse Prevention and Treatment Block Grant funds, under which women and
children are priority populations for treatment.
Prescription drug drop-off event details and how-to develop a Prescription drop off community
program tool-kit was developed and is available on the ADHS website.
The Title V County Health Prevention contracts are growing through the levels of the Spectrum of
Prevention. Their suicide prevention activities include community education and building
coalitions. Two out of six counties are addressing teenage suicide prevention.

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 the service
system.
Bureau of Women's & Children's Health will work on promoting mental wellness messaging in
existing maternal and child health programs in collaboration with Division of Behavioral Health
Services.
The Title V County Health Prevention contracts will continue to grow through the levels of the
Spectrum of Prevention. Their injury prevention activities will include community education and
building coalitions to address teenage suicide prevention.

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

2006

2007

2008

2009

2010

82

82

82.5

83

91

104

Annual Indicator
Numerator
Denominator
Data Source

77.5
960
1238

78.8
971
1232

76.4
890
1165
AZ Birth
Certificates

90.0
995
1106
AZ Birth
Certificates

88.9
842
947
AZ Birth
Certificates

2011
91.5

2012
92

2013
92.5

Final
2014
93

Final
2015
93.5

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 - 2010
The 2010 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 - 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.
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 CY 2010, 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
APT site visits to birthing hospitals, maternal transports were reviewed for appropriateness and
technical assistance is provided to the hospital.
The Licensed Midwife Program reviewed quarterly reports from licensed midwives for any infants

105

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.
The Health Start program integrated 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 in two counties where there is
currently no NICP contractor.

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

Pyramid Level of Service
DHC ES
PBS
IB
X
X

b. Current Activities
The maternal transport component of the High Risk Perinatal Program (HRPP) continues funding
for 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 presented 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

106

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 continue to provide 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 in two counties where there is
currently no NICP contractor.

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)]

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

2006

2007

2008

2009

2010

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

81
81.9
71331
87053
AZ Birth
Certificates

2011
83

2012
84

2013
85

Final
2014
86

Final
2015
87

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 3year moving average cannot be
applied.
Is the Data Provisional or Final?
Annual Performance Objective
Notes - 2010
The HP 2020 Goal is 77.9%.

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.
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 2010, Health Start provided educational services to 2,358
unduplicated enrolled clients. The program provided a total of 12,484 home and/or office visits.

107

The program increased outreach to the most vulnerable populations, Native Americans and
African Americans, in targeted communities to focus on new prenatal enrollments. Approximately
36% 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 provides
technical assistance and educational materials on oral health and premature, low-birth weight
infants for external partners and organizations.
The ADHS Midwife Licensing Program reviewed data from 616 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 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
found 657 callers to have presumptive eligibility for Baby Arizona in 2010.
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 educated health professionals on the
relationship of oral health and pregnancy risks.
2. Health Start Community Health Workers educated 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
quality for Medicaid.
6.
7.
8.
9.
10.

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

b. Current Activities

108

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.
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.
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 pregnancy. 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 BWCH 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.
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.
BWCH will monitor rates of prenatal care and explore potential impact of changes in Medicaid
coverage.

D. State Performance Measures
State Performance Measure 1: The percent of high school students who report having
experienced physical violence by a dating partner during the past 12 months.

109

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

2006

2007

2008

2009

2010

2014
10.6

11.8
302
2557
Youth Risk Behavior
Survey
Final
2015
10.6

Is the Data Provisional or Final?
Annual Performance Objective

2011
10.6

2012
10.6

2013
10.6

Notes - 2010
The estimate represents the percent of high school students that reported being hit, slapped, or
physically hurt on purpose by their boyfriend or girlfriend (CI: 9.9-14.0%)
a. Last Year's Accomplishments
Bureau of Women's & Children's Health staff agreed upon this new state performance measure
as a proxy for measuring violence as part of the Title V priority on reducing intentional injury.
The Title V funded Yavapai County project provided education about healthy and abusive dating
relationships to 675 twelve to eighteen year olds using a Safe Dates course. Four hundred and
eighty eight students completed this course. This course included education about the causes
and consequences of relationship violence; self esteem; positive communication; anger
management; and conflict resolution.
The Rural Domestic Violence Services Network (RDVSN) program includes six domestic violence
shelters in Arizona. This program is funded by federal Family Violence Prevention and Services
Act funding. The six shelters provided 230 healthy relationship presentations and/or workshops
to a total of 5,532 youth and teens in rural communities. Topics included domestic violence 101,
how to break up safely, warning signs of teen dating violence, self esteem, how to help a friend,
dating bill of rights, cycle of violence, power and control, bullying and cyber stalking. Twenty-two
youth ages 12-17 self reported abuse.
The CDC-funded Sexual Violence Prevention and Education Program provided sexual violence
prevention multi-sessions across three counties. From July 1, 2010 until April 30, 2011 we have
reached a total of 17,898 elementary, high school, college and professional groups. Subjects in
the workshops include: Bullying & Sexual Violence, Consent, Dating Violence, Drug Facilitated
Rape, Gender Roles, Healthy Relationships, Masculinity & Sexual Violence, Media Advocacy,
Oppression, Primary Prevention of Sexual Violence, Role of Bystanders and Sexual Harassment;
Arizona laws on sexual assault. Arizona delivers this message in a variety of ways; we
incorporate the Nine Principles of Prevention, the social-ecological model and the Spectrum of
Prevention.
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
(AzCADV) is the lead agency and in partnership with BWCH and the Arizona Family Planning
Council has piloted clinic sites to implement grant activities.

Table 4b, State Performance Measures Summary Sheet

110

Activities
1. Sexual Violence Prevention and Education Program provides
education in key areas of preventing sexual violence.
2. The Rural Domestic Violence Services Network provides
violence prevention education activities to youth in rural Arizona.
3. Yavapai County provides education about healthy and abusive
dating relationships using a Safe Dates course.
4.
5.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X

b. Current Activities
RDVSN agencies provided 53 presentations, events, and/or workshops to 2,464 youth the first
quarter of 2011. Two of the events entitled "Teen Maze" were held in separate rural communities
both educating over 650 youth in this one day event. Teen Maze is a fun interactive event with
the goal of educating teens on topics of safe dating, tobacco and drug effects, alternatives to
violence, abstinence, sexually transmitted diseases and safe choices. Both events were a
coordinated effort of local agencies including domestic violence shelters, police and fire
departments, health and fitness educators, boys and girls clubs, and coalitions and community
groups committed to providing education and support services for communities.
Sexual Violence Prevention and Education Program will continue to provide education in key
areas of preventing sexual violence: Bullying & Sexual Violence, Consent, Dating Violence, Drug
Facilitated Rape, Gender Roles, Healthy Relationships, Masculinity & Sexual Violence, Media
Advocacy, Oppression, Primary Prevention of Sexual Violence, Role of Bystanders and Sexual
Harassment; Arizona laws on sexual assault. Collaboration is being planned among two
contractors whose focus is peer-to-peer education to create a video exploring the prevention of
dating violence.
Yavapai County is providing education about healthy and abusive dating relationships using a
Safe Dates course.

c. Plan for the Coming Year
The Title V funded Yavapai County project will continue to provide education about healthy and
abusive dating relationships using a Safe Dates course. This course includes education about
the causes and consequences of relationship violence; self esteem; positive communication;
anger management; and conflict resolution.
Contingent on continued funding, all six Rural Domestic Violence Service Network agencies plan
to continue providing domestic violence prevention programs in their respective communities.
Sexual Violence Prevention and Education will continue to provide education in key areas of
preventing sexual violence, using the multi-session / social-ecological approach.
Sexual Violence Prevention and Education Program will begin to pilot evaluation tools which will
cover key messages of primary prevention of sexual violence.
Health Start will revise the policy and procedure manual and the community health worker

111

training manual to incorporate the information provided during the Project Connect training.
During annual site visits, the Health Start Program Manager will monitor to ensure that each client
is screened for domestic/dating violence and that appropriate referrals are provided as needed.
Health Start contract staff will attend a mandatory training as an expansion of AzCADV's Project
Connect and will learn how to effectively screen Health Start clients for domestic/dating violence.
Approximately twenty five percent of Health Start clients are under twenty years of age. First
Things First home visitation projects have also been invited to attend the domestic/dating
violence screening training as well. AzCADV also provides a list of resources to everyone who
receives Project Connect training so clients can receive appropriate referrals.
The BWCH is conducting a scan/inventory of existing prevention programs for adolescents that
will include efforts related to promoting healthy relationships and violence prevention. BWCH
staff is collaborating with the ADHS Division of Behavioral Health and the Governor's Office for
Children, Youth and Families on the development of the survey tools. At a minimum, the final
product will allow schools and other agencies/individuals working with youth to refer teens to
needed services, identify gaps and coordinate training opportunities.
Bureau of Women's & Children's Health will work with other programs throughout ADHS and
external partners to identify opportunities to further integrate violence prevention into existing
programs.

State Performance Measure 2: The percent of high school students who are overweight or
obese.
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

2006

2007

2008

Is the Data Provisional or
Final?
Annual Performance
Objective

2011
27

2012
26.5

2013
26

2009

2010

27.7
652
2354
Youth Risk Behavior
Survey (2009)
Final

27.7
652
2354
Youth Risk Behavior
Survey (2009)
Final

2014
25.5

2015
24.9

Notes - 2010
Arizona overweight=14.6% and obese=13.1%. U.S. overweight=15.8% and obese=12.0%. YRBS
asks high school students to report height, weight, age and gender. Overweight is students who
were >= 85th percentile but < 95th percentile for body mass index, by age and sex, based on
reference data. Students who were >= 95th percentile are obese. The HP 2020 Goal for
adolescent obesity is 16.1%
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

112

interested community partners. Speakers conducted 3 presentations on childhood obesity and
how community organizations can contribute to behavior and policy change to various local
organizations. During 2010, their website had 5,408 hits and a total of 4,484 visitors. Sixty four
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. 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 368 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.
The Nurse Family Partnership program in Yavapai County was 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. In 2010, 139 women and 109 babies were served. Each participant
received education and support related to breastfeeding, nutrition, and physical activity.
The Women Together for Health (WTFH) program in Maricopa County was funded through a Title
V Community Health Grant. The WTFH program provides women of childbearing age with limited
education, family income, and employment opportunities with education and support on physical
activity, healthy weight, dietary quality, stress management. Seven hundred and seventy one
women participated in the WTFH program. Eighty three percent of these women were from
minority populations. Approximately 60% of the women who completed the program either
maintained or reduced their BMI during participation.
Mariposa Community Health Center in Nogales Arizona provided culturally appropriate and
linguistically relevant interventions to reduce overweight and obesity among Hispanic women and
adolescents by promoting healthy weight, positive dietary habits, increased physical activity and
stress reduction. Approximately 150 women participated in the Salud Si program. At the end of
the eight week programs, 74% of the women had decreased their BMI.

