Maternal and Child Health Services Title V Block Grant State Narrative for Arizona Application for 2013 Annual Report for 2011 Document Generation Date: Friday, September 14, 2012 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 ........................................................................................................ 28 D. Other MCH Capacity ............................................................................................................. 30 E. State Agency Coordination .................................................................................................... 34 F. Health Systems Capacity Indicators ...................................................................................... 38 IV. Priorities, Performance and Program Activities ....................................................................... 40 A. Background and Overview .................................................................................................... 40 B. State Priorities ....................................................................................................................... 41 C. National Performance Measures ........................................................................................... 45 Performance Measure 01: ...................................................................................................... 45 Form 6, Number and Percentage of Newborns and Others Screened, Cases Confirmed, and Treated ................................................................................................................................... 48 Performance Measure 02: ...................................................................................................... 50 Performance Measure 03: ...................................................................................................... 53 Performance Measure 04: ...................................................................................................... 57 Performance Measure 05: ...................................................................................................... 60 Performance Measure 06: ...................................................................................................... 64 Performance Measure 07: ...................................................................................................... 68 Performance Measure 08: ...................................................................................................... 72 Performance Measure 09: ...................................................................................................... 74 Performance Measure 10: ...................................................................................................... 77 Performance Measure 11: ...................................................................................................... 79 Performance Measure 12: ...................................................................................................... 83 Performance Measure 13: ...................................................................................................... 86 Performance Measure 14: ...................................................................................................... 89 Performance Measure 15: ...................................................................................................... 92 Performance Measure 16: ...................................................................................................... 95 Performance Measure 17: ...................................................................................................... 97 Performance Measure 18: .................................................................................................... 100 D. State Performance Measures.............................................................................................. 103 State Performance Measure 1: ............................................................................................ 103 State Performance Measure 2: ............................................................................................ 107 State Performance Measure 3: ............................................................................................ 109 State Performance Measure 4: ............................................................................................ 112 State Performance Measure 5: ............................................................................................ 116 State Performance Measure 6: ............................................................................................ 118 State Performance Measure 7: ............................................................................................ 121 State Performance Measure 8: ............................................................................................ 124 E. Health Status Indicators ...................................................................................................... 126 F. Other Program Activities ...................................................................................................... 127 G. Technical Assistance .......................................................................................................... 129 V. Budget Narrative ..................................................................................................................... 130 Form 3, State MCH Funding Profile ..................................................................................... 130 2 Form 4, Budget Details By Types of Individuals Served (I) and Sources of Other Federal Funds .................................................................................................................................... 130 Form 5, State Title V Program Budget and Expenditures by Types of Services (II) ............ 131 A. Expenditures ........................................................................................................................ 132 B. Budget ................................................................................................................................. 132 VI. Reporting Forms-General Information ................................................................................... 136 VII. Performance and Outcome Measure Detail Sheets ............................................................. 136 VIII. Glossary ............................................................................................................................... 136 IX. Technical Note ....................................................................................................................... 136 X. Appendices and State Supporting documents ........................................................................ 136 A. Needs Assessment .............................................................................................................. 136 B. All Reporting Forms ............................................................................................................. 136 C. Organizational Charts and All Other State Supporting Documents .................................... 136 D. Annual Report Data ............................................................................................................. 136 3 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 January 2012; expires January 31, 2015. 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, 4 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// /2013/ The Bureau of Women and Children's Health posted a notice on the ADHS BWCH website asking for feedback and comments about the Block Grant application and Program Managers sent links to the 2012 Application to their contractors and partners asking for input. The ADHS Facebook page also linked to the application and asked for feedback and comment. A survey through Survey Monkey was also included on the web page. The Bureau Chief has utilized the Agency Update period during First Things First Board and Arizona Perinatal Trust meetings to direct people to the Title V Application for review and feedback. //2013// 5 II. Needs Assessment In application year 2013, Section IIC will be used to provide updates to the Needs Assessment if any updates occurred. C. Needs Assessment Summary While Arizona's 2010 Needs Assessment Summary provided an overview of the state partnership efforts, capacity to address MCH needs, and health status of MCH populations, this summary will provide updates. Like many other states, Arizona has experienced high rates of home foreclosures, poverty, and households on food stamps. Unemployment rates had been as high as 9.5% in February 2010, which was not long after achieving a historic low of 3.7% in July of 2007. In June 2012, Arizona's unemployment rate was 8.2%, the same as the national rate. At the same time, Arizona has experienced substantial declines in state revenue. In state fiscal year (FY) 2009, Arizona had the largest decrease (42.5%) in income tax revenue in the nation. Beginning in 2009-2010, nearly all state funded maternal and child health programs were completely eliminated due to state budget cuts. The one remaining state funded MCH program remains substantially reduced. Given Arizona's forecasts of revenue and expenditures, the state is expected to have a balance of $431 million for FY2013; however, the expiration of a temporary 1-cent sales tax would create a severe deficit starting the following year. Arizona's population trends are also of interest. While the population overall has continued to grow since the last needs assessment, the number of births have steadily decreased since record highs in 2007(102,687). By 2010, the total number of births (87,053) decreased by 15.2% compared to the 2007. The number and proportion of Hispanic births also decreased each year from 2008 to 2010. A brief look at the state priority needs follows. Teen pregnancy dropped by 30% in Arizona over the last three years; the steepest decline in the nation. Arizona moved from being fifth to twelfth highest teen birth rate in the nation. Community concern about teen pregnancy was evidenced during the public input process for the 2010 Needs Assessment. The number of children classified as obese and overweight have been increasing in Arizona. The latest NSCH survey (2007) noted that percentage of overweight or obese children in Arizona have increased at higher rates than any other state. For youth 10 to 17 years of age, there was a 45.9% increase in the prevalence of obesity from 2003 to 2007, which was the greatest increase in the nation. More than half of all reproductive age women in Arizona are either overweight or obese. 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. Injuries are the leading causes of death for Arizonans ages 1-44 years. Motor vehicle accidents remain the leading cause of death among Arizona children (ages 3-14 years), prompting the state to implement new booster seat laws and interventions in 2012. Homicides, suicides, and 6 prescription drug abuse remain significant issues for teens and young adults. Additionally, the dating violence among Arizona high school students that had increased significantly between 2003 and 2007 has since plateaued. Improving preventive health services for children remains a priority, as initially highlighted by the group of stakeholders and ADHS staff charged with setting general MCH priorities. This priority ranked highest of any other priority during the Needs Assessment public input sessions. The oral health of children residing in Arizona is significantly worse than for their national peers. The most recent data from Arizona's Healthy Smiles, Healthy Bodies(weighted) survey reported that 30 % of children ages 2-4 years in Arizona had untreated tooth decay, compared to only 16 percent of their peers nationally. One measure of mental health is how frequently mental distress occurs. In Arizona, nearly one-in five women ages 18-44 years 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 frequent mental distress. BWCH survey results and comments provided during public input sessions had indicated that mental health and substance use/abuse (including alcohol as well as illegal drug use) were critical issues that need to be addressed. The needs assessment data shows a relatively high proportion of unmet need for auditory services. The number of children with special health care needs (CSHCN) reporting an unmet need for hearing aids or hearing care has decreased since the 2010 Needs Assessment, from about one-to-four children with special health care needs, to one-to-seven (25% vs. 14%). 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. Reducing unmet need for hearing services was selected as a priority on the 2010 Needs Assessment and the Office for Children with Special Health Care Needs will continue to address this gap in service. 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 this transition and, subsequently, preparing CYSHCN for transition to adulthood continues to be a 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 had often spoken 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 remains a priority. 