Table 4b, State Performance Measures Summary Sheet
Activities
1. Title V Community Grant address obesity prevention.
2. ADHS is 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
Beginning 2011, the Title V funded County Health Prevention contracts are addressing
preconception health, which includes focus on obesity prevention, nutrition and physical activity.

113

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 and other ADHS programs are working together to
integrate obesity prevention messaging and programming.

c. Plan for the Coming Year
ADHS will be working on department-wide strategies to reduce and prevent obesity throughout
Arizona. Promoting physical activity and nutrition has been selected as a department-wide
priority. Bureau of Women's and Children's Health will work in partnership with rest of
Department in achieving strategic actions yet to be determined.
Bureau of Women's & Children's Health is working with the Bureau of Nutrition & Physical Activity
to develop a wellness program for WIC and Community Health Workers, including special focus
on obesity prevention. The program is expected to be launched in 2012.
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.
Arizona's application for the federal Community Transformation Grant submitted in July 2011
includes several activities that would improve environment of schools to be more supportive of
healthy eating and physical activity. If funded, ADHS would work with 13 rural county health
departments to implement a variety of policy and environmental interventions in the next four
years.

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

2006

2007

2008

2009

2010

33

32.5

32

31.5

31

25.8
191
739

25.0
188
753

29.0
238
821
AZ Vital
Records data

31.5
256
813
AZ Vital
Records data

32.0
262
818
AZ Vital
Records

114

Is the Data Provisional or
Final?
Annual Performance
Objective

2011
31

2012
30.5

2013
30

Final

Final

2014
29.5

2015
29

Notes - 2010
The 2008 birth cohort was used in this analysis.
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.
a. Last Year's Accomplishments
In 2010, 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. It is anticipated that Arizona
will begin using this in 2012; 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 utilizing
$320,000 in state funding. This program has served approximately 14,000 women in FY2010. In
FY2011 services were revised to target high risk populations within specific regions of the state.
Contracts were awarded to Mohave County and Campesinos Sin Fronteras, serving the Yuma
border area. Services are inclusive of strategic social marketing campaigns around knowledge
and awareness of the importance of taking folic acid. The program has served approximately
12,000 women in FY2011 and has received over 200,000 media impressions.
The Bureau of Women's & Children's Health used Title V funding to help fund the Nurse Family
Partnership Program in Yavapai County. The project served 139 low-income new moms with 109
babies under the age of two, pregnant women, and pregnant teens. Ninety-five percent of the
babies born to the Nurse Family Partnership had birth weights greater than 2500 grams. Apache
and Navajo County Public Health Services Districts, through Title V funding, distributed
educational material on preconception health
The BWCH Office of Women's Health implemented the Liveitchangeit.com campaign through
funding by HRSA's First Time Motherhood grant. The campaign targeted African American men
and women ages 18-30 to increase awareness about preconception health and the life course
perspective. It consisted 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
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. BWCH also
partnered 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 provided Grand Round
presentations at Level III hospitals.

115

The BWCH and the March of Dimes hosted a Preconception Health Summit in April 2010, which
included presentations from national and local experts on preconception health. The objectives
of the summit were to increase the knowledge of preconception health, identify the salient clinical
characteristics of preconception care, identify ways of increasing access to it, and strengthen
health systems to include it. Attendees reported that their views on and knowledge about
preconception health and health care improved and of those who provided direct care, the
majority indicated their willingness to change the way preconception health care was being
provided. DVDs of the summit were produced and distributed to partners throughout the state.
BWCH convened a task force to develop a statewide preconception health strategic plan. The
strategic plan is intended to serve as a roadmap for stakeholders in the public and private sectors
who are interested in advancing preconception/interconception health and health care. The task
force consisted of representatives from hospitals, county health departments, community health
centers, ADHS staff and health plans. The three strategic plan goals focus on 1) Public
Awareness 2) Healthy Behaviors and 3) Access and Quality of Preconception Healthcare.

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 &
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. Title V County Health projects are implementing
preconception health strategies at multiple levels of spectrum of
prevention.
6. BWCH promotes preconception health materials and
strategies.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X

X
X

X

b. Current Activities
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 Title V County Health Prevention contracts are continuing to grow through the levels of the
Spectrum of Prevention. Their preconception health activities include community education,
building coalitions, changing organizational practices, and developing policies.
The final version of Arizona's Preconception Health Strategic Plan was completed and distributed
to MCH stakeholders in April 2011. The task force will continue to meet to focus on
implementation of the strategic plan .
The BWCH is participating on the CDC's Preconception Health Consumer Workgroup, which
allows Arizona to be an active partner in national efforts to promote preconception health and
health care. Arizona will be able to disseminate and utilize current marketing strategies for

116

increasing public awareness of preconception health.
The results and implementation of the LiveitChangeit.com campaign were presented during the
June 2011 National Preconception Health Summit.
ADHS continues to support the folic acid education and distribution program for low-income
women of childbearing age through county health and community health centers.

c. Plan for the Coming Year
Child Fatality Review Program will issue annual report in November 2011, 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 Title V County Health Prevention contracts will continue to grow through the levels of the
Spectrum of Prevention. Their preconception health activities will include community education,
building coalitions, changing organizational practices, and developing policies. Navajo County
Public Health District is offering courses in preconception health in high schools, gynecologists
offices, pediatrician offices, and public agencies. Women are being screened related to
preconception care and referred to appropriate programs. Coconino County Public Health District
is developing a resource directory of preconception health care providers in Coconino County.
Apache County Public Health Services District is providing "Take Two" presentations to medical
service providers regarding preconception health. Apache County Public Health Services District
is also working with high school nurses to provide education on preconception health. Yavapai
County Community Health Services is developing a preconception health toolkit to distribute to
providers and community partners. Yavapai County Community Health Services is also
developing a wellness survey to assess preconception health in the workplace and in schools.
Gila County is partnering with schools and other youth organizations to address the importance of
healthy lifestyles in teens.
A preconception health toolkit will be developed to assist with training community health workers,
home visiting staff and other health care and social service providers on how to educate their
clients/patients about preconception health.
BWCH, the Preconception Health Task Force members and other stakeholders will continue to
work on identifying and implementing strategies designed to increase awareness about the
importance of preconception health and enhance access to preconception health care.
Folic Acid Education and Distribution Program activities will include statewide vitamin distribution
and emphasis of social marketing outreach to increase knowledge, attitude, and beliefs around
folic acid consumption.

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

2006

2007

2008

2009

2010

117

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

7478

7477

7477

7476

7000

6,902.9
89255
1293014

6,681.6
92588
1385725

6,835.2
90940
1330464
AZ Hospital
Discharge
data

7,077.9
95037
1342722
AZ Hospital
Discharge
data
Final

7,558.6
96070
1271006
AZ Hospital
Discharge
Data
Final

2011
7400

2012
7250

2013
7100

2014
6950

2015
6800

Is the Data
Provisional or Final?
Annual Performance
Objective

Notes - 2010
If the 2010 rate of emergency department visits for unintentional injuries had met the preformance
objective of 7000 per 100,000 children age 1-14 years, approximately 7,100 visits would have
been prevented.
Notes - 2008
The 2008 data was not available prior to completion of the narrative sections in this grant.
a. Last Year's Accomplishments
The Safe Kids program manager provided certification child passenger safety training to two
communities in Arizona.. 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 summer 2011. The program has contracted with the American Academy of
Pediatrics, Arizona Chapter to be the certifying body.
In 2010, the Injury Prevention program provided county specific injury fact sheets and county
child fatality fact sheets for county health departments. The program also conducted a second
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.
Child Care Licensing updated their rules for both day care centers and home care facilities. With
input from the Injury Prevention Program, all infants must be placed on their backs to sleep in
cribs that are devoid of toys, blankets and other potential suffocation objects. Children who are
transported by the facility must be in approved restraint as outlined by state law and are
prohibited from sitting in front of an active airbag. Wheelchairs that are used for transportation
purpose will need to be labeled for approved use in a motor vehicle.
The High Risk Perinatal Program (HRPP) Community Health Nurses and the Health Start
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

118

to correct the situation, thereby reducing risk and the potential for preventable emergency room
visits.
The Title V Community Health Grants program funded "Safe Dates", a co-educational injury
prevention course for adolescents 12 to 18 years of age. The project provided 675 participants
with information about healthy and abusive dating relationships. During 2010, 675 adolescents
participated in at least one class with 488 students completing the entire curriculum.
Through Yavapai County's Title V funded Nurse Family Partnership, 55 low income first time
mothers which were new to the program in 2010, received education and support related to
safety, injury prevention, feeding position, and sleep position.
The Title V funded Early Childhood Education/Child Care Health Consultant in Pima County
provided 187 encounters in preschools which include assessment, consultation, and
recommendations regarding playground safety.
The 17th 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 strengthening current legislation regarding
pool fencing to require four-sided fencing with appropriate gates for all backyard pools where
children live or play.

Table 4b, State Performance Measures Summary Sheet
Activities
1. HRPP Community Health Nurses and Health Start workers
conduct home safety 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. County Health projects address injury prevention through
education, coalitions, organizational practices, and policy
development.
7.
8.
9.
10.