7 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// /2013/ The decline of population seen since 2009 and 2010 in Arizona has leveled off. In 2011, the estimated population of Arizona is 6,438,178. This is a slight increase from 2010 (less than a 1% increase). There were no significant changes in the composition of the population by age group and county since the previous year. //2013// 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 8 births minus the number of deaths. The net natural increase in Arizona accounted for 32 percent of the population growth during the last decade. The remaining growth (19 percent) was from the net international migration, or people moving here from other countries minus the number of people moving out. The rapid growth seen in Arizona as a whole has not been evenly distributed throughout the state. During the years between 1999 and 2009, growth rates in Arizona's 15 counties ranged from a low of two percent in Greenlee County (from 8,535 residents to 8,688) to a high of 89 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// /2013/ In 2011, births continue to decline like previous years. The total number of resident births in 2011 was 85,190. That is a 2.1% decline from 2010.//2013// 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// /2013/ The pattern of declining Hispanic births has continued. In 2011 White non-Hispanic births were 38,699 and Hispanic or Latino births totaled 32,399. The decline in total births in Arizona continues to be driven by the reduction in Hispanic or Latino deliveries. //2013// 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// /2013/ In June 2012, the Supreme Court struck down three of the four sections of SB 1070. //2013// 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// /2013/ The total number of women of childbearing age in Arizona has stopped decreasing and in 2011 slightly increased by less than 1% to 1,271,867. //2013// 9 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// /2013/ The population estimates for Arizona, indicate that in 2011 approximately 28 % of Arizona's population is Hispanic or Latino of any race. White (58.7 %) made up the largest single race. //2013// The racial makeup of Arizona varies by age group. Among older age groups, the population is predominantly white, while the proportion of the population represented by Hispanics is highest among the younger groups. Over 40 percent of those younger than five are Hispanic compared to eight percent of people 75 and older. Twenty-one federally-recognized American Indian tribes are located in Arizona, each representing a sovereign nation with its own language and culture. Tribal lands span the state and even beyond state borders, with the Navajo Reservation crossing into New Mexico and Utah, and the Tohono O'odham Reservation crossing international boundaries into Mexico. Some counties have high proportions of American Indians. Eighty percent of Apache County, 48 percent of Navajo County, and 30 percent of Coconino County residents are American Indians. LANGUAGE SPOKEN Arizona residents are more likely to speak a language other than English at home (28 percent in Arizona compared to 20 percent nationally), and more likely to report speaking English "less than very well" (12 percent in Arizona compared to 9 percent nationally). Among Arizona residents 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 10 graders read below proficiency, compared to 38 percent in the rest of the nation. NAEP reading achievement varied considerably by race and ethnicity. Higher proportions of Native American, Hispanic, and Black public school students tested below the basic level in reading achievement, while Asian students were more likely to test at proficient or higher. In fiscal year 2008, 4 percent of students dropped out of public school from grade seven through nine. This represents an improvement over the dropout rates from the 2003-2004 school- year of 6 percent. The dropout rate for boys (4 percent) was somewhat higher than the dropout rate for girls (3 percent). However, the dropout rate among Native America students was twice the statewide rate. The Arizona Department of Education also tracks cohorts of students and measures the percent who graduate within four years. The graduation rate for the cohort that would be expected to graduate by 2007 was 73 percent. Girls were more likely to graduate within four years (78 percent) than boys (69 percent). However, the graduation rate varied considerably by race and ethnicity. Only 55% of Native Americans completed high school in four years, while 81% of White students graduated in four years. ECONOMY Arizona incomes, as measured by average wage, earnings per employee, and per capita income, have always tended to be lower than national averages. In 2007, the average per capita personal income in Arizona was 85 percent of the national average. Per capita income within Arizona varied from a high of 94 percent of the national average in Maricopa County to a low of 53 percent in Navajo County. According to US Census estimates, Arizona's median household income in 2008 was lower than the rest of the nation ($51,009 in Arizona compared to $52,209), ranking 29th. Over the course of the last decade, the civilian workforce in Arizona has grown 22 percent from 3 million individuals in 2001, to more than 3 million in 2010. During this time, the composition of the jobs has changed. The largest decrease in terms of both number and proportion of jobs lost during this time period was in construction. In 2001, there were 173,600 construction jobs in 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// /2013/ In May 2012, the Kaiser State of Health Report showed Arizona ranked 10th in 11 economic distress. Arizona still ranked high in foreclosure rates (2nd) and increased in food stamp participation (8th), but showed ‘improvement' relative to other states in the percent change in annual unemployment (42nd). It is important to note that this year the actual unemployment rate in Arizona (8.2 percent, May 2012) is the same as the national rate (8.2 percent). //2013// 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 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// /2013/ The 2010 American Community Survey (ACS) showed 17.4 percent of Arizonans living in poverty. This is an increase from previous years. In 2010 ACS showed increases in the rates of poverty among women (18.2 percent), children under 18 years (24.4 percent), Black or African Americans (25.1 percent), American Indian and Alaskan Natives (36.9 percent), and Hispanic or Latinos (26.6 percent). //2013// 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 12 recession began in state fiscal year 2007, sales tax revenues have decreased 22 percent, personal income tax revenues have decreased 38 percent, and corporate income tax revenues have decreased 57 percent. In state fiscal year 2009, Arizona had the largest decrease (42.5 percent) in income tax in the nation. While the general fund used to receive $50 in revenue per $1,000 of personal income in the mid 1990's, it currently receives less than $30. A structural deficit was created as taxes were permanently reduced during years of high revenues without corresponding decreases in the budget. Even when the economy recovers and begins to expand, revenues are projected to only rise to $36 per $1,000 income, which is 28 percent lower than the historical norm. The result of these economic forces is a budget deficit projection in Arizona for 2010 of $5 billion dollars, representing 52 percent of the total general fund budget. This is the second largest proportional state budget deficit in the nation, exceeded by California, where a $52 billion deficit represents 57 percent of their budget. The average budget deficit nationally is 29 percent. To balance the fiscal year 2009 budget, every state agency was given a lump sum reduction with discretion of where to cut. Agencies used a combination of program cuts, unpaid furlough days, and reductions in force, among other methods, to reduce their budgets. To help balance the 2011 budget, employees of each state agency will take a combination of pay reductions and furlough days for each of the next two fiscal years, which will result in an overall annual compensation reduction of five percent. All state employees will take the same furlough days, according to a state-mandated schedule, which will shut down state government on those days. In addition, Arizona state buildings including, the state capitol, the state hospital and state prisons have been put up for sale. Other state agencies serving children experienced significant cuts. The state budgets for both the Arizona Department of Education and Arizona Department of Economic Security were reduced by 20 percent between state fiscal years 2008 and 2011. Examples of program cuts that Arizona has enacted outside of the Department of Health Services that affect the maternal-child population include: • A cap on KidsCare (which is the state's CHIP program). • Elimination of temporary health insurance for people with disabilities who are coping with serious medical problems. • Elimination of general assistance, a program designed to provide time-limited case assistance to adults with physical or mental disabilities. • Elimination of independent living supports for 450 elderly residents and respite-care funding for 130 caregivers. • Eliminated preschool for 4,328 children. • Increased in-state undergraduate tuition between 9 and 20 percent. • Reduction of TANF cash assistance grants for 38,500 low-income families. • Elimination of substance abuse services for 1,400 parents and guardians. • Decreased homeless shelter capacity by 1,100 individuals. • Stopped accepting new families in its child care assistance program in February, 2009 (denying assistance to more than 10,000 children.) 13 Over the past three years, ADHS has dramatically reduced spending and staffing levels in an effort to bring spending in line with state revenues. Excluding the money that goes toward the matching funds that are required for Medicaid (AHCCCS), Behavioral Health and Children's Rehabilitative Services, the overall ADHS General Fund budget has been reduced by more than 47 percent during the past 3 years. Seventeen million dollars in operating budgets were cut during that time period, including the entire licensure budget of $10 million. Fiscal Year 2010 cuts include: • Suspended enrollment in Children's Rehabilitative Services for more than 4,000 children who are not enrolled in AHCCCS; • Reduced approximately 8,800 home visits to newborns discharged from neonatal intensive care, and enrolled in the High Risk Perinatal Program; • Suspended all prenatal block grants to county health departments for services to 19,000 women and children; • Eliminated the Hepatitis C and Valley Fever public health prevention programs; • Reduced county contracts for tuberculosis care by more than 50 percent; • Eliminated all state funding for children's vaccines; • Suspended remaining HIV surveillance contracts with Maricopa and Pima County; • Suspended remaining county grants for diabetes prevention; • Suspended all retinal and podiatry screenings for diabetics; • Suspended all grants to counties for public health personnel; • Reduced support for both Arizona Poison Control Centers by more than 50 percent; • Eliminated all birth defect call center services. State funding for maternal and child health programs within the Bureau of Women's & Children's Health reached a high of $10 million in state fiscal year 2007 and comprised 44 percent of the bureau's total budget; by state fiscal year 2010, state funding had dropped by 64 percent to a total of $3 million. State appropriated funds now comprise 18 percent of the bureau's budget. State general funding for Health Start, Abstinence Education, County Prenatal Block Grant, and Pregnancy Services was completely eliminated. The budget for the High Risk Perinatal Program has been reduced by nearly 60 percent. State funding for the Children's Rehabilitative Services Program have also been eliminated. A one percent three-year temporary sales tax known as Proposition 100 was passed in a special election on May 18, 2010, with 64 percent of the vote. A projected $1 billion per year will be raised by the tax. If the initiative had failed, a legislative contingency plan would have cut another $900 million from the 2011 state budget. /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// /2013/ During SFY 2012, there were no additional cuts to programs affecting women and children.//2013// 14 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), 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 15 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 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// /2013/ In April, 2012, three of the major hospitals serving children contributed $125 million to meet the federal match for Kids Care enabeling AHCCCS to temporarily open enrollment for 22,000 children on the waiting list. //2013// /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 SpendDown 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// 16 /2013/ /2013/AHCCCS is in process of designing an integrated health model to ensure optimal access to important specialty care as well as effective coordination of all service delivery.//2013// //2013// 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 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 cranialfacial 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 State-Only 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 StateOnly 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 17 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, low-income, 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 underserved areas. All federally designated HPSAs are automatically designated as Arizona shortage areas. In addition, Arizona's system involves the application of an index which weights 14 indicators such as providers to population ratios, travel time, percent of population below poverty, and adequacy of prenatal care. As of May 2010, there are five state designated Arizona Medically Under-Served Areas. According to the American Medical Association Masterfile, there were 57,698 general pediatricians in the United States in 2007, representing about 8 pediatricians per 10,000 children age 0-17. Arizona has 914 general pediatricians, representing 5 pediatricians per 10,000 children age 0-17. The majority of pediatricians practice in Maricopa (68 percent) and Pima (22 percent) Counties. A recent survey of primary care pediatricians raised significant concerns about the adequacy of children's access to pediatric subspecialists, 18 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. /2013/There continues to be a shortage of pediatric physical, speech and occupational therapists, which results in 17.6% or one out of six CSHCN in Arizona having an unmet need for these services, according to the 2009/2010 NS-CSHCN.//2013// 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 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// /2013/ Arizona received over $6 million in grants for community health centers.//2013// B. Agency Capacity 19 The Arizona Department of Health Services (ADHS) houses the Title V program. The State Maternal & Child Health (MCH) program resides within the Bureau of Women's & Children's Health, and the Children with Special Health Care Needs program resides within the Office for Children with Special Health Care Needs. This section will highlight statutes relevant to the Title V program; the general capacity of ADHS to promote and protect the health of all mothers and children, including children with special health care needs; and culturally competent approaches. State Statutes Relevant to Title V Program Arizona Revised Statute (A.R.S.SS36-691) formally accepts Title V and designates ADHS as the Title V agency: A. This state accepts the conditions of title V of the social security act, entitled "grants to states for maternal and child welfare", enacted August 14, 1935, and as amended. B. The department of health services is designated as the state agency to cooperate with the department of health, education and welfare for the administration of part 1 and part 4 of title V, of the social security act. Additional state statutes authorize some maternal and child health programs or functions but are not specific to Title V. The statutory list of functions (A.R.S. 36-132) of ADHS includes: encourage and aide in coordinating local programs concerning maternal and child health, including midwifery, antepartum and postpartum care, infant and preschool health and the health of school children, including special fields such as the prevention of blindness and conservation of sight and hearing; encourage, administer and provide dental health care services and aid in coordinating local programs concerning dental public health, in cooperation with the Arizona dental association. Subject to the availability of monies, develop and administer programs in perinatal health care. State statute (A.R.S. 36-697) authorized the Health Start program, administered by Bureau of Women's & Children's Health; the program is required to serve pregnant women, children and their families. The program is required to be statewide, based in identified neighborhoods and delivered by lay health workers through prescheduled home visits or prescheduled group classes that begin before the child's birth or during the postnatal period and that may continue until the child is two years of age. Statute also requires the program to develop and distribute an Arizona Family Resource Directory to enable parents to obtain information that is critical to the development of their young children. State statute (A.R.S. 36-899.01) also requires ADHS to administer a program of hearing evaluation services administered to all children as early as possible, but in no event later than the first year of attendance in any public or private education program, or residential facility for handicapped children, and thereafter as circumstances permit until the child has attained the age of sixteen years or is no longer enrolled in a public or private education program. Bureau of Women's & Children's Health administers this program and provides administrative rules and technical assistance to schools to implement required hearing screening. The Child Fatality Review Program is authorized by state statute (A.R.S. 36-3501). The State Child Fatality Review Team is required to conduct an annual statistical report on the incidence and causes of child fatalities and submit a copy of this report, including its recommendations for action, to the Governor and legislative leadership on or before November 15 of each year. The Team is also required to develop protocols for child fatality investigations including protocols for law enforcement agencies, prosecutors, medical examiners, health care facilities and social 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 20 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. 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. 21 In 2009, the Title X network provided care to 16 percent more unduplicated clients from the previous year. Pregnancy & Breastfeeding/Baby Arizona Hotline Bureau of Women's & Children's Health operates the Pregnancy & Breastfeeding and Baby Arizona Hotline with two bilingual Certified Lactation Consultants. Baby Arizona is a program to help pregnant women begin the important prenatal care they need while waiting for the AHCCCS eligibility process. The hotline also has an International Board Certified Lactation Counselor available to answer all breastfeeding questions after normal business hours and to answer technical questions 24 hours a day, seven days a week. High Risk Perinatal /Newborn Intensive Care Program For nearly 40 years, the BWCH High Risk Perinatal Program/Newborn Intensive Care program has provided maternal and neonatal transports, hospital and inpatient physician services, and community health nursing to families, and served over 5,000 families in FY09. The program provides emergency maternal and neonatal transports, hospital and inpatient physician services, and community health nursing. Follow-up services support the family during transition from the hospital to home; conduct developmental, physical, and environmental assessments; provide education and guidance; and direct families to programs and services. During home visits, community nurses also assess other children in the home to identify children at risk and screen mothers for postpartum wellness. Budget cuts during fiscal year 2010 eliminated approximately 8,800 home visits to newborns who had previously been in newborn intensive care. Eligibility criteria were also changed to require a minimum five day stay (previously three days) in the NICU to be enrolled in the program. Because the program suffered a budget reduction of about 60%, Title V funds are being used to help offset some of the reduction while the program continues to operate at reduced capacity. Health Start Health Start applies a community based model that utilizes Community Health Workers or promotoras to identify, screen and enroll at risk pregnant or postpartum women and their families and assists them with obtaining early and consistent prenatal care, provides prenatal and postpartum education, information and referral services, advocacy and emphasizes timely immunizations and developmental assessments for their children. In 2009, the Health Start Program was provided in 100 targeted high risk communities in ten counties and provided services to 2,300 women and their families. Health Start is funded with state lottery dollars. Domestic Violence and Sexual Violence Services In state fiscal 2008, Arizona state agencies administered over $26 million in federal and state funding dedicated to domestic violence. In contrast, state agencies administered just over $2 million in the same year for sexual assault. All state agencies involved in domestic and sexual violence services, including Arizona Department of Health Services, meet regularly as the State Agency Coordination Team, to address common issues and ensure services are coordinated throughout the state. The BWCH administers the federal Family Violence Prevention and Services Act Grant. These funds are used primarily to support shelter and services in rural Arizona, known as the Rural Safe Home Network. Funds also support infrastructure-building activities of the Arizona Coalition Against Domestic Violence. Between October 1, 2008 and September 30, 2009 the Rural Safe Home Network programs provided 14,567 shelter nights to 466 women, 515 children and three men. Programs provided 1,825 hours of batterers' intervention services to 572 people, as well as 766 domestic violence training and prevention services to 24,741 participants. BWCH also administers the only funding source dedicated solely to primary prevention of sexual violence. The Arizona's federally funded Sexual Violence Prevention and Education Program 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 22 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. /2013/ The Medical Services Project has been successful in recruiting dentists to participate in the program.//2013// 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. /2013/ To address the gap between Newborn Hearing Screening and school, the Sensory Program used Title V funds to purchase additional hearing screening equipment to lend out to early childhood settings. Partners are disseminating information of the ability to borrow equipment to the early childhood community.//2013// 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 23 unfunded state mandate, BWCH dedicates Title V dollars to support the program. The Office of Oral Health contracts with county health departments to provide school-based dental sealants and screenings to over 10,000 children per year. OOH manages the Arizona Fluoride Mouthrinse program, providing approximately 20,000 children in participating schools with fluoride mouthrinse annually. OOH supports the efforts of communities to fluoridate their water systems through providing technical assistance, training, and workshops for community fluoridation campaigns. 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. /2013/A voluntary pediatric designation system for hospital emergency departments is now in place in Arizona. The Arizona Chapter of the American Academy of Physicians was awarded the contract to be the certifying body. The Office of Injury Prevention was awarded a regionalization grant to establish pediatric emergency designation system in rural and tribal areas. //2013// 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 24 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 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// /2013/Four abstinence and eight PREP grants were awarded to community based organizations throughout Arizona.//2013// /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. 25 Covered services include surgeries and other inpatient hospital services; pediatric physician specialty care; physical, speech, and occupational therapies, laboratory, radiology and pharmacy services; vision services; durable medical equipment, such as orthotics and wheel chairs; and social services. CRS does not cover basic primary care that is not related to the CRS diagnosis. The ultimate aim of the CRS program is to enhance members' quality of life through the appropriate utilization of services, optimizing their functionality and minimizing their need for emergency care. The relative scarcity of some specialists poses a challenge for delivering timely services, especially to members who live in remote areas of the state. The CRS program offers statewide management of these specialists and innovative strategies to ensure that services are coordinated and delivered timely throughout the state. In addition to members and providers traveling to clinics, members also receive services through the use of telemedicine and in field/outreach clinics. Before March of 2009, CRS covered the cost of medical services for children that did not qualify for AHCCCS, but were below certain family income limits. These members were called StateOnly members. However in March 2009, due to budget cuts, all State-Only members assumed all responsibility for payment for medical services, regardless of income, but were able to cap their fees at rates no higher than AHCCCS provider scheduled rates. In December of 2009, further cuts resulted in the suspension of all State-Only services, and approximately 4,000 members were disenrolled from CRS. Consequently, only members who are enrolled in an AHCCCS Health Plan remain enrolled. Cultural Competent Approaches Culture is defined as a shared, learned, symbolic system of values, beliefs and attitudes that shapes and influences perception and behavior. People typically think of culture as the foods, music, folk costumes, holidays, and religious beliefs associated with different countries and ethnic groups. But culture influences all aspects of everyday life. It is learned and maintained through social interaction. One's own culture seems natural and normal, and is taken for granted. John Culkin (as quoted in Edmund Carpenter's "They Became What They Beheld") said "We don't know who discovered water, but we're certain it wasn't a fish." In fact, people often believe that their own culture is superior to that of others. Other's views can be experienced as wrong, or as a distortion. It can be difficult to realize that what works so well for you, may not work in another's cultural context. 