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

b. Current Activities
For 2011, the Emergency Medical Services for Children is developing model pediatric specific
inter-facility transfer agreements for hospitals and continues working toward the creation of a
pediatric designation system for emergency departments.
The Title V County Health Prevention contracts are continuing to grow through the levels of the
Spectrum of Prevention. These contracts will increase activities around community education,
building coalitions, changing organizational practices, and developing policies. Projects address a
variety of injury issues, including poison prevention, safe sleep, motor vehicle safety, and falls.

119

Health Start Community Health Workers and Community Health Nurses conduct the Safe
Home/Safe Child home environmental assessments for every postpartum client. They work with
the family to correct the situation, thereby reducing risk and the potential for injuries. They work
with the family to educate clients and their families on how to avoid and reduce home related
risks such as fire hazards, drownings and poisonings.

c. Plan for the Coming Year
The HRSA funded EMS Children program will begin implementation of a voluntary pediatric
designation process for hospital emergency departments using the American Academy of
Pediatrics Arizona Chapter as the designating body.
The Injury Prevention Program, in partnership with Indian Health Services, will be conducting
Indian Health Service's Level I and II Injury Prevention Training and updating the Ride Safe
Curriculum.
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.
The Title V County Health Prevention contracts will continue to grow through the levels of the
Spectrum of Prevention. These contracts will increase activities around community education,
building coalitions, changing organizational practices, and developing policies.
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. A training on Safe Home/Safe Child
assessment will be held for all Community Health Workers.
BWCH will be implementing the federal Maternal, Infant, Early Childhood Home Visiting Program.
Healthy Families will be implemented in Pinal County, Nurse Family Partnership will be
implemented in Tucson, and Family Spirit will be implemented with White Mountain Apache Tribe.
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 in south Phoenix. Programs aim to reduce drug/alcohol abuse, teen suicide, juvenile
delinquency, gang involvement, child abuse and domestic violence, as well as to increase parent
knowledge of early childhood development, improve parenting practices, and to help families
enhance relationships and decrease conflict through behavioral management and support.

State Performance Measure 5: The percent of women having a subsequent pregnancy
during the inter-pregnancy interval of 18-59 months.
Tracking Performance Measures
[Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)]

Annual Objective and
Performance Data
Annual Performance

2006

2007

2008

2009

2010

120

Objective
Annual Indicator
Numerator
Denominator
Data Source
Is the Data Provisional or
Final?
Annual Performance
Objective

2011
45

2012
45.5

2013
46

41.7
24748
59309
AZ Birth and Fetal
Death Certificates
Final

43.8
24330
55589
AZ Birth and Fetal
Death Certificates
Provisional

2014
46.5

2015
48

a. Last Year's Accomplishments
BWCH staff chose to use a measure of inter-pregnancy intervals as an indicator of progress on
the new Title V preconception health priority of improving women's health prior to pregnancy.
Stakeholders and staff recognized how critical planned pregnancies and birth spacing is to
preconception health and improving birth outcomes. Office of Assessment & Evaluation
conducted research and obtained input from local experts to develop an appropriate measure.
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.
The Reproductive Health/Family Planning Program worked with contractors to improve access for
low income clients to preconception care within family planning. Maricopa Integrated Health
Services utilized 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 has piloted
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 focused on how to develop a
reproductive life plan with their clients.
The final version of Arizona's Preconception Health Strategic Plan was completed and distributed
to MCH stakeholders in April 2010. The task force will continue to meet, however the focus will
now be on implementation of the strategic plan which may result in revised stakeholder
representation on the task force. Each meeting this year will include an update on progress
made with respect to the strategies and action steps contained in the plan.
The BWCH was invited to participate on the CDC's Preconception Health Consumer Workgroup
and this will allow Arizona to be an active partner in national efforts to promote preconception

121

health and health care. In addition, Arizona will be able to disseminate and utilize current
marketing strategies for increasing public awareness of preconception health.

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. Office of Women’s Health is leading preconception health
initiatives.
4. Title V County Health projects are implementing
preconception health strategies at multiple levels of spectrum of
prevention.
5.
6.
7.
8.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X

X

X
X

X

b. Current Activities
The Reproductive Health/Family Planning contractors continue to receive level Title V funding via
a unit reimbursement process for providing program required services. The Reproductive
Health/Family Planning Program works with contractors to improve access for low income clients
to preconception care within family planning.
BWCH Office of Assessment & Evaluation is conducting detailed analysis of birth outcomes and
characteristics of inter-pregnancy intervals among births in Arizona. The data is being used to
provide a baseline for this measure as well as to inform MCH program managers and interested
partners.
Children's Rehabilitative Services member handbook includes resources for family planning and
STD and HIV testing.
BWCH Office of Women's Health continues to lead preconception health initiatives, including the
work of the statewide taskforce and implementation of statewide preconception health plan.
Office of Women's Health is participating on CDC's Preconception Health Consumer Workgroup.
BWCH is using Title V to fund six county health departments to implement preconception health
activities across the spectrum of prevention, with emphasis on coalition-building, organizational
practices, and policy development.

c. Plan for the Coming Year
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

122

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.
Health Start Program will be trained by the Arizona Coalition Against Domestic Violence to
provide screening of women for domestic violence in the home 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. BWCH will explore opportunities to enhance
interconception education, particularly regarding appropriate birth spacing, among home visiting
programs and WIC program.
The Title V County Health Prevention contracts will continue to grow through the levels of the
Spectrum of Prevention. Their preconception health activities will include community education,
building coalitions, changing organizational practices, and developing policies.
BWCH, the Preconception Health Task Force members and other stakeholders will continue to
work on identifying and implementing strategies designed to increase awareness about the
importance of preconception health and enhance access to preconception health care.

State Performance Measure 6: Percent of Medicaid enrollees age 1-14 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
Is the Data Provisional or Final?
Annual Performance Objective

2006

2011
48

2007

2012
49

2008

2009

2010

2013
50

42.9
240529
560823
AZ Medicaid
Final
2014
51

47.3
281134
594701
AZ Medicaid
Final
2015
52

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 worked closely with the Arizona Health Care Cost
Containment System in identifying opportunities to increase access to preventive services for
eligible enrollees. 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 two 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 provided technical assistance and training to 65
providers and administrators on Early Childhood Caries and treatment programs.
The Office of Oral Health maintained Intergovernmental Agreements with counties to provide
school-based dental screenings, referrals and sealants to children in low-income schools. The
Office of Oral Health collaborates with First Things First to promote and implement prevention

123

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 five pilot teledental sites in Arizona including Northern Arizona
University (NAU) School of Dental Hygiene, one tribal site and one site targeted at Head Start
children in rural areas.
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' and dentists 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 dental providers
and school nurses to assist with the provision of dental services 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. The child is provided with a referral form
to a participating health care provider and the school nurse makes the appointment. In 2010, the
Medical Services Project provided dental services to 25 individual children. In 2010, the Medical
Services Project developed new collaborative partnerships with the following organizations:
Kidzzaam Dentistry in Prescott Valley, Magic Smiles Dental, By developing collaborative
partnership with these organizations, we are better able to assist Medical Services Project (MSP)
participants.
The Office of Oral Health participated in planning and implementation of the American Indian Oral
Health Summit. The summit reviewed tribal needs; identified potential strategies to address
regional oral health workforce shortages; and developed objectives and broad action steps.

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

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X

b. Current Activities
Through a HRSA Workforce Grant, the Office is developing and implementing teledentistry
demonstration models and collaborating with the established teledentistry sites providing services
to rural areas and training and education to dental providers. The goal is to promote and develop
enhanced dental teams (utilizing teledentistry practice, affiliated practice and other strategies) to

124

improve workforce capacity, diversity and flexibility for providing oral health services to
underserved populations and areas. Major activities include (1) building local infrastructure, (2)
developing enhanced dental team practice models to increase dental care access to the
underserved preschool/school age children and promote early prevention to pregnant
women/parents/caregivers, and (3) providing communication to build linkages, develop webbased information and share successes. Grant activities have established four Regional Oral
Health Coordinators to serve 10 of Arizona's 15 counties; developed 4 new or expanded Regional
Oral Health Coalitions; completed 4 regional needs assessments; and aimed to complete 4
regional oral health improvement plans. Partnerships have been built that implement 5 enhanced
dental team practice models with plans to develop 9 additional practice models. The Grant has
integrated enhanced dental team strategies into 3 health initiatives for increasing access to care
and establishing dental homes for children ages 0-5, Head Start children, and tribal population.

c. Plan for the Coming Year
The Office of Oral Health will continue to monitor AHCCCS Health Plans on policies for dental
care and case management, collaborate with school-based dental clinics, and partner with private
organizations and foundations to enhance prevention activities. The Office will continue to work
with the Arizona Dental Association and Arizona Dental Hygiene Association in an effort to
improve the number of providers for the underserved. Tracking of AHCCCS utilization for care
will continue, as will collaboration with internal state agencies and external partners 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 to promote
the 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 counties and seek to increase the number of children
served.
Through the 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 facilitated 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 Health to
enhance integration of oral health strategies into existing programs, such as Health Start and
WIC.
The Title V funded Medical Services Project will continue to provide access to and utilization of
dental care, for Arizona's uninsured children from low-income families. The Medical Services
Project provides delivery of services in participating dentists' offices to children without health
insurance and to those who do not qualify for public assistance. The Medical Services Project
creates a system of linkages between dental providers and school nurses to assist with the
provision of dental services to the target population. School nurses identify children who are
eligible to participate in the Medical Services Project and facilitate their enrollment. The Medical
Services Project will continue to increase the number of participating dental care providers.
BWCH Office of Children's Health will explore possible enhancements to home visiting programs
in regards to oral health services.

State Performance Measure 7: Percent of women age 18 years and older who suffer from
frequent mental distress.
Tracking Performance Measures

125

[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

2006

2007

2008

2009

2010

10.2
375
3686
AZ
BRFSS

11.9
385
3239
AZ
BRFSS
Final
2014
9.5

11.9
385
3239
AZ BRFSS

Is the Data Provisional or Final?
Annual Performance Objective

2011
11

2012
10.5

2013
10

Provisional
2015
9

Notes - 2010
Frequent mental distress is defined as having 14 or more mentally unhealthy days as measured
by the question: "Now thinking about your mental health, which includes stress, depression, and
problems with emotions, for how many days during the past 30 days was your mental health not
good?"
a. Last Year's Accomplishments
BWCH selected this as a new state performance measure for the Title V priority of improving the
behavioral health of women and children. While Arizona did not select a measure specific to
substance abuse, MCH programs also promote substance abuse prevention. The Health Start
Program, for example, has institutionalized fetal alcohol spectrum disorders screening, brief
intervention, and referral protocol into the program.
The Health Start Program implemented the Edinburgh Postnatal Depression Scale (EPDS)
screening as part of the family follow-up visits for all postpartum clients. Community Health
Workers were provided training on the EPDS screening tool and instructed on how to score the
results. Referral resources were identified and lists of service providers were distributed.
Community Health Workers educated all clients on the postpartum warning signs of depression
and perinatal mood and anxiety disorders.
HRPP/NICP Community Health Nurses continue to provide the Edinburgh Postnatal Depression
Scale (EPDS) screening as part of the home visit made to infants, children and their families after
discharge from the Neonatal ICU or Pediatric ICU. Each Community Health Nursing agency
contracted with HRPP/NICP has developed a list of referral resource service providers for the
community they serve. The community health nurses educate their clients on warning signs of
postpartum depression as well as perinatal mood and anxiety disorders
BWCH distributed Every Woman Arizona preconception health materials that included
information on mental wellness, depression, and substance abuse.

Table 4b, State Performance Measures Summary Sheet
Activities
1. Health Start Community Health Workers provide postpartum
depression screening and educate clients on signs of depression
and perinatal mood disorders.
2. HRPP Community Health Nurses provide postpartum
depression screening and educate clients on signs of depression
and perinatal mood disorders.
3. BWCH promotes strategies to enhance mental wellness
among women.

Pyramid Level of Service
DHC ES
PBS
IB
X

X

X

126

4. ADHS is working on department-wide integration of behavioral
health and physical health.
5.
6.
7.
8.
9.
10.

X

b. Current Activities
The Health Start Program continues to provide the Edinburgh Postnatal Depression Scale
(EPDS) screening as part of the family follow-up visits for all postpartum clients. Community
Health Workers were provided continuing education on the EPDS screening tool. Referral
resources were updated and lists of service providers were distributed. Community Health
Workers educated all clients on the postpartum warning signs of depression and perinatal mood
and anxiety disorders.
HRPP/NICP Community Health Nurses continue to provide the Edinburgh Postnatal Depression
Scale screening as part of the home visit made to infants, children and their families after
discharge from the Neonatal ICU or Pediatric ICU. Each Community Health Nursing agency
contracted with HRPP/NICP has developed a list of referral resource service providers for the
community they serve. The community health nurses educate their clients on warning signs of
postpartum depression as well as perinatal mood and anxiety disorders.
BWCH promotes mental wellness among women through preconception health materials and
women's health week activities. The 2011 Women's Health Week events sponsored by
ADHS/BWCH included a presentation on Women's Mental Health and Wellness with a guided
relaxation exercise. In addition, women attending the events were able to obtain free chair
massages and the state contracted health plans provided information about the mental health
and wellness services they offer their members.

c. Plan for the Coming Year
ADHS has launched a department-wide effort to better integrate behavioral health and physical
health. Division of Behavioral Health is implementing mental health first aide training statewide.
The Health Start Program Manager will continue to attend a Division of Behavioral Health
Women's Treatment Workgroup to discuss Health Start services and fetal alcohol screening. The
workgroup consists of behavioral health providers. There are ongoing discussions regarding
making cross referrals; linking pregnant behavioral health clients with home visitation services
and linking Health Start clients with behavioral health services as needed.
The Health Start Program will provide a training workshop for Community Health Workers in this
program and other home visitation programs in the state, on the Edinburgh Postnatal Depression
Scale (EPDS) to expand screening during family follow-up visits for all postpartum clients.
Referral resources and lists of service providers will be updated and distributed. Community
Health Workers will continue to educate all clients on the postpartum warning signs of depression
and perinatal mood and anxiety disorders.
BWCH staff is participating in the development of a DBHS Adult System of Care Strategic Plan
that is focused on the integration of mental health and physical health.
HRPP/NICP Community Health Nurses will continue to provide the Edinburgh Postnatal
Depression Scale (EPDS) screening as part of the home visit made to infants, children and their
families after discharge from the Neonatal ICU or Pediatric ICU. Each Community Health Nursing

127

agency contracted with HRPP/NICP will developed an updated list of referral resource service
providers for the community they serve. The community health nurses will continue to educate
their clients on warning signs of postpartum depression as well as perinatal mood and anxiety
disorders.
BWCH will provide education regarding mental wellness and depression as part of women's
health week activities. BWCH will continue to work with Division of Behavioral Health Services to
identify appropriate mental wellness messaging as well as identify opportunities for integration of
mental wellness into existing programs. BWCH will participate in ADHS initiatives to further
integrate behavioral health and public health interventions.
BWCH will monitor the impact of the Affordable Care Act as it relates to access and availability of
behavioral health services for adult women in urban and rural areas of the state and work with
ADHS Health Systems Development and DBHS on coordination of services for the maternal and
child health population. Information will be shared with BWCH partners as it becomes available
and technical assistance will be provided as needed.

State Performance Measure 8: Percent of newborns who fail their initial hearing screening
who receive appropriate follow up services.
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

2006

2007

2008

2009

2010

77.7
2829
3643
AZ Early
Hearing and
Detection

77.9
2110
2710
AZ Early
Hearing and
Detection
Final

77.9
2110
2710
AZ Early Hearing
and Detection

2014
85

2015
86

Is the Data Provisional
or Final?
Annual Performance
Objective

2011
79

2012
81

2013
83

Provisional

a. Last Year's Accomplishments
The Arizona (AZ) Newborn Screening Program (NBS) instituted three important elements to
address this performance measure. First, Arizona participated with several other state EHDI
programs to develop an 8 minute video and public service announcements in English and
Spanish targeted to encourage parents to obtain the follow-up needed after the initial fail of the
newborn hearing screen. More than 200 copies have been distributed throughout Arizona
including hospital screening programs, parent groups, inter-agency partners and others. The
second was the introduction of the Arizona Hands & Voices, Guide By Your Side (GBYS) FollowThrough program. The program coordinator works closely with NBS, sharing information on the
status of infants who failed the initial screen. In addition to site visits with the High Risk
Coordinator, GBYS visited four birthing hospitals in western AZ, and two in northeastern AZ.
Bilingual brochures describing GBYS Follow-Through services for families are distributed at
participating hospitals. The program paired a trained Parent Guide with a hospital screening
program. Each hospital customized at what point they have the guides interact with their
screening program. The third was a follow-up coordinator that is dedicated to tracking and followup of high-risk infants (NICU stay for greater than 5 days and failing the hearing screen) in order

128

to reduce the loss to follow up to 10% or less. The role of the high-risk coordinator is to foster
communications between hospital discharge managers and newborn hearing screening program.
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 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.
ADHS reviewed with licensed midwives who are completing the hearing screening
following the infant's birth. One licensed midwife was performing the hearing screening tests. The
remaining midwives have been provided information regarding where to obtain the test or are
referring the families to a pediatrician or hospital facility for review of the newborns ability to hear.

Table 4b, State Performance Measures Summary Sheet
Activities
1. Newborn Screening Program provide on-site technical
assistance and training for hearing screening.
2. Newborn Screening Program is enhancing education for
parents and providers.
3. Sensory Program collaborates with the University of Arizona
to train hearing screening trainers.
4. Sensory Program disseminates information about mandatory
school hearing screening and ADHS Rules.
5. Sensory Program purchases, repairs and calibrates hearing
screening equipment to loan to Arizona’s Schools.
6. OCSHCN directs families who lack services or coverage to
healthcare, resources and family support.
7. OCSHCN supports family partners in development and review
of resources and funds translation of family materials.
8. OCSHCN supports training and technical assistance to
medical providers and early education programs.
9.
10.

Pyramid Level of Service
DHC ES
PBS
IB
X
X
X
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 families. 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 vs. outpatient screening results; and optimizing the timing of
calls to hospitals vs. parents or medical home providers.
A new provider pocket guide was recently developed and distributed to all care providers in the
state and includes a workflow for patients who are navigating the EHDI system of care. These
materials have been evaluated by parents and practitioners; survey results indicate they are
useful.

129

Office for Children with Special Health Care Needs (OCSHCN) is working with the state's
Interagency Coordinating Council (AzEIP ICC) 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 and working on updating training with assessment tools and how to
communicate screenings to parents.

c. Plan for the Coming Year
NBS plans to expand coordination efforts to reach the families of infants who are lost to follow-up.
This will be accomplished through data integration, parent outreach efforts and surveys, ensuring
that families have family-centered and culturally sensitive access to information about where to
get screened, including mechanisms to reach those underserved in the current EHDI system.
Included in this partnership will be technology enhancements, such as data sharing and
infrastructure building, data exchange, and training to include broader use of the eLearning
platform for training to hearing screeners, physicians, community health centers, Early Head
Start programs and physicians' offices.
The hearing screening database has been upgraded and will be expanded to include access by
all hospitals, audiologists and other providers in a two-way role based secure environment. This
expansion, paid for under the CDC Data integration grant, will result is a significant reduction in
loss to documentation. Ongoing on-site training to audiologists and ENT practices, including rules
for reporting data, will be expanded to include best practices as well as technology education.
OCSHCN funds will be used to support the EAR Foundation of Arizona contract with NBS that is
funded through state revenues to support ADHS' follow-up efforts. OCSHCN will be working with
EAR Foundation of Arizona and other EHDI stakeholders to build infrastructure for screening
beyond the newborn period.
Community Health nurses and Health Start workers will review hearing screening results with
parents. ADHS Bureau of Women and Children's Health (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 distribute to parents who choose home birth.
OCSHCN and AzEIP ICC survey that identifies who does follow-up hearing screening and
resources for families with children ages 0-5 will be disseminated. The ADHS Division of
Licensing will provide an updated list of audiologists in the state.
OCSHCN will continue to direct families to the EAR Foundation of Arizona for hearing aids,
cochlear implant batteries, repairs and audiology testing for children. OCSHCN and EHDI will
partner with North Dakota to use the North Dakota hearing telemedicine protocol developed
under a HRSA grant.