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 26 negotiate expectations. Sometimes personal adaptations are needed, but often full participation requires institutional change in terms of policies and practices. In order to ameliorate the harmful effects of failing to appreciate another's everyday reality, OCSHCN promotes cultural relativism. Activities are designed to promote an understanding that your experience of the world is only one of many possibilities, and you cannot judge a culture using the standards of your own culture. Activities are not so much oriented towards trying to understand the intricacies of every other potential cultural belief system, which can have the unintended consequence of stereotyping (which is an over-generalization about a group) but to sensitize staff towards listening for what others may be thinking and remaining open to hearing their points of view and adapting to it. Nowhere is it more critical to appreciate one's taken for granted assumptions than when a health care provider and a family must together decide on an appropriate course of treatment. The provider brings his or her own assumptions of what is necessary and good, which are influenced by their cultural expectations and training. They may have their own feelings about the child, and may be oriented towards a cure or amelioration of disability. The family's priorities could be different, but they are dependent upon the provider to help them to understand risks and possibilities of different treatment options. OCSHCN embeds cultural competence concepts into contract language and training, which go beyond requirements for reading level, interpretation, translation, and alternative formats, and include best practices for family-centered care, including people-first language and disability etiquette. Satisfaction surveys are conducted and analyzed to identify areas of strengths and opportunities for improvement. OCSHCN involves families and youth with special health care needs in policy and resource development, and makes translation and interpretation services available to other community partners. OCSHCN's cultural competence committee brings in regular speakers to address the unique perspectives of culturally diverse groups. The following are just a few examples of how services are linguistically and culturally appropriate, and family centered in Arizona. Arizona Department of Health Services houses the Arizona Health Disparities Center within the Bureau of Health Systems Development. The Arizona Health Disparities Center organizes frequent brown bag speakers that highlight the many cultures present in Arizona. The Arizona Health Disparities Center provides regular updates through email and through its website on news, funding opportunities, publications and events related to health disparities. Subscribers receive links/attachments to the latest resources identified by AHDC on their selected topic by email. 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. 27 The Office of Women's Health has implemented a social marketing campaign targeting African Americans around a message of preconception health. The campaign consists of radio spots, billboards, brochures, mood piece, website and E-blasts, and educational presentations in African American churches and other appropriate venues in Maricopa County and other areas of the state. The Phoenix Chapter of the Black Nurses Association conducts presentations and trains barbers and beauticians on preconception health so they can educate their clients. The graduate chapters of Black fraternities and sororities at Arizona State University staff exhibit tables and provide education at large gatherings. In the Bureau of Women's & Children's Health, the many Title V funded contracts with community-based organizations include in the scope of work language requiring services to be culturally competent. 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, 28 sexual assault services, family violence prevention and services/Rural Safe Home Network, Health Start, and First Time Motherhood. The office lead's the bureau's preconception health initiative and the Department's Women's Health Week activities. The Office of Children's Health provides leadership for planning, program development, and management of initiatives and programs related to children. Programs administered by this office include the Title V Community Health Grants, Pregnancy & Breastfeeding/Baby Arizona/WIC Hotline, Children's Information Center, High Risk Perinatal Program, Sensory Program, Medical Services Project for uninsured children, Project LAUNCH, and early childhood initiatives. The Office of Oral Health (OOH) provides leadership for planning, program development, and management of oral health initiatives. The office administers the school-based sealant program, fluoride mouthrinse program, and first dental visit by age one campaign. OOH provides technical assistance, training, and workshops for community fluoridation campaigns, and works to develop the current dental workforce by creating linkages with the Bureau of Health Systems Development scholarship and loan forgiveness programs. OOH administers a HRSA Oral Health Workforce grant which is developing teledentristry sites to provide oral health services to underserved populations. Injury Prevention & Child Fatality Review Section leads the Department's assessment of injuries and child fatality, as well as planning and program development for injury prevention. This section includes overseeing the state injury prevention plan, injury prevention advisory council, injury epidemiology, Child Fatality Review Program, Unexplained Infant Death Council, Emergency Medical Services for Children Program, and the Pediatric Advisory Council for Emergency Services. /2013/The Injury Prevention and Child Fatality Review Section became an office, reflecting the evolution that injury prevention has taken as one of our strategic priorities. //2013// 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. /2013/The responsibility of the State Systems Development Initiative was transferred to the Bureau of Health Status and Vital Statistics.//2013// 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 29 and other child serving agencies through training and education. Best practices are focused on family-centered care, cultural competence, medical home, and pediatric to adult transition. The Division of Consumer Rights is responsible for the development, monitoring and oversight of the Notice, Appeal, Claims Dispute and Administrative Hearing processes for CRS members, providers, and applicants for CRS eligibility and enrollment to ensure compliance with all state and federal requirements related to these processes. The Division of Quality, Utilization, and Medical Management assures appropriate utilization of services through monitoring authorization and denial processes, and overseeing compliance with service plans. Timeliness and quality of services is improved through investigating member complaints, auditing credentialing and medical records, monitoring of performance improvement projects and compliance with clinical practice guidelines. The Compliance and Policy Division's responsibilities include developing contracts and overseeing performance audits for contracted providers, tracking AHCCCS deliverables, policy development and the HIPAA Compliance Program. The Compliance Division notifies contractors of areas of non-compliance and evaluates corrective action responses. The Assessment and Evaluation Division is responsible for analysis and reporting that support every other function in the Office, including development of management reports, statistical analysis, data validation, study design and interpretation, performance measure development, surveys, predictive modeling, and needs assessment. /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. 30 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. 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. 31 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 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. /2013/ Jeanette Shea retired and Sheila Sjolander became the Assistant Director of Public Health Prevention Services. Mary Ellen Cunningham became the Chief of the Bureau of Women's and Children's Health. Dr. Khaleel Hussaini was promoted to become the Chief of the Bureau of Health Status and Vital Statistics. Emma Kibisu has been hired to become the Chief of the Office of Assessment and Evaluation. Ms. Kibisu has many years of combined national and international health experience including evaluation and research. She holds a Master's of Science in International Health Policy and Management from Brandeis University. Dyanne Herrera became the Bureau's MCH epidemiologist in June 2011. Ms. Herrera previously was a CDC/CSTE Epidemiology Fellow and has worked on MCH capacity building in the border region, and has presented various MCH studies at local and national conferences. She holds a Master's in Public Health with a concentration in Epidemiology from the University of Florida.//2013// 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. 32 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 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 33 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// /2013/ ADHS adopted a new five year strategic plan for 2013-2017. The Strategic Priorities for the next five years are: Impact Arizona's Winnable Battles, Integrate Physical and Behavioral Health, Promote and Protect Public Health and Safety, Strengthen Statewide Public Health Infrastructure and Strengthen ADHS Integration, Effectiveness and Adaptability. The Winnable battles include: to promote nutrition and physical activity to reduce obesity, reduce tobacco and substance abuse, reduce health care associated infections, reduce suicide and reduce teen pregnancy. Four of the five winnable battles align with the MCH challenges of the Title V Services Block Grant. //2013// 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, 34 Arizona Rural Women's Health Network, Arizona Asthma Coalition, Taskforce on Alcohol and Drug-Exposed Infants, Arizona School Nurse Consortium, Rocky Mountain Public Health Education Consortium, the Arizona Association of Community Health Centers, the Arizona Developmental Disabilities Network (consisting of the Institute for Human Development University Center of Excellence for Developmental Disabilities (UCEDD), Sonoran UCEDD, Arizona Developmental Disabilities Planning Council, Arizona Center for Disability Law, local oral health coalitions, and the Arizona chapters of the Dental Association and Dental Hygiene Association. ADHS also leads collaborative efforts to address specific public health issues. For example, ADHS coordinates an Injury Prevention Advisory Council that works on development and implementation of the state injury prevention plan. ADHS also coordinates the Pediatric Advisory Committee for Emergency Services, which helps facilitate accomplishment of performance objectives of the HRSA Emergency Medical Services for Children Program. The Unexplained Infant Death Council and State Child Fatality Review Teams address deaths of children and strategize around areas of preventability. The Office of Oral Health has established regional oral health workgroups to facilitate strategic planning for the state oral health workforce plan. Staff works with University of Arizona to develop services for children with neuro-developmental and related disabilities. In addition, ADHS has multiple partnerships in place with higher institutes of learning that provide education for the health professions. For example, staff participates on advisory boards, provide technical assistance and consultation on public health curricula, and mentor students. Most ADHS maternal child health programs contract with local organizations to carry out the mission of the programs. These organizations are primarily county health departments, non-profit human services agencies, and community health centers. Programs coordinate regular contractor meetings to provide educational opportunities, technical assistance, and opportunities for networking. Collaboration with other state agencies occurs on a regular basis. The Governor's Office for Children, Youth, and Families facilitates monthly meetings of the State Agency Coordination Team, which is comprised of all state agencies providing any kind of services related to domestic violence and sexual violence. The State Interagency Coordinating Council for Infants and Toddlers, which includes Department of Economic Security(DES)/Arizona Early Intervention Program (AzEIP), AHCCCS, Division of Developmental Disabilities (DDD), Arizona Schools for 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. /2013/ Four of the state agencies involved in early childhood joined together to look at the early childhood system. This group, the Inter Agency Leadership Team, consists of the Arizona departments of Health Services, Education and Economic Security as well as the Early Childhood Development and Health Board also known as First Things First and Inter tribal Council of Arizona. This team collaboratively makes all decisions for the ACA Maternal, Infant and Early Childhood grant, not only the decision of where to implement the evidence based programs but as these agencies together build a system of early childhood home visiting decisions regarding core competencies, regionalization, community development and professional development.//2013// 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 35 community organizations to involve family and youth partners in agency decision-making. ADHS works particularly closely with the state's Medicaid agency, AHCCCS, participating in many AHCCCS Health Plan meetings. Health Start, Community Nursing, and Hotline staff all facilitate families enrollment in both Medicaid and SCHIP programs. OCSHCN staff assists families in understanding eligibility requirements and help with application processes for various programs that serve CSHCN. Baby Arizona is a program to help pregnant women begin prenatal care while waiting for AHCCCS eligibility. Baby Arizona providers help women apply for AHCCCS and pre-enroll her into a health plan, and women begin prenatal care at no cost while their eligibility is processed. If a woman is determined to be ineligible for AHCCCS, she and her Baby Arizona doctor work out a reasonable payment plan and continue care. The Bureau of Women's & Children operates the Baby Arizona hotline and assists callers in how to apply for AHCCCS and helps them locate a prenatal care provider. ADHS works with the Social Security Administration to review Social Security Income applications, and informing families of potential services. Interagency Services Agreements are in place with AHCCCS to operate the Baby Arizona Hotline, and the Children's Rehabilitative Services Program as a carve out for Medicaid-eligible children with special health care needs. BWCH and OCSHCN staff work closely with Newborn Screening, Genetics Services Advisory Committee, the Arizona Chapter of the AAP, Community Health Centers, Community Health Nurses, and AzEIP to identify resources to ensure that children and youth receive Early and Periodic Diagnosis and Treatment (EPSDT) services for children and youth. The Arizona Community of Practice on Transition (AzCoPT) offers additional opportunities for cooperation among Department of Education (ADE), Vocational Rehabilitation, Southwest Institute for Families and Children with Special Health Care Needs, DDD, BHS, and young adults. This partnership of stakeholders promotes collaboration and coordination for transition planning, professional development and youth involvement. At the annual ADE Transition conference, partners will co-present "Partnering for Transition," describing the role of each agency in coordinating transition for young adults with disabilities and special health care needs. This presentation will be available online to Vocational Rehabilitation, Behavioral Health, and DDD case managers, as well as special educators, reinforcing collaboration across agencies, inclusive of health care, for successful transition. ADHS also works with DES Family Assistance Administration which provides families with nutrition assistance, cash assistance, emergency food assistance and applications for AHCCCS health insurance. The agencies strategize ways to include the nutritional needs of children with special health care needs in FAA policy and programs allowing for better planning and access to resources to meet the needs of all children and families who require nutrition assistance. ADHS staff participates in a monthly Genetics Services Advisory Committee with the Arizona Schools for the Deaf and Blind, EAR Foundation of Arizona, and pediatric genetics services providers to discuss emerging practice around newborn screening, diagnosis and provision of care to children with heritable disorders. Additionally, ADHS staff takes part in Mountain States Genetics Regional Collaborative Center's (MSRGCC) annual meeting which includes professionals and consumers from Texas, New Mexico, Arizona, Utah, Colorado, Wyoming, 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 36 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. /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 37 women's health conference. //2012// /2013/ The Arizona Department of Health Services has partnered with the Arizona Chapter of the March of Dimes and the Arizona Perinatal Trust to take up the challenge of the Association of State and Territorial Health Officers to reduce prematurity by 8% by 2014. ADHS plans to target efforts at preconception health, eliminating elective inductions before 39 weeks, reinvigorate the safe sleep campaign and increasing prenatal and early childhood home visiting. //2013// /2013/ /2013/OCSHCN is an active participant in the 9th Annual American Indian Disability Summit 2013 Planning Committee.//2013// /2013/The Office of Oral Health participates on the Governor's Advisory Council on Aging - Oral Health subcommittee. The goal of the subcommittee is to improve the oral health of older/vulnerable adults through developing strategies for increasing partnerships and sustainability of programs and resources. OOH has posted resources developed in part by the oral health subcommittee at the following link: http://www.azdhs.gov/cfhs/ooh/adults-seniors.htm.//2013// F. Health Systems Capacity Indicators The discussion of Health Systems Capacity Indicators will focus on access to care. For 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 was 100 percent but the number of enrollees decreased. According to 2011 data provided by Arizona's Medicaid agency (Arizona Health Care Cost Containment System), 100 percent of infants enrolled in health plans that contract with AHCCCS received at least one initial periodic screen. However, the number of enrollees declined approximately 18 percent in 2011 compared to 2010 and this followed a decrease of 31 percent between 2009 and 2010. For Health Systems Capacity Indicator 03: The percent State Children's Health Insurance Program (SCHIP) enrollees whose age is less than one year during the reporting year who received at least one periodic screen decreased dramatically in 2011. Due to the economic difficulties of the state, in 2010, the enrollment for Arizona's SCHIP, KidsCare was frozen. As a result, eleven infants under one year of age were served by the KidsCare program in 2011. In April 2012, one time funding from three children's hospitals enabled KidsCare to open enrollment for up to 22,000 children beginning with those on the waiting list. These decreases are worrisome. The Bureau of Women's and Children's Health had already identified access to and quality of preventive health services for children as a priority. The freeze on KidsCare, coupled with the decrease of Medicaid enrollment has raised alarms in Arizona's public health community. BWCH is using a multipronged approach to address the situation. One measure has been to work to increase understanding of the importance of preventive health services for children. The BWCH home visiting programs, the High Risk Perinatal Program, Project LAUNCH and Health Start educate families about the importance of a medical home and help the families to access care. The BWCH Title V Hot Lines, Pregnancy and Breastfeeding, Baby Arizona, Children's Information and WIC provide families connections to resources. The Hot Lines have information about immunizations, dental care, local health departments and community health centers. BWCH is coordinating with others in the maternal and early childhood community to develop public education opportunities about the importance of preventive care. The ACA Maternal, Infant and Early Childhood Home Visiting grant has afforded Arizona the opportunity to develop a strong 38 system of early childhood home visiting. A Task Force comprised of agencies and nonprofit organizations is helping to craft the system. Each of the models' home visitors works to assist the parent and child into care. This includes helping to ascertain if the family or child is eligible for AHCCCS (Medicaid) and if not, to help them locate a community clinic. The importance of a medical home is stressed to the parent. In addition, this system is in the process of developing standards of practice for home visitors to ensure each visitor, no matter the model has a full understanding of the importance of early screening and medical care. 39 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 40 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 41 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 42 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 43 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// 44 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 2007 2008 2009 2010 2011 100 100 100 100 100 100.0 85 85 100.0 93 93 AZ Office of Newborn Screening 100.0 115 115 AZ Office of Newborn Screening 100.0 113 113 AZ Office of Newborn Screening 100.0 102 102 AZ Office of Newborn Screening Final Final 2015 100 2016 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 2012 100 2013 100 2014 100 a. Last Year's Accomplishments The Arizona Department of Health Services' (ADHS) Office of Newborn Screening (NBS) reported 84,817 initial bloodspot screens. Of those screened, 102 were diagnosed with clinically significant disorders, including 56 cases of primary congenital hypothyroidism; 5 cases of congenital adrenal hyperplasia; 3 cases of classic Galactosemia; 6 cases of sickle cell anemia and 3 cases of hemoglobin SC disease--both hemoglobinopathies; 3 cases of classic Phenylketonuria; 2 cases of Biotinindase Deficiency, 1 case of Argininosuccinic Acidemia; 5 cases of Medium-chain acyl-CoA dehydrogenase deficiency ; 1 case of Very Long-chain acylCoA dehydrogenase deficiency; 1 case of Glutaric Acidemia Type 1; 2 cases of Methylmalonic Acidemia--1 Mutase deficiency and 1 Cobalamin deficiency; and 14 cases of cystic fibrosis (CF). In all, 102 primary target disorders were confirmed. Secondary findings included an additional 833 disorders or traits, including 150 CF carriers and 655 hemoglobinopathy traits. In 2011 there were 112 presumptive positive screens closed without confirmation. Of these, 29 babies (representing 45 abnormal specimens) expired while the remaining either moved out of state or the parents declined services. Through joint efforts between AZ NBS, physicians, hospitals and clinical specialists, the program located 100% of infants confirmed with primary target disorders, provided case management services up through definitive diagnosis and initiation of treatment, and ensured the availability of appropriate medical management services. 45 Partnership-building continued to be an important aspect of the newborn screening services provided. Monthly sub-specialty meetings with pediatric hematologists, endocrinologists, pulmonologists, metabolic geneticists, and audiologists occurred as with the prior year. Two new committees were active during this period; a budget subcommittee of the Newborn Screening Advisory Committee (NBSAC) met to review projected budget shortfalls and develop recommendations that would minimize the impact on services, and a committee was convened to review the Clinical Laboratory Standards Institute (clsi.org) guideline for screening sick and preterm infants (NICU committee). The meetings of the NICU committee resulted in the creation of a five-hospital NICU pilot project, which was scheduled for 2012. Within ADHS, collaborative efforts with the High Risk Perinatal Program (HRPP), Office of Children with Special Health Care Needs (OCSHCN), and Licensure resulted in the creation of family-centered materials for NICU graduates, families of babies with Sickle Cell trait and midwives. External partnership development continued to be an integral component of the program. Members of the NBS team attended the Mountain States Genetic Regional Collaborative Center (MSGRCC) (http://www.msgrcc.org/) 2011 bi-annual meetings and served on the Emergency Preparedness and Newborn Screening workgroups. In 2011, our State Laboratory Bureau Chief, Dr. Victor Waddell, was appointed as the president of The Association of Public Health Laboratories (APHL) (http://www.aphl.org/Pages/default.aspx); this combined with participation of the Office Chief for NBS on the APHL Quality Indicators committee ensured the active involvement of the Arizona NBS program in developing and following national quality standards. Education to providers, including hospitals, community health clinics and private practices was expanded through a joint effort with The EAR Foundation of AZ (EFAZ). Combining bloodspot and hearing education and outreach efforts proved to be a successful model and is described under current year activities. The NBS Provider Guidelines were updated in 2011 with a clarification statement posted to the web, reflecting a revised message emphasizing early collection, timely receipt of specimens and reducing unsatisfactory (UNSAT) specimens. As a result, by the end of 2011 the total of UNSAT specimens was reduced to below 1% (0.79%), a first for the program. Continued training occurred through hospital site visits, attendance at nursing and medical assistant conferences, baby fairs and other public health venues. 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 continued to educate parents about the need for second screens 4. The Community Health Nurses educated families about the importance of a second newborn screen 5. OCSHCN supports family advisor to partner 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. 6. OCSHCN supports training and technical assistance to medical providers and early education programs 7. 8. 