E. Health Status Indicators
Introduction
/2012/ With the exception of infants born at very low birth weight, indicators of birth weight
for all births and singleton births showed little improvement in 2010. Health Status
Indicators for the death rates from motor vehicle injuries continued to decline significantly
in 2010. Increases were noted in non-fatal injury for children 14 years and younger during
2010. //2012//Rates of Chlamydia among adult females continued to rise. This in part may be

130

due to increased access to and promotion of testing for Chlamydia rather than a true rate
increase among at-risk populations. Population data is reflecting the effects of the current
economic recession. /2012/ Total births continued to decline in 2010 (-6.0 percent), //2012//
with the largest reduction among Hispanic or Latino births. As expected, poverty rates among
Arizonans increased in 2010. /2012/ The release of complete 2010 Census data will provide
final data for some of the provisional measures. //2012//

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
2006
2007
2008
2009
Annual Indicator
7.1
7.1
7.1
7.1
Numerator
7266
7285
7026
6573
Denominator
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
Notes - 2008
The 2008 data was not available prior to completion of the narrative sections in this grant.

2010
7.1
6155
87053

Final

Narrative:
/2012/ The data estimate remained unchanged for the previous five years. Arizona had a
significantly lower estimate of low birth weight than the HP 2020 Goal of 7.8 percent.
Compared to the HP 2020 Goal, Arizona had 635 fewer low weight births than expected.
Black and African Americans remain more at risk for low birth weight in Arizona (11.4%)
compared to White non-Hispanics (6.7%), Hispanic or Latinos (6.8%), American Indians
(7.0%), and Asian or Pacifica Islanders (8.5%). //2012//All data for low birth weight infants
were obtained from 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 in all Health Start sites 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

131

the March of Dimes. BWCH established a Preconception Health Taskforce and developed a
statewide preconception health plan. /2012/ Starting in 2011, Title V funding has been
provided to six county health departments to implement preconception health strategies.
//2012// 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
2006
2007
2008
2009
2010
Annual Indicator
5.7
5.6
5.6
5.7
5.6
Numerator
5632
5599
5392
5123
4736
Denominator
99216 99889 96347 90032 84520
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.

Narrative:
/2012/ The data estimate has not significantly changed for the previous five years. There is
no HP 2020 Goal for singleton birth weight. //2012//All data for very low birth weight infants
were obtained from 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 in all Health Start sites 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

132

and disseminated. In 2010, Arizona held its first preconception health summit in conjunction with
the March of Dimes. BWCH established a Preconception Health Taskforce and developed a
statewide preconception health plan. /2012/ Starting in 2011, Title V funding has been
provided to six county health departments to implement preconception health strategies.
//2012// 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
2006
2007
2008
2009
2010
Annual Indicator
1.2
1.2
1.2
1.2
1.1
Numerator
1229
1223
1156
1106
947
Denominator
102042 102687 99215 92616 87053
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.

Narrative:
/2012/ Although the estimate only declined from 1.2 to 1.1 percent, this was a significant
reduction (Chi square=4.492(1), p<0.03) . Arizona also had a significantly lower estimate of
very low birth weight than the HP 2020 Goal of 1.4 percent. Compared to the HP 2020
Goal, Arizona had 272 fewer very low weight births than expected. Black or African
Americans were more likely to be born at very low birth weight (2.7%) compared to White
non-Hispanics (.9%), Hispanic or Latino (1.1%), American Indians (1.2%), and Asian or
Pacific Islanders (1.4%). //2012//All data for low birth weight infants were obtained from 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

133

program in all Health Start sites 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 and developed a
statewide preconception health plan. /2012/ Starting in 2011, Title V funding has been
provided to six county health departments to implement preconception health strategies.
//2012// 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 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
2006
2007
2008
2009
2010
Annual Indicator
0.9
0.9
0.9
1.0
0.9
Numerator
882
902
850
856
735
Denominator
99216 99889 96347 90032 84520
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.

Narrative:
/2012/ The estimate for singletons has not changed significantly since 2006. There is no
Healthy People 2020 Goal for singleton birth weight. Arizona had a significantly lower
estimate of very low birth weight for all infants than the HP 2020 Goal of 1.4 percent.
Compared to the HP 2020 Goal, Arizona had 272 fewer very low weight births than
expected. //2012//
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.

134

The Health Start Program integrated the Alcohol Screening and Brief Intervention Services
program in all Health Start sites 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 and developed a
statewide preconception health plan. /2012/ Starting in 2011, Title V funding has been
provided to six county health departments to implement preconception health strategies
//2012//. 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
2006
2007
2008
2009
2010
Data
Annual Indicator
8.6
8.9
7.8
7.6
7.6
Numerator
119
126
108
109
103
Denominator
1390127 1412725 1379172 1434985 1358059
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 not yet available. Estimates for 2008 are provisionally set at the 2007 rate until
data becomes available in the Fall of 2009.

Narrative:
/2012/ The death rate due to unintentional injuries among children aged 14 years
decreased from 8.6 per 100,000 to 7.6 per 100,000, although the decline was not
significant. The Healthy People 2020 Goal for death due to unintentional injuries among all
persons is 36 per 100,000. //2012//The data for mortality is available from the Arizona Death
Certificate.
/2012/ The Injury Prevention Program adopted 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

135

programs in ADHS and outside agencies. Within this Injury Plan, data-based surveillance
guides the process for determining which actions and strategies will be most effective in
reducing injury. The Child Fatality Review Program collects, analyzes and disseminates
data for every child death in Arizona. The State Child Fatality Review Team makes specific
recommendations for legislation and education to prevent unintentional injuries among
children. //2012//
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 2009, two First Things First Regional Councils offered grants to target injury prevention among
children five years of age and younger.
/2012/ Title V funding support injury prevention activities in six county health departments.
Lack of funding at local level is a barrier to inplementation of injury prevention statewide.
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
conduct environmental risk assessments during every home visit in order to reduce the
risk of infant injury and death. //2012//

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
2006
2007
2008
2009
2010
Data
Annual Indicator
4.0
4.0
2.7
3.5
2.1
Numerator
56
57
39
50
29
Denominator
1390127 1412725 1429459 1434985 1358059
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.

136

The 2008 data were not available prior to completion of the descriptive analyses and program
narratives.

Narrative:
/2012/ The rate of death for unintentional injuries due to motor vehicle crashes declined
significantly since 2006 (Chi sqare=7.959(1), p<0.005) to 2.1 per 100,000 children aged 14
years and younger. The total number of MVC deaths among children has declined by
nearly 50 percent since 2006. The Healthy People 2020 goal for persons of all ages is 12.4
deaths per 100,000. //2012//All mortality data were gathered from the Arizona Death Certificate.
The BWCH has multiple programs that attempt to reduce the mortality rate from motor vehicle
crashes among children. The Title V Community Health Grants fund contractors to train car and
booster seat technicians as well as purchase and distribute those safety seats. In addition, the
program funds contractors that conduct education in high schools for teen parents about proper
use of restraint seats. These contractors will continue to build infrastructure and influence policy.
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.
/2012/ 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 summer of 2011. In addition, the
program is developing inter-facility transfer agreements for hospitals.
The Arizona legislature has not passed booster seat or primary seat belt legislation that
could safeguard the lives of older children and teens. //2012//

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
2006
2007
2008
Annual Indicator
32.4
26.7
22.1
Numerator
287
237
200
Denominator
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

2009
16.8
153
912687

2010
12.2
110
904166

137

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.

Narrative:
/2012/ The death rate for unintentional injuries due to motor vehicle crashes among youth
aged 15 through 24 years has declined each year during the reporting period. Compared
with 2006 (32.4 per 100,000) the rate in 2010 (12.2 per 100,000) was significantly lower in
2010 (Chi square=82.625(1), p<0.00001). //2012//All mortality data were gathered from the
Arizona Death Certificate.
The Injury Prevention Program continues to provide technical assistance for the 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 tool kit for implementing a Battle of the Belt program is b made
available to high schools throughout Arizona.
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 analyzes trends observed due to the enactment of graduated driving license restrictions
for teen drivers.
/2012/ The Title V County Health Prevention program funds contractors that implement
education in high schools about driving while under the influence of alcohol. //2012//
The Arizona Legislature has not passed 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.

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
2006
2007
2008
Data
Annual Indicator
190.0
177.2
163.6
Numerator
2641
2504
2338
Denominator
1390127 1412725 1429459
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?
Notes - 2008

2009

2010

235.9
3385
1434985

239.4
3251
1358059

Final

Final

138

The 2008 data was not available prior to completion of the narrative sections in this grant.

Narrative:
/2012/ As the rate of death for injuries declines in Arizona, the rate of all non-fatal injuries
among children aged 14 years and younger has significantly increased from 190 per
100,000 in 2006 to 239 per 100,000 in 2010 (Chi-sqaure=78.37(1), p<0.00001). Falls
remained the largest contributing cause of non-fatal injury among this age cohort. //2012//
The data were obtained through analysis of appropriate e-codes in the Arizona Hospital
Discharge Database.
The Injury Prevention Program adopted 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.
/2012/ Within this Injury Plan, data-based surveillance guides the process for determining
which actions and strategies will be most effective in reducing injury. Unintentional falls
are the leading cause of non-fatal injury for children ages 0-14 in Arizona //2012//.
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
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.

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
2006
2007
2008
Data
Annual Indicator
50.7
45.3
34.3
Numerator
705
640
491
Denominator
1390127 1412725 1429459
Check this box if you cannot report the
numerator because

2009

2010

38.6
554
1434985

36.6
497
1358059

139

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.

Narrative:
/2012/ The rate of nonfatal injuries due to motor vehicle crashes among children aged 14
years and younger declined in 2010, but not significantly. Compared to 2006 (50.7 per
100,000) the rate in 2010 (36.6 per 100,000) was significantly lower (Chi-square=31.293,
p<0.0001). //2012//The data were obtained through analysis of appropriate e-codes in the
Arizona Hospital Discharge Database.
/2012/ The Arizona Safe Kids Coalition. Local Coalition accomplishments include regular
car seat check up events, a permanent car seat testing site, child passenger safety (CPS)
technician certification and development of resource materials for public education.
//2012//
/2012/ In 2010, //2012//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.
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.
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
2006
2007
2008
Annual Indicator
211.2
206.6
165.2
Numerator
1871
1837
1493
Denominator
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.

2009
161.1
1471
912887

2010
137.6
1244
904166

140

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.

Narrative:
/2012/ The rate of nonfatal injuries due to motor vehicle crashes for youth aged 15 through
24 years old continued to decline in 2010. Compared to 2009 (161.1 per 100,000) the rate in
2010 (137.6 per 100,000) was significantly lower (Chi-square=16.889, p<0.00004). //2012//
The data were obtained through analysis of appropriate e-codes in the Arizona Hospital
Discharge Database.
The Injury Prevention Program continues to provide technical assistance for the 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 tool kit for implementing a Battle of the Belt program is made
available to high schools throughout Arizona.
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 analyzes trends observed due to the enactment of graduated driving license restrictions
for teen drivers.
/2012/ The Title V Community Health Grant program funds contractors that implement
education in high schools about driving while under the influence of alcohol. //2012//
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
2006
2007
2008
2009
Annual Indicator
29.0
30.7
30.2
30.7
Numerator
6188
6600
6595
6771
Denominator
213698 215079 218545 220555
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.

2010
28.9
6491
224302

Final

141

Narrative:
/2012/ Although the rate of Chlamydia for 15 through 19 year old women did not decline
significantly in 2010 (28.9 per 1,000) compared with 2006 (29.0 per 1,000), the rate in 2010
was significantly lower compared to the rate (30.7 per 1,000) in 2009 (Chisquare=11.926(1), p<0.0006). There is no specific Healthy People 2020 Goal for Chlamydia
rates, but HP 2020 does have a 'developmental goal' of reducing Chlamydia incidence
among 15-44 year old females. Sexually transmitted disease data come from the Arizona
Department of Health Services (ADHS) Sexually Transmitted Disease Control Program.
//2012//
/2012/ The Arizona Department of Health Services (ADHS) Sexually Transmitted Disease
Control Program (STDCP) manages the Infertility Prevention Project (IPP) component of
the CDC Comprehensive STD Prevention Services (CSPS) Cooperative Agreement grant.
The overall goal of the IPP is to assess and reduce the prevalence of chlamydia infection
and associated complications. This is accomplished through increased education and
training, targeted screening, timely and effective treatment, effective partner referral and
treatment, and dissemination of chlamydia-related information to providers and policy
makers in order to reduce infertility among women through the screening and treatment of
chlamydia. The STDCP partners closely with the Arizona Family Planning Council and its
delegate Title X clinics as well as the WIC Title V program and their clinics to address
issues related to both the IPP and adolescent health. In 2010, nearly 27,000 women were
screened for chlamydia under this Project with over 20,000 of these women being under
the age of 26. //2012//
/2012/ The Partnership to Address the increasing Trends in Health disparities for African
American Women, Adolescents, and Youth in Sexual health (PATHWAYS) collaborative
group meets bimonthly to partner to bring awareness to and address health disparities
among the African American population in Arizona.
The STDCP also works closely with community partners, including the Arizona Women,
Infants and Children (WIC) Program and their contractors serving distinct targeted
populations, to enhance education and prevention efforts and to actively identify
additional community partners and collaborations.
The STDCP will continue to partner with the WIC Program and their contractors in an effort
to educate WIC participants. The program will also promote STD testing in adolescents
reached under abstinence and comprehensive sex education programs.
In response to the disproportionately high rates of gonorrhea among African Americans
living in Arizona, the Arizona STDCP undertook an analysis in early 2010. Information
from this analysis was used to identify three zip codes in Maricopa County with the
highest number of reported gonorrhea cases among African Americans. The ADHS
STDCP has identified community health clinics located within or near these zip codes and
is in the process of establishing a relationship with these clinics to educate and to design
a means to increase the screening of both chlamydia and gonorrhea in those areas by
instituting screening via the Infertility Prevention Project. //2012//

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
2006
2007
2008
Annual Objective and Performance
Data
Annual Indicator
11.2
10.7
8.5

2009

2010

10.5

11.6

142

Numerator
11849
11652
11265
11855
12041
Denominator
1061924 1085698 1326554 1124281 1038255
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.

Narrative:
/2012/ The rate of reported Chlamydia among women aged 20-44 years increased
significantly in 2010 to 11.6 per 1,000 (Chi-square=54.751(1), p<0.0001). The increase may
be due to increased testing of women in this age cohort. Information about 2010 rates by
race/ethnicity were not available at this time from the Arizona Department of Health
Services (ADHS) Sexually Transmitted Disease Control Program (STDCP). These data will
be available later in 2011 in the Sexually Transmitted Diseases Report, 2010 at:
http://www.azdhs.gov/phs/oids/std/reports.htm //2012//
/2012/ The Arizona Department of Health Services (ADHS) Sexually Transmitted Disease
Control Program (STDCP) manages the Infertility Prevention Project (IPP) component of
the CDC Comprehensive STD Prevention Services (CSPS) Cooperative Agreement grant.
The overall goal of the IPP is to assess and reduce the prevalence of chlamydia infection
and associated complications. This is accomplished through increased education and
training, targeted screening, timely and effective treatment, effective partner referral and
treatment, and dissemination of chlamydia-related information to providers and policy
makers in order to reduce infertility among women through the screening and treatment of
chlamydia. The STDCP partners closely with the Arizona Family Planning Council and its
delegate Title X clinics as well as the WIC Title V program and their clinics to address
issues related to both the IPP and adolescent health. In 2010, nearly 27,000 women were
screened for chlamydia under this Project with over 20,000 of these women being under
the age of 26.
The Partnership to Address the increasing Trends in Health disparities for African
American Women, Adolescents, and Youth in Sexual health (PATHWAYS) collaborative
group meets bimonthly to partner to bring awareness to and address health disparities
among the African American population in Arizona.
The STDCP also works closely with community partners, including the Arizona Women,
Infants and Children (WIC) Program and their contractors serving distinct targeted
populations, to enhance education and prevention efforts and to actively identify
additional community partners and collaborations.
The STDCP will continue to partner with the WIC Program and their contractors in an effort
to educate WIC participants. The program will also promote STD testing in adolescents
reached under abstinence and comprehensive sex education programs.
In response to the disproportionately high rates of gonorrhea among African Americans
living in Arizona, the Arizona STDCP undertook an analysis in early 2010. Information
from this analysis was used to identify three zip codes in Maricopa County with the

143

highest number of reported gonorrhea cases among African Americans. The ADHS
STDCP has identified community health clinics located within or near these zip codes and
is in the process of establishing a relationship with these clinics to educate and to design
a means to increase the screening of both chlamydia and gonorrhea in those areas by
instituting screening via the Infertility Prevention Project. //2012//

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
87053
73110
4328
5815
Children 1
368662
319226
17329
22007
through 4
Children 5
453680
389325
22787
29761
through 9
Children 10
448664
381316
23103
33070
through 14
Children 15
461582
390052
22649
37481
through 19
Children 20
442584
379736
19928
30895
through 24
Children 0
2262225 1932765 110124 159029
through 24

Asian

Native
Hawaiian
or Other
Pacific
Islander

More
than
one
race
reported

Other
and
Unknown

3293

0

0

507

10100

0

0

0

11807

0

0

0

11175

0

0

0

11400

0

0

0

12025

0

0

0

59800

0

0

507

Notes - 2012
Narrative:
/2012/ The estimated total population of children 0-24 residing in Arizona in 2010
(2,262,225) agrees with the U.S. Census 2010.
The percentages of population breakdowns by age and race/ethnicity were not available
from the U.S. Census prior to completion of this grant. Other than for the infant category
which is available on the Arizona Birth Certificate, shares for each race/ethnicity in other
age groups were estimated to be equivalent to the 2009 Census estimate. These data will
be revised according to the release of 2010 Census data by age and race/ethnicity. //2012//
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)
Total NOT Hispanic
CATEGORY
or Latino
TOTAL POPULATION BY
HISPANIC ETHNICITY
Infants 0 to 1
52213
Children 1 through 4
209602

Total Hispanic
or Latino
34333
159060

Ethnicity Not
Reported
507
0

144

Children 5 through 9
Children 10 through 14
Children 15 through 19
Children 20 through 24
Children 0 through 24

271308
262369
307076
296350
1398918

182372
186295
154506
146234
862800

0
0
0
0
507

Notes - 2012
Narrative:
/2012/ The estimated total population of children 0-24 residing in Arizona in 2010
(2,262,225) agrees with the U.S. Census 2010.
The percentages of population breakdowns by age and race/ethnicity were not available
from the U.S. Census prior to completion of this grant. Other than for the infant category
which is available on the Arizona Birth Certificate, shares for each race/ethnicity in other
age groups were estimated to be equivalent to the 2009 Census estimate. These data will
be revised according to the release of 2010 Census data by age and race/ethnicity. //2012//
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

105

80

10

14

1

0

0

0

2910

2400

151

331

23

0

0

5

6401

5254

401

643

79

0

0

24

66427

55976

3301

4303

2502

0

0

345

11210

9397

465

524

688

0

0

136

87053

73107

4328

5815

3293

0

0

510

Notes - 2012
Narrative:
/2012/ Total live births to women in Arizona declined 6.0 percent in 2010 compared to 2009.
This marked the third year of a decline in the number of births in Arizona, from a high of
102,687 in 2007 (15.2 percent total decline). This change was driven by reductions in the
number of live births to; Hispanic or Latinas (-10.5%), White non-Hispanics (-2.5%), and
American Indians (-5.8%). //2012//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

145

births to Hispanic or Latinas in Arizona. The significant decline in live births will have profound
effects on the caseloads for maternal and child health programs.
/2012/ The rate of births to females aged 15-19 continued a secular decline in 2010. The
rate declined from 49.1 per 1,000 in 2009 to 41.5 per 1,000 in 2010, a 15.5 percent
reduction. Final 2010 Census estimates by gender, age and race/ethnicity were not
available for use as denominators to calculate rates. However, the total number of
Hispanic or Latina teen births in 2010 (n=5280) was 15.6% lower compared to 2009
(n=6254). //2012// All data were obtained through Arizona Vital Statistics, 2010.