9. Pyramid Level of Service DHC ES PBS IB X X X X X X 46 10. b. Current Activities The website (www.aznewborn.com ) was completely revamped and launched to coincide with Public Health week in April 2012. A social media presence has also been created and includes Twitter, Facebook, and blogs related to NBS. Coordinated outreach with local and national experts is being achieved through public-private partnerships with the AZ American Academy of Pediatrics (AAP) and others. Based on national recommendations, NBS began an evaluation of the feasibility of adopting serial screening in the NICU. ADHS initiated a pilot project and at the conclusion of the pilot, the data will be analyzed and outcomes reviewed. Data infrastructure development, including the creation of a data exchange between Vital Records and NBS hearing screening has been successfully implemented. Matching rates are being maintained between 85-95%. OCSHCN, Southwest Human Development, Raising Special Kids, and Arizona's Early Intervention Program (AzEIP) are partnering to develop and produce a Neonatal Intensive Care Unit (NICU) Parent Resource to assist families, in navigating and accessing timely services. A new Family Advisor was identified to partner on the development of an emergency planning resource for families. The BWCH representative at the Arizona Perinatal Trust site visits continues to review the NBS scorecard reflecting the hospital's rate of unsatisfactory or late specimens. c. Plan for the Coming Year With four years of decreasing births, the program has experienced decreased fee revenues which, combined with large legislative fund sweeps from a previous fiscal year, created chronic challenges with budgeting, staffing and planning. To cover this shortfall, ADHS made several one-time funding transfers and BWCH made a significant amount of Title V funding available. The program reduced operating costs through holding vacant positions, utilizing less expensive contract employees and other cost-saving measures. We will continue to focus on reducing the numbers of unsatisfactory and batched specimens received and to improve the false positive rates and positive predictive values for our tests. Also, using culturally sensitive materials, we will continue 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 local resources. Staff will review and update brochures as well as expand provider educational materials. OCSHCN and NBS will continue to revise and translate notification letters and fact sheets for all disorders identified by NBS. OCSHCN will continue to direct families identified through the NBS Program to healthcare, services, and family support and work with NBS partners to identify system barriers for newly diagnosed newborns. Title V funding will continue to provide a safety-net for families who are unable to provide needed metabolic formulas for their children. OCSHCN will explore possible ways to support Arizona's participation in the Medical Home Portal. Through an Emergency Planning Project, NBS, EAR Foundation of Arizona, OCSHCN, Phoenix Children's Hospital Genetics Program and parents of children receiving genetic services will develop an emergency planning resource for families. OCSHCN will work with hospitals, the AZ EHDI program and providers to establish a telemedicine connection for hearing screening follow-up. HRPP-CHN will continue to educate families about the need for a second newborn screen and 47 facilitate referral to a medical home for those screens. In an effort to ensure comprehension of the urgency of the screens, NBS will continue to help ensure that CHN have bilingual staff available. Our partnership with the HRPP program to work with hospitals during Arizona Perinatal Trust site visits will also continue. Finally NBS will work with Indian Health Services, the Arizona tribes and other laboratories that analyze NBS specimens to develop data sharing mechanisms to help minimize disparities between tribal and non-tribal newborns in the provision of newborn screening services. Similarly, a recent announcement that the Department of Defense has contracted with a private laboratory, Perkin Elmer Genetics, to provide all newborn screening testing will require similar efforts to ensure all newborns, wherever they are tested, receive the best service possible. 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 Biotinidase Deficiency Cystic Fibrosis Homocystinuria Maple Syrup Urine Disease betaketothiolase deficiency Tyrosinemia Type I Very LongChain Acyl-CoA Dehydrogenase Deficiency 86599 2011 (A) Receiving at least one Screen (1) (B) No. of Presumptive Positive Screens (C) No. Confirmed Cases (2) No. 84817 % 97.9 No. 123 No. 3 (D) Needing Treatment that Received Treatment (3) No. % 3 100.0 84817 97.9 855 56 56 100.0 84817 97.9 87 3 3 100.0 84817 97.9 3 2 2 100.0 84817 97.9 224 2 0 0.0 84817 84817 84817 97.9 97.9 97.9 174 371 228 14 0 0 14 0 0 100.0 84817 97.9 0 0 0 84817 97.9 182 0 0 84817 97.9 6 1 1 100.0 48 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) 21-Hydroxylase Deficient Congenital Adrenal Hyperplasia 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 84817 97.9 5 1 1 100.0 84817 84817 97.9 97.9 5 42 0 0 1 0 84817 97.9 12 0 0 84817 97.9 2 0 0 84817 97.9 11 0 0 84817 97.9 12 1 1 84817 97.9 12 0 0 84817 97.9 0 0 0 84817 97.9 19 1 1 100.0 84817 97.9 7 6 6 100.0 84817 97.9 188 5 5 100.0 84817 97.9 22 5 5 100.0 84817 97.9 0 0 0 84817 97.9 11 0 0 84817 97.9 12 1 1 84817 97.9 2 0 0 15922 4271 0 0 4684 562115 0 12071 0 1500 0 1500 100.0 100.0 100.0 49 Performance Measure 02: The percent of children with special health care needs age 0 to 18 years whose families partner in decision making at all levels and are satisfied with the services they receive. (CSHCN survey) Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2007 56 53.6 2012 57.4 2008 54 53.6 2009 55 53.6 2010 54 53.6 2011 57.4 66.2 SLAITS SLAITS SLAITS SLAITS 2013 57.4 2014 57.4 Final 2015 57.4 Final 2016 57.4 Notes - 2011 For 2011-2014, indicator data come from the National Survey of Children with Special Health Care Needs (CSHCN), conducted by the U.S. Health Resources and Services Administration and the U.S. Centers for Disease Control and Prevention in 2009-2010. This survey was first conducted in 2001. The same questions were used to generate this indicator for both the 2001 and the 2005-06 CSHCN survey. However, in 2009-2010 there were wording changes and additions to the questions used to generate this indicator. The data for 2009-2010 are NOT comparable to earlier versions of the survey. All estimates from the National Survey of CSHCN are subject to sampling variability, as well as survey design flaws, respondent classification and reporting errors, and data processing mistakes. 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. a. Last Year's Accomplishments Since 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, OCSHCN has been using the intergovernmental agreement with AHCCCS, Arizona's Medicaid Program, to work closely with and support family and youth involvement in policies, program and practices that affect the UnitedHealthcare (UHC), Arizona Physicians IPA-Children's Rehabilitative Services (APIPA-CRS) delivery system, telemedicine services and administration of social service funds. The APIPA-CRS Ombudsman and OCSHCN staff met quarterly to further develop 50 partnership opportunities that included promotion of UHC's open house to families and professionals, ongoing exchange of program updates, participation on conference calls with APIPA-CRS Clinic Liaisons to discuss what resources and technical assistance OCSHCN can provide to families and providers, promoting the availability of family and youth involvement contract that helped support APIPA-CRS' family involvement initiatives and Raising Special Kids' role as Arizona's Family to Family Health Information Center and Arizona Chapter for Family Voices. The APIPA-CRS Ombudsman and OCSHCN presented to 35 administrators on how OCSHCN and APIPA-CRS would continue to work together to support families in decisionmaking beyond the CRS Transition at a Quarterly Statewide Division of Developmental Disabilities Area Program Managers/ District Program Managers' Meeting. Participation extended beyond ADHS as families were made available to other agencies so that family participation was incorporated into their activities. OCSHCN worked with the Medicaid agency by providing training to AHCCCS health plans through their Quality Management/MCH Quarterly meetings on incorporating family-centered practices for children with special health care needs, the transition of APIPA-CRS and how OCSHCN supported family and youth involvement through Building Partnerships for Quality Care (BPQC) contract with RSK that compensated families, consumers and youth for their time and expertise. OCSHCN incorporated family involvement in its day to day management, including participation in Home Visiting stakeholders' meetings throughout Arizona, an Annual APIPA-CRS Flagstaff Family Fun Day, hiring panels for several ADHS staff positions, development of contracts, proposal evaluation committees, focus groups around the state regarding proposed changes to the AHCCCS system and Family Advisor available on-site to ADHS offices. OCSHCN's Youth Advisor, Peter Graf, was instrumental in engaging young adults with SHCN from a communitybased program to partner in the development of the House Bill 2103, Home Baked Goods & Confectionaries training video. The video which was posted on the ADHS website highlights employment opportunities for families of CYSHCN, youth and adults with developmental disabilities. Raising Special Kids provided family-centered care training to 93 medical, dental and nursing students and coordinated 78 resident-in-training home visits with 58 Family Faculty (host families) and 58 CYSHCN focused on the day-to-day life issues related to children and youth with special health care needs (CYSHCN). OCSHCN sponsored resident and physician training, which took place in the homes of families of CYSHCN to better acquaint them on a "day in the life of a CYSHCN" and to learn how to make decisions with families as partners in decision-making. OCSHCN kept a log to track contacts (in-person, telephone, email, webpage) and provided 255 families with information, support and guidance on navigating the systems of care. The Navigating the System online training created by families was launched and hosted on the OCSHCN webpage. All training content delivered by OCSHCN incorporated key messages on the development of family, youth, and consumer involvement in decision-making. OCSHCN promoted families as decision-makers within ADHS and provided technical assistance to other child-serving agencies including Arizona's Department of Education (ADE), Early Intervention Program, Division of Developmental Disabilities, Vocational Rehabilitation Services and Developmental Disabilities Planning Council. Table 4a, National Performance Measures Summary Sheet Activities 1. Families and youth develop and review contracts, policies, curriculum, training, and resources 2. Building Partnership for Quality Care contractors recruit, train, Pyramid Level of Service DHC ES PBS IB X X 51 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. Families, consumers and youth evaluate curriculum, materials and websites for ease of use, family friendliness and accessibility 6. OCSHCN sponsors resident and physician training so they can learn how to make decisions with families as partners. 7. 8. 9. 10. X X X X b. Current Activities OCSHCN uses the BPQC contract to recruit, train and compensate families, consumers and youth for their time and experience. OCSHCN actively partners with APIPA-CRS to support family/youth involvement in review of member notices, resource materials and training. Families participated in writing a CDC grant on improving health of people with disabilities and the APIPACRS redesign was supported by the BPQC. Information and web link to AHCCCS webpage posting regarding redesign of CRS and family input survey was disseminated to Family Advisors. Family Advisors are developing and reviewing the 2012 AZ Medical Home Care Coordination Manual. Family participation is well received in ADHS' Zero to Five Workgroup, Home Visiting Task Force, Project LAUNCH and NBS Emergency Planning. Other activities include review of ADE Resource Guides for Supporting Children with Life-Threatening Food Allergies and Delivery of Specialized Health Care. Family Advisors vetted new curriculum, Hospital to Home: Caring for Children with Medically Fragile Health, vetted by Family Advisors. Family Advisors are co-training in AZ's Coalition for Military Families Symposium and Annual Transition Conference. OCSHCN partners on ADHS' new Population Health Policy Intergovernmental agreements (IGA) with Health Departments with a focus on inclusion of CYSHCN. IGAs are designed to impact policy, system, and environmental change in Arizona counties at the community, organizational, and individual level. c. Plan for the Coming Year OCSHCN will continue to work closely with and support family and youth involvement within all lines of business including APIPA-CRS at UnitedHealthcare (UHC) Community Plans that serve 44% of the state's special needs population of approximately 680,000 members including APIPACRS that serves approximately 25,000 CYSHCN. OCSHCN will participate in quarterly community networking partners' meetings hosted by UHC at the Disability Empowerment Center. OCSHCN will continue to use a variety of methods to promote family participation in decisionmaking within ADHS and other child-serving agencies. OCSHCN will work with other ADHS programs including the Division of Behavioral Health Services to develop and issue a new request for proposal to support family, consumer and youth involvement as ADHS' BPQC contract is due to expire in 2014. OCSHCN will continue to provide education, trainings, technical assistance and resources on best practices for CYSHCN to health plans, school nurses, therapists and providers on cultural competence as it relates to chronic health conditions, families as decision-makers, medical home 52 and care coordination for CYSHCN, pediatric to adult transition and navigating the system of care. OCSHCN will continue to involve families and consumers in the development of curriculum and online training including the AzDB 101, a new online tool available to assist individuals receiving federal and/or state assistance to assess the effect of various work/school scenarios on benefits, particularly healthcare. OCSHCN will also continue to support the development of family, youth, and consumer involvement in decision-making, promote families as decision-makers in other child-serving agencies. Technical