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
37
Women 15 through
1046
17
Women 18 through
2956
19
Women 20 through
40829
34
Women 35 or older
7343
Women of all ages
52211

Total Hispanic or
Latino
68

Ethnicity Not
Reported
0

1859

5

3421

24

25253

345

3731
34332

136
510

Notes - 2012
Narrative:
/2012/ Total live births to women in Arizona declined 6.0 percent in 2010 compared to 2009.
This marked the third year of a decline in the number of births in Arizona, from a high of
102,687 in 2007 (15.2 percent total decline). This change was driven by reductions in the
number of live births to; Hispanic or Latinas (-10.5%), White non-Hispanics (-2.5%), and
American Indians (-5.8%). //2012//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 significant decline in live births will have profound
effects on the caseloads for maternal and child health programs.
/2012/ The rate of births to females aged 15-19 continued a secular decline in 2010. The
rate declined from 49.1 per 1,000 in 2009 to 41.5 per 1,000 in 2010, a 15.5 percent
reduction. Final 2010 Census estimates by gender, age and race/ethnicity were not
available for use as denominators to calculate rates. However, the total number of
Hispanic or Latina teen births in 2010 (n=5280) was 15.6% lower compared to 2009
(n=6254). //2012//All data were obtained through Arizona Vital Statistics, 2010.

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

American
Indian or

Asian

Native
Hawaiian

More than
one race

Other and
Unknown

146

American

Native
Alaskan

or Other
Pacific
Islander

reported

Total deaths

All
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
through 24

519

386

48

47

11

2

22

3

117

92

5

14

3

0

3

0

58

43

4

1

5

2

1

2

65

52

2

8

1

0

2

0

220

158

14

34

3

1

3

7

422

308

25

68

4

3

5

9

1401

1039

98

172

27

8

36

21

Notes - 2012
The adoption of 'more than one race' by the OMB and Census has resulted in lower rates of
infant mortality across the other singular race groups.

Narrative:
/2012/ Total infant deaths declined by n=28 in 2010 compared to 2009; however, the infant
mortality rate increased, but not significantly,from 5.9 in per 1,000 live births 2009 to 6.0 in
2010 per 1,000 live births. Arizona is meeting the Healthy People 2020 Goal of 6.0 infant
deaths per 1,000 live births. //2012//The data for infant mortality is found in Advanced Vital
Statistics Report, 2010 Arizona.
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.

147

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
281
Children 1 through 4
72
Children 5 through 9
37
Children 10 through
37
14
Children 15 through
137
19
Children 20 through
294
24
Children 0 through
858
24

Total Hispanic or
Latino
235
45
19

Ethnicity Not
Reported
3
0
2

28

0

76

7

119

9

522

21

Notes - 2012
Narrative:
/2012/ Total infant deaths declined by n=51 in 2009 compared to 2009. Even with the
substantial changes in the total population of infants, the infant mortality rate increased
from 5.9 in per 1,000 live births 2009 to 6.0 in 2010 per 1,000 live births. //2012// 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.

148

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
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)

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

1554094

89908

127819

47820

0

0

0

2010

37.0

0.0

0.0

0.0

0.0

0.0

0.0

0.0

2010

3.4

3.0

8.3

5.7

1.2

0.0

0.0

0.0

2010

829722

633908

58910

90440

14935

0

0

31529

2010

20198

16739

518

1446

561

0

0

934

2010

10514

7932

1464

762

83

0

0

273

2010

534416

421329

41752

55504

5146

1811

0

8874

2010

266722

239160

16953

5517

3625

1467

0

0

2010

4307.0

4306.0

7615.0

3048.0

1356.0

0.0

0.0

0.0

2010

4.3

3.9

4.7

9.9

1.5

0.0

0.0

0.0

2010

Total
All
Races

White

1819641

Notes - 2012
The total 0-19 year old population is based on the 2010 Census. Shares of 0-19 year old
population are estimated based on 2009 population estimates until US Census releases the 2010
state population by race/ethnicity and age
The estimate for single parent households is available from the Annie E. Casey Foundation Kids
Count Data Center.
http://datacenter.kidscount.org/data/acrossstates/Rankings.aspx?loct=2&by=v&order=a&ind=106
&dtm=430&tf=38
In previous years Arizona reported this estimate based on results from the 2000 Census.
However, the 2010 Census estimates for this measure are not available at this time.

149

Foster care totals as of September 20, 2010 (see
https://www.azdes.gov/appreports.aspx?Category=57&subcategory=20&menu=154)

Narrative:
The Teen Pregnancy Prevention Program (TPP) actively works with juvenile detention facilities
and Juvenile Probation Courts to provide education on teen pregnancy prevention to incarcerated
youth and to those on probation. Inter-agency collaboration has enabled a State Lottery funded
program such as the TPP to reach a cohort of youth that would otherwise be missed with
traditional outreach in public schools.
Several BWCH programs have an active role in linking clients to TANF, WIC, Medicaid and
SNAP. Those programs include Health Start, High Risk Perinatal Program, Title V Hotline,
Community Health Grants, and Domestic Violence.
/2012/ The Arizona Legislature passed a Medicaid Reform Package that would reduce
costs to the State General Fund by an estimated $500 million. Proposed changes would
result in an estimated 130,000 to 160,000 people losing AHCCCS medical coverage during
the next year. Some of these changes are described below.
Federal authorities approved the elimination of Arizona's Medicaid Spend Down Program
and effective May 1, 2011, people can no longer qualify for AHCCCS by factoring in high
medical costs to reduce their income low enough to meet eligibility requirements (40%
FPL). Of the 5,785 currently receiving assistance from this program, 700 to 1,000 of those
covered are children. It is likely that this change will impact those families enrolling in the
High Risk Perinatal Program (HRPP). When a baby is transported and/or admitted into a
NICU they are enrolled into HRPP. Contracted hospitals are required to enroll uninsured
families into AHCCCS. When a family is determined ineligible for AHCCCS, the hospital
can only bill the family for the amount designated on a sliding fee scale established by the
HRPP and agrees to accept an enrollment fee of $250 as payment in full. Hospitals would
not be able to bill families with incomes up to 100% of the FPL. It is uncertain whether this
change will result in hospitals reassessing the current contract terms if fewer families are
able to enroll in AHCCCS and they cannot bill families.
Other proposed changes to AHCCCS include freezing medical coverage for childless
adults effective July 1, 2011 and eliminating enrollment of parents earning 75% - 100% of
the FPL. These changes require Federal approval. Public interest groups are challenging
these changes in court because they were enacted as a result of a voter approved
proposition, Prop 204. The Arizona Association of Community Health Centers and the
Keogh Health Connection have launched a campaign encouraging AHCCCS and
Supplemental Nutrition Assistance Program recipients to reenroll early enough to avoid
losing their benefits and avoid the possibility of being ineligible to reenroll due to revised
eligibility requirements. The campaign is called "Don't Get Dropped" which encourages
health care providers to remind their patients to reenroll and provides tools for patients to
self manage their coverage. Public health and BWCH have a role in educating our clients
about changes impacting AHCCCS eligibility. //2012//

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)
Total NOT
Total
CATEGORY
Hispanic or
Hispanic or
Miscellaneous Data BY
Latino
Latino
HISPANIC ETHNICITY

Ethnicity Not
Reported

Specific
Reporting
Year

150

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)

1118096

701545

0

2010

0.0

0.0

37.0

2010

2.6

4.7

0.0

2010

458836
7670

370886
11594

0
934

2010
2010

6359

3882

273

2010

235198

290344

8874

2010

92354

174368

0

2010

4031.0

4783.0

0.0

2010

3.6

5.4

0.0

2010

Notes - 2012
Narrative:
The Teen Pregnancy Prevention Program (TPP) actively works with juvenile detention facilities
and Juvenile Probation Courts to provide education on teen pregnancy prevention to incarcerated
youth and to those on probation. Inter-agency collaboration has enabled a State Lottery funded
program such as the TPP to reach a cohort of youth that would otherwise be missed with
traditional outreach in public schools.
Several BWCH programs have an active role in linking clients to TANF, WIC, Medicaid and
SNAP. Those programs include Health Start, High Risk Perinatal Program, Title V Hotline,
Community Health Grants, and Domestic Violence.
/2012/ The Arizona Legislature passed a Medicaid Reform Package that would reduce
costs to the State General Fund by an estimated $500 million. Proposed changes would
result in an estimated 130,000 to 160,000 people losing AHCCCS medical coverage during
the next year. Some of these changes are described below.
Federal authorities approved the elimination of Arizona's Medicaid Spend Down Program
and effective May 1, 2011, people can no longer qualify for AHCCCS by factoring in high
medical costs to reduce their income low enough to meet eligibility requirements (40%
FPL). Of the 5,785 currently receiving assistance from this program, 700 to 1,000 of those
covered are children. It is likely that this change will impact those families enrolling in the
High Risk Perinatal Program (HRPP). When a baby is transported and/or admitted into a
NICU they are enrolled into HRPP. Contracted hospitals are required to enroll uninsured
families into AHCCCS. When a family is determined ineligible for AHCCCS, the hospital
can only bill the family for the amount designated on a sliding fee scale established by the
HRPP and agrees to accept an enrollment fee of $250 as payment in full. Hospitals would
not be able to bill families with incomes up to 100% of the FPL. It is uncertain whether this
change will result in hospitals reassessing the current contract terms if fewer families are
able to enroll in AHCCCS and they cannot bill families.
Other proposed changes to AHCCCS include freezing medical coverage for childless
adults effective July 1, 2011 and eliminating enrollment of parents earning 75% - 100% of
the FPL. These changes require Federal approval. Public interest groups are challenging
these changes in court because they were enacted as a result of a voter approved
proposition, Prop 204. The Arizona Association of Community Health Centers and the
Keogh Health Connection have launched a campaign encouraging AHCCCS and
Supplemental Nutrition Assistance Program recipients to reenroll early enough to avoid
losing their benefits and avoid the possibility of being ineligible to reenroll due to revised
eligibility requirements. The campaign is called "Don't Get Dropped" which encourages

151

health care providers to remind their patients to reenroll and provides tools for patients to
self manage their coverage. Public health and BWCH have a role in educating our clients
about changes impacting AHCCCS eligibility. //2012//

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
1803950
1375895
413324
30422
1819641

Notes - 2012
Narrative:
/2012/ The estimates for population by geographic area are provisional until Summary File
No. 1 for Arizona is released by the 2010 US Census. //2012//

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
6508334.0
10.0
21.2
39.2

Notes - 2012
Narrative:
/2012/ The total population of Arizona was estimated to have decreased by 1.3 percent
according to U.S. Census 2010. The effects of the economic recession and job losses in
Arizona likely reduced immigration into the state from other states and Latin America. The
recession was also responsible for increases in poverty across each category. Ten
percent of Arizonans were classified as severely poor, 21.2 percent were living below 100
percent of the federal poverty level, and 39.2 percent were below 200 percent of the federal
poverty level. //2012// These poverty estimates are likely reflected in the increases in the
percentages of Arizonans on food stamps and temporary assistance for needy families.

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

Total
1874836.0
15.4
31.5

152

200% of poverty

51.1

Notes - 2012
Narrative:
/2012/ According to the 2010 Census, the population of 0-19 year olds decreased in
Arizona by 0.8 percent from 2009. According to the U.S. Census Current Population
Survey, an estimated nearly one-in-three children under 20 years old were living at or
below the federal poverty line, and more than half were below 200 percent of the federal
poverty level. //2012//

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, 2009 and October 31, 2010, the
program reached 15,722 unduplicated Arizonans with multi-session workshops of 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.
/2012/ In 2011, in line with the state plan on Primary Prevention of Sexual Violence, BWCH
expanded training on Bystander Intervention Skills ("Bar Campaign') to include staff at
alcohol serving establishments in three key areas of the state. The outcome is to increase
staff's knowledge of sexual violence primary prevention issues, strategies, policies and
enhance their skills in being an active bystander in an alcohol-related environment.
//2012//
Toll-Free Hotlines

153

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.
/2012/ BWCH operates six toll-free hotlines: the Children's Information Center (CIC), the
Pregnancy and Breastfeeding Hotline, and the WIC Hotline, the WIC Complaint Hotline, the
Folic Acid Hotline, and 311 BABY. The WIC Complaint Hotline takes complaints from
consumers about stores that may not carry WIC approved foods or won't honor certain
WIC approved foods. They also take complaints from stores about possible fraud. 311
BABY is a national hotline that connects callers with a local number regarding topics
related to prenatal health. //2012//
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
154

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.
ADHS Bureau of Women's & Children's Health requests that HRSA works with Indian Health
Services at federal level to facilitate data sharing of Indian Health Services hospitals with the
state's Bureau of Health Statistics.
Bureau of Women's & Children's Health requests assistance with development of evidence-based
preconception health models that state public health agencies can implement. Examples of
effective social marketing and toolkits that could be used by community health workers as well as
professionals would be beneficial. The Bureau also requests technical assistance with
incorporating the lifecourse perspective into strategic planning and program development in a
practical manner.

155

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 2010
Budgeted Expended
7035771
4912593

FY 2011
Budgeted Expended
7090511

FY 2012
Budgeted Expended
7065379

1166773

1436796

612223

1920000

6063683

5522410

7734184

7625192

0

0

0

0

6790456

24695055

31969534

7472018

0

0

0

0

21056683

36566854

47406452

24082589

70982759

70862006

74092038

53932696

92039442

107428860

121498490

78015285

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 2010
Budgeted Expended

FY 2011
Budgeted Expended

FY 2012
Budgeted Expended

2079462

1238028

1819821

3713835

1765108

1221060

3739081

5608571

9202688

8265938

6097680

9393274

6419851

24857588

33794776

3845832

156

Special
Healthcare Needs
e. Others
885997
634716
1499676
1158238
f. Administration
703577
349524
455418
362839
g. SUBTOTAL
21056683 36566854 47406452
24082589
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
93713
100000
c. CISS
0
0
0
d. Abstinence
0
0
1260250
Education
e. Healthy Start
0
0
0
f. EMSC
130000
130000
130000
g. WIC
0
0
45136403
h. AIDS
0
0
0
i. CDC
0
0
0
j. Education
0
0
0
k. Other
FAMILY
1700000
1868628
1766500
VIOLENCE
MI&EC HOME
0
0
1893443
VISITING
NGIT FASD264199
227669
250000
SAMHSA
ORAL HEALTH
0
384092
384000
WORKFORC
PREP
0
0
1099600
PROJECT
900946
900000
900000
LAUNCH
RAPE PREV ED
651448
640456
624000
SEXUAL
0
282410
198000
ASSAULT SVCS
STATE INJURY
116748
127358
180500
SURVEIL
WOMENS HLTH
0
0
10000
CONF
1ST TIME
497213
500000
0
MOTHERHOOD
CRS
59610387
68937712
0
KIDS CARE
6717174
0
0
SPINAL HEAD
300000
0
0
INJURY

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

I. Direct Health
Care Services
II. Enabling
Services
III. Population-

FY 2010
Budgeted Expended
5305578
25942811

FY 2011
Budgeted Expended
35021005

FY 2012
Budgeted Expended
4350018

3241647

1642852

2306163

3583506

6039920

4945507

4748460

10765807

157

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

6469538

4035684

5330824

5383258

21056683

36566854

47406452

24082589

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.
/2012/Over the past four 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.
The Children's Rehabilitative Services moved to the state's Medicaid program, AHCCCS,
as of January 1, 2011. This transition, along with re-establishment of new Title V priorities,
caused a delay in programmatic planning and implementation, consequently impacting the
ability of the Office for Children with Special Health Care Needs to obligate and expend
Title V funds as normal.//2012//

B. Budget
The estimated Title V allocation for Arizona, FFY2011, is $7,090,511. For FFY 2011, 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 2011, 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

158

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.
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
/2012/The estimated Title V allocation for Arizona, FFY2012, is $7,065,370. For FFY 2012,
32.90% ($2,324,671) of the Title V Block grant will be allocated for preventative and primary
care needs for children and adolescents; 31.71% ($2,240,632) will be allocated to children
with special health care needs; 30.25% ($2,137,237) will be allocated for women, mothers,
and infants and 5.14% ($362,839) will be budgeted for administrative costs.
It is projected that there will be $1,920,000 unobligated funds from our FY2011 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. $420,000 will be used to support the Empower Program.
For FFY 2012, the state's match and maintenance of effort includes State General, Lottery,
Dental Sealant funds. The $9,624,950 in State General funds include High Risk Perinatal
Services, Adult Cystic Fibrosis, Child Fatality Review Program, Newborn Screening, 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. $250,000 is from fees generated by the Dental
Sealant Program. Arizona's FY2012 match and overmatch of $15,097,210 continues to
exceed the maintenance of effort amount of FY1989's $12,056,360.
Other federal funds administered by the MCH Chief besides the MCH Title V Block Grant
Program include 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, Abstinence Education

159

Grant Program, Personal Responsibility Education Program, Women's Health Conference
support project, Maternal, Infant and Early Childhood Home Visiting Program, and Project
Launch.
Core Public Health Infrastructure - $2,434,019: Bureau of Women's and Children's Health
(Part A & B): $1,209,640 will support the Department's birth defect registry, management
service, information technology automation, assessment, evaluation and epidemiologic
analysis, Child Fatality services, Midwife Licensing, and the Empower Program. New intergovernmental agreements are in place with six county health departments to use Title V to
support infrastructure for injury prevention and preconception health, including policy and
organizational strategies.
Office of Children with Special Health Care Needs (Part C): $1,224,379 will support
administrative initiatives, Education, Training, Support Services and Advocacy, Outreach
and Member Services. A Request for Grant Application is currently out for bid to secure
community-based projects that will address Title V priorities. Once established, these
projects are expected to remain in place for the next four years.
Population-Based Services: $974,406 is budgeted for initiatives that include the Sensory
Program, Pregnancy and Breastfeeding Hotline, Breastfeeding Consultation,
Immunizations, Early Childhood, and Oral Health services for children. New intergovernmental agreements are in place with six county health departments to use Title V to
support population-based strategies for injury prevention and preconception health,
including raising public awareness and providing community education.
Enabling and Non-Health Support: $1,487,497 will support the Medical Home Project and
the Pregnancy, Breastfeeding Hotline and Children with Special Health Care Needs, which
includes respite and palliative care services.
Direct Health Care Service: $1,806,618 will support community nursing services for highrisk infants, and Reproductive Health services for women.
Indirect Administrative Costs: $362,839//2012//

160

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.

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.

161