assistance will be provided on how to develop mechanisms to support parents and youth. OCSHCN will continue to partner on ADHS' new Population Health Policy Intergovernmental agreements (IGA) with Health Departments with a focus on inclusion of CYSHCN. IGAs are designed to impact policy, system, and environmental change in Arizona counties at the community, organizational, and individual level. OCSHCN also will continue to sponsor resident and physician training, which takes place in the homes of families of CYSHCN 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 expand representation of families and include youth to serve on the Arizona Leadership Education in Neurodevelopmental Disabilities (LEND) Advisory Group. OCSHCN will explore the potential of partnering with ADHS' Bureau of Emergency Preparedness, Arizona's Developmental Disabilities Planning Council, Statewide Independent Living Council, and Department of Economic Security on developing emergency preparedness resources and tools for families of CYSHCN. Family participation will be incorporated into this initiative. Performance Measure 03: The percent of children with special health care needs age 0 to 18 who receive coordinated, ongoing, comprehensive care within a medical home. (CSHCN Survey) Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2007 52.5 40.4 2012 47.1 2008 41 40.4 2009 41 40.4 2010 40 40.4 2011 47.1 36.1 SLAITS SLAITS SLAITS SLAITS 2013 47.1 2014 47.1 Final 2015 47.1 Final 2016 47.1 Notes - 2011 53 For 2011-2014, indicator data come from the National Survey of Children with Special Health Care Needs (CSHCN), conducted by the U.S. Health Resources and Services Administration and the U.S. Centers for Disease Control and Prevention in 2009-2010. Compared to the 2001 CSHCN survey, there were wording changes, skip pattern revisions, and additions to the questions used to generate this indicator for the 2005-06 CSHCN survey. The data for the 2001 and 2005-2006 surveys are not comparable for NPM 3. However, the same questions were used to generate the NPM 3 indicator for both the 2005-2006 and 2009-2010, therefore these two surveys are comparable. All estimates from the National Survey of CSHCN are subject to sampling variability, as well as survey design flaws, respondent classification and reporting errors, and data processing mistakes. 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. a. Last Year's Accomplishments Since 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, OCSHCN has been using the intergovernmental agreement with AHCCCS, Arizona's Medicaid Program, to work closely with and support family and youth involvement in policies, program and practices that affect the Arizona Physicians IPA-Children's Rehabilitative Services (CRS) delivery system, telemedicine services and administration of social service funds. The APIPA-CRS Ombudsman and OCSHCN staff met quarterly to further develop partnership opportunities that included ongoing exchange of program updates, participation on conference calls with APIPA-CRS Clinic Liaisons to discuss OCSHCN's transition to Bureau of Women's and Children's Health, the availability of the family and youth involvement contract that helped support APIPA-CRS' family involvement and Raising Special Kids' (RSK) role as Arizona's Family to Family Health Information Center. The Arizona Telemedicine Program made specialty services available to 247 CYSHCN unique Yuma APIPA-CRS members. Specialty clinics included pediatric orthopedics, neurology and neurosurgery. When telemedicine events were evaluated families reported saving an average of eight (8) work hours by attending the telemedicine event instead of an in-person visit. One hundred and seventy seven (177) or 94.15% reported they would use telemedicine again. OCSHCN and RSK reinforced the importance of the family perspective in the service delivery system by creating opportunities for families to participate in focus groups and through an online survey hosted on the AHCCCS website regarding the Children's Rehabilitative Services redesign. The medical home (MH) model was integrated into all published materials, trainings and presentations to 213 medical staff, 524 school nurses who served over 36,000 CYSHCN, 253 therapists and social services staff, 70 health plan staff and others such as the Arizona Children's Association quarterly CSHCN trainings for foster parents, Arizona Therapy Association, annual Coordinated School Health Conference and other ADHS staff. OCSHCN presented to AHCCCS Quality Management/MCH Quarterly Health Plan Coordinators on the technical assistance and resources OCSHCN provided to professionals and families. As a member of the Arizona Early Intervention Program-Interagency Coordinating Council for Infants and Toddlers, OCSHCN has 54 been a partner in the development of a team based family model. OCSHCN funded medical residency training to 78 residents and physicians who participated in training and home visits through RSK's contract. Arizona's MH Care Coordination Manuals (CDs) were distributed to 1,021 physicians, providers, families, school nurses, therapist and others. A survey monkey was developed to solicit input on improving the manual's content from Arizona's School Nurse Consortium and School Nurses Association of Arizona and hosted on the OCSHCN website. The American Academy of Pediatrics gave OCSHCN permission to translate the Emergency Information Card to Spanish. OCSHCN provided the Spanish translation to AAP for their use. Emergency Information Cards were distributed to 1,123 families and providers through individual contacts, trainings and community outreach. OCSHCN's Health Care Organizer incorporated information about accessing information, resources and technical assistance to promote effective advocacy and partnering with health care professionals. Community partners helped OCSHCN convene groups of up to 10 families for training delivered locally. Fourty families learned from one another's brainstorming, information sharing, and of the importance and benefits of keeping a medical file, increased their understanding of the services a CYSHCN may need and helped support families to actively participate in decision-making. The expandable organizer, in English and Spanish, has tabs for care coordination, dental/oral health, emergency planning, legal options, medical history, insurance, prescriptions, school and immunizations. OCSHCN worked with refugee resettlement programs to develop programs and resources for 35 families of CYSHCN who were new to the US on cultural brokering, understanding Arizona's complex system of care, how to be a self-advocate, what questions to ask their health care providers and appeal rights. 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, and resources. 3. Arizona’s 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 CYSHCN, including medical home. 5. OCSHCN funds translation services for written and web based materials to community partners on behalf of CYSHCN. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X X b. Current Activities 55 OCSHCN offers education, trainings, technical assistance and resources on best practices for CYSHCN to health plans, school nurses, therapists and providers. OCSHCN partners with RSK, Arizona's Family Voices Chapter and Family to Family Health Information Center to integrate mental health with existing physical health curriculum in the physician residency training. An evaluation workgroup including family members, health plans, medical and behavioral health professionals convened to review existing curriculum, develop recommendations for integration of behavioral and physical health best practices. OCSHCN collaborates with Division of BHS' Family Involvement Subcommittee, focusing on health care integration, and shares information on medical home, MH Care Coordination Manual and AAP's Emergency Information Form in English and Spanish. OCSHCN is converting the Breaking the Diagnosis training to video format focusing on family and physician interaction and communication around difficult diagnoses. The Navigating the Systems of Care in Spanish will soon be posted on the OCSHCN webpage. OCSHCN partners with APIPA-CRS and RSK providing regional Collaborative Therapies Conferences for families to access information on services, communication strategies and familycentered care. OCSHCN joined AzAAP Care Coordination Learning Community where ideas, challenges, documents, and healthcare systems barriers are identified and resources shared. c. Plan for the Coming Year Medical home will continue to be a key component of all outreach activities and OCSHCN staff will work with other ADHS programs, child-serving agencies and community partners to educate on best practices for CYSHCN and their families. OCSHCN will continue to use the Building Partnerships for Quality Care (family, consumer and youth involvement) contract to recruit, train and compensate families, consumers and youth for their time and experience. OCSHCN staff will continue to provide information and referral to families on understanding their rights and 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. Arizona's Medical Home Care Coordination Manual will continue to be adapted yearly and vetted by families and school nurses to reflect the changing systems of care and distributed to other ADHS offices, state agencies, providers, community partners and family organizations and posted on the OCSHCN webpage. OCSHCN will continue to provide 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 CYSHCN, including medical home. OCSHCN will be partnering with other ADHS offices to establish a new Learning Management System within Training Finder Real-time Affiliated Integrated Network (TRAIN), the nation's premier learning resource for professionals who protect the public's health. OCSHCN will explore the potential of having its new online training curriculum, Breaking the Diagnosis, piloted by home visitors and other professionals. Training incorporates the principles of family centered care and medical home concept. OCSHCN will explore partnering opportunities with the Bureau of Health Systems Development to promote the medical home model with health providers to improve service delivery for CYSHCN. 56 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 2007 61 58.1 2012 62 2008 59 58.1 2009 59 58.1 2010 58 58.1 2011 62 52.9 SLAITS SLAITS SLAITS SLAITS 2013 62 2014 62 Final 2015 62 Final 2016 62 Notes - 2011 For 2011-2014, indicator data come from the National Survey of Children with Special Health Care Needs (CSHCN), conducted by the U.S. Health Resources and Services Administration and the U.S. Centers for Disease Control and Prevention in 2009-2010. This survey was first conducted in 2001. The same questions were used to generate the NPM 4 indicator for the 2001, 2005-06, and 2009-2010 CSHCN surveys. All estimates from the National Survey of CSHCN are subject to sampling variability, as well as survey design flaws, respondent classification and reporting errors, and data processing mistakes. 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. a. Last Year's Accomplishments Since 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, OCSHCN has been using the intergovernmental agreement with AHCCCS, Arizona's Medicaid Program, to work closely with and support family and youth involvement in policies, program and practices that affect the Arizona Physicians IPA-Children's Rehabilitative Services (CRS) delivery system, telemedicine services and administration of social service funds. The APIPA-CRS Ombudsman and OCSHCN staff met quarterly to further develop partnership opportunities that included ongoing exchange of program updates, participation on conference calls with APIPA-CRS Clinic Liaisons to discuss OCSHCN's transition to Bureau of Women's and Children's Health (BWCH), the availability of the family and youth involvement contract that helped support APIPA-CRS' 57 family involvement and Raising Special Kids' (RSK) role as Arizona's Family to Family Health Information Center. 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 700 families of CSHCN. Families and providers received OCSHCN's Making the Most of Your Healthcare resource with information in English and Spanish on how to use public or private health plan member and provider services, health plan member handbooks, and offer guidance on negotiating rates with doctors. This resource also supported families whose children are uninsured and underinsured with resources to prescription discount programs, federally funded qualified community health centers, the Pre-Existing Condition Insurance Plan through the Patient Protection and Affordable Care Act and other charitable foundations. Over 4,000 copies of this resources was distributed in trainings, outreach and community events and in customized electronic or hard copy resource packets for families and professionals. Families were informed about the application processes for SSI, AHCCCS and early intervention services. OCSHCN referred CSHCN to the EAR Foundation of Arizona 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 APIPA-CRS. 1,149 letters were mailed to SSI applicants under age 21 informing them about medical coverage and programs for which their CYSHCN may be eligible including OCSHCN contact information. These letters frequently generated follow up calls from families who received further assistance with applying for services and identifying community resources for things such as prescription medications and therapy services. OCSHCN informed 213 medical staff, 524 school nurses, 253 therapists and social services staff, 70 health plan staff and other community partners of eligibility requirements and services available to CYSHCN. OCSHCN supported the BWCH's CIC and Community Health Nursing through funding and training about public and private health insurance options, services and programs for CYSHCN. OCSHCN presented on health resources including SSI, AHCCCS, PCIP at the Arizona's Eleventh Annual Transition Conference, Tempe Elementary School District #3, Arizona's School Nurse Consortium and School Nurses Association of Arizona conferences and the Developmental Disabilities Nurses Association. Charitable funds were identified such as the UnitedHealthcare-Children's Foundation and AFCCA Foundation for Children through school nurses, to help families offset medical costs. 255 contacts were tracked in the call log and barriers were 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 hosted on the OCSHCN webpage. Given the changing enrollment and eligibility requirements caused by budget cuts, the training directs users to the respective websites for most current information available. OCSHCN staff and families partnered with AHCCCS on beta testing the Arizona's Disability Benefits 101, new online tool available to assist individuals receiving federal and/or state assistance to assess the effect of various work/school scenarios on benefits, particularly healthcare. Table 4a, National Performance Measures Summary Sheet Activities Pyramid Level of Service 58 DHC 1. OCSHCN works with the Children's Information Center (CIC) Hotline, CHN Program, school nurses, and other programs, to educate families about sources of health care coverage. 2. OCSHCN refers CSHCN to the EAR Foundation of AZ for hearing aids, cochlear implant batteries, repairs and audiology testing. 3. 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. 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 works with families and providers to find coverage for medical care and services to uninsured or underinsured CYSHCN. 6. OCSHCN educates school nurses, providers, and other community partners on eligibility requirements and services available to CSHCN. 7. 8. 9. 10. ES PBS IB X X X X X X b. Current Activities OCSHCN works with families and providers to find coverage for medical care and services to uninsured or underinsured CYSHCN. Families are 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. The Making the Most of Your Healthcare resource in English and Spanish is incorporated into NICU packets disseminated by Raising Special Kids. OCSHCN provides information and training on PCIP, requirements to prevent insurance companies from excluding children with pre-existing conditions from coverage and young adults up to age 26 remaining on their health care plans. Families receive information about SSI, AHCCCS programs, and early intervention services. Letters are mailed to families identified by the Arizona Birth Defects Registry and SSI to inform them about medical coverage and programs for which they might be eligible. A call log tracks contacts and barriers identified by families in gaining access to services and health insurance. This information is shared with responsible agencies. OCSHCN educates school nurses, providers, and other community partners on eligibility requirements and services available to CSHCN. OCSHCN supports the CIC Hotline and the Community Health Nursing Programs through funding and training about public and private health insurance options, services and programs. OCSHCN distributes new information about KidsCare II health care coverage. c. Plan for the Coming Year OCSHCN will continue to work families and providers to find coverage for medical care and services to uninsured or underinsured CYSHCN. Families will be educated to use their health plan's member and provider services, member handbook, negotiate with their doctor about rates 59 for services and navigate the system of care. OCSHCN's Making the Most of Your Healthcare resource will continue to provide families support and resources in English and Spanish on how to use public or private health plan member and provider services, health plan member handbooks, and offer guidance on negotiating rates with doctors. This resource will continue to also support families, whose children are uninsured and underinsured with resources to prescription discount programs, federally funded qualified community health centers, the PreExisting Condition Insurance Plan through the Affordable Care Act and other charitable foundations. OCSHCN has been using national sources to provide informational resources and training on the Pre-Existing Condition Insurance Plan (PCIP) to families, providers, educators, social workers, school nurses, other child-serving agencies and ADHS programs. Families will continue to receive information about SSI, AHCCCS programs, and early intervention services. Letters will be mailed to families identified by the Arizona Birth Defects Registry and Social Security Administration-SSI to inform them about medical coverage and programs for which they might be eligible. A call log will track contacts to OCSHCN by telephone, email or website including barriers identified by families in gaining access to services and health insurance that will be shared with responsible agencies. OCSHCN will continue to 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 United Healthcare-Children's Foundation, to help families offset medical costs. Information and resources on KidsCare II will continue to be shared through contacts and distributed at outreach events. 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. OCSHCN will translate flyers and outreach materials for DB 101 and incorporate them into all our trainings and outreach. 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 2007 75 86.5 2012 89.1 2008 87 86.5 2009 87 86.5 2010 86 86.5 2011 89.1 59.7 SLAITS SLAITS SLAITS SLAITS 2013 89.1 2014 89.1 Final 2015 89.1 Final 2016 89.1 60 Notes - 2011 For 2011-2014, indicator data come from the National Survey of Children with Special Health Care Needs (CSHCN), conducted by the U.S. Health Resources and Services Administration and the U.S. Centers for Disease Control and Prevention in 2009-2010. Compared to the 2001 CSHCN survey, there were revisions to the wording, order, and number of questions used to generate this indicator for the 2005-06 CSHCN survey. The questions were also revised extensively for the 2009-2010 CSHCN survey. Therefore, none of the three rounds of the surveys are comparable. All estimates from the National Survey of CSHCN are subject to sampling variability, as well as survey design flaws, respondent classification and reporting errors, and data processing mistakes. 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. a. Last Year's Accomplishments OCSHCN staff responded to over 250 family contacts 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. 1,149 letters were mailed 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 coordinated through a contract with Raising Special Kids that provided familycentered care training to 93 medical, dental and nursing students and coordinated 78 resident-intraining home visits with 58 Family Faculty (host families) and 58 CYSHCN focused on the dayto-day life issues related to children and youth with special health care needs (CYSHCN). Staff trained 524 school nurses, who served over 36,000 CYSHCN, on supporting students with SHCN so that they can stay in school and participate in the least restrictive and most inclusive school environment. Training focused on strategies for communicating with physicians, school IEP teams, child-serving agencies, families, and their role in helping students become their own advocates until their CYSHCN can begin to advocate on their own. OCSHCN trained school nurses from Arizona's School Nurse Consortium, School Nurses Association of Arizona and Developmental Disabilities Nurses Association on how to assist and support families in navigating the 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. OCSHCN funded Ronald McDonald House (RMH) Charities of Phoenix that enabled out-of-town families residing in Apache, Coconino, Mohave, Navajo and Yuma Counties to stay near their hospitalized CYSHCN receiving needed treatment or surgeries. OCSHCN's partnership with RMH Phoenix provided 183 visits for an average stay of 8 days. OCSHCN supported 23 children, over 16% of all care hours provided at Ryan House. This equates to 80 overnight stays that were from 24-48 hours each, totaling approximately 3,880 total care hours. 61 The Arizona Telemedicine Program made specialty services available to 247 unique Yuma APIPA-CRS members. Specialty clinics included pediatric orthopedics, neurology and neurosurgery. Assessing effectiveness of telemedicine services was accomplished through individual evaluations completed by families and telemedicine service providers. Of the two hundred and eleven (211) responses, families traveled an average 12.05 miles to the telemedicine event. Had those same families traveled to a face-to-face visit, the average travel distance would have increased to 250.43 miles. Families reported saving an average of eight (8) work hours by attending the telemedicine event instead of an in-person visit. One hundred and seventy seven (177) or 94.15% reported they would use telemedicine again. OCSHCN incorporated family participation into the Home Visiting Task Force and stakeholders' meetings throughout Arizona. As a member of the Arizona Early Intervention ProgramInteragency Coordinating Council for Infants and Toddlers, OCSHCN has been a partner in the development and implementation of the team based family model with respect to importance of coordination of care and has 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 staff and families partnered with AHCCCS on beta testing Arizona's Disability Benefits 101, new online tool available to assist individuals receiving federal and/or state assistance to assess the effect of various work/school scenarios on benefits, particularly healthcare. OCSHCN converted its training on navigating Arizona's system of care into an online interactive class hosted on the OCSHCN website. Given the changing enrollment and eligibility requirements caused by budget cuts, the training directs users to the respective websites for most current information available. 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 represents ADHS on the AzEIP-ICC, and keeps them informed on changing aspects of the system of care for CSHCN. 3. 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. 4. OCSHCN funds the Arizona Telemedicine Program membership fees. 5. OCSHCN funds the Ryan House to provide respite and pediatric palliative care in a home-like setting for CYSHCN and their families. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X X 62 b. Current Activities OCSHCN works closely with UnitedHealthcare (UHC) Community Plans who serve 44% of Arizona's special needs population of approximately 680,000 members. Of these, approximately 25,000 CYSHCN are enrolled in APIPA-CRS. OCSHCN participates at community and outreach events sharing information about how OCSHCN and APIPA-CRS continue to work together to support families in decision-making, transition to adulthood, navigating the system of care and medical home. OCSHCN funds Ronald McDonald House Charities of Southern Arizona that enables out-of-town families to stay near their hospitalized CYSHCN receiving needed treatment or surgeries. OCSHCN partners on ADHS' new Population Health Policy Intergovernmental agreements (IGA) with Health Departments with a focus on inclusion of CYSHCN. IGAs are designed to impact policy, system, and environmental change in Arizona counties at the community, organizational, and individual level. OCSHCN is partnering with ADHS' Bureau of Emergency Preparedness, Arizona's Developmental Disabilities Planning Council, Statewide Independent Living Council, and Department of Economic Security to develop emergency preparedness tools for families of CYSHCN. OCSHCN, Southwest Human Development, Raising Special Kids, and Arizona's Early Intervention Program (AzEIP) partner on Smooth Way Home, an initiative to develop and produce a Neonatal Intensive Care Unit Manual to assist families, in navigating and accessing timely early intervention services. c. Plan for the Coming Year OCSHCN will continue to work closely with UnitedHealthcare (UHC) Community Plans at trainings, community and outreach events with information about how OCSHCN and APIPA-CRS continue to work together to support families in decision-making, transition to adulthood, navigating the system of care and medical home. OCSHCN will continue to fund Ronald McDonald House Charities of Phoenix and Southern Arizona to enable out-of-town families to stay near their hospitalized CYSHCN and Ryan House to provide inpatient respite and pediatric palliative care in a home-like setting. OCSHCN will continue to partner on ADHS' new Population Health Policy Intergovernmental agreements (IGA) with County Health Departments with a focus on inclusion of CYSHCN. IGAs are designed to impact policy, system, and environmental change in Arizona counties at the community, organizational, and individual level, as well as Bureau of Emergency Preparedness, Arizona's Developmental Disabilities Planning Council, Statewide Independent Living Council, and Department of Economic Security to develop emergency preparedness tools for families of CYSHCN. 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. OCSHCN will continue to train medical and dental students on family centered care practices and promote family home visits. Training will focus on strategies for communicating with physicians, school IEP teams, school nurses, child serving agencies, and families, and nurses' roles in helping students become self-advocates, and supporting families in navigating the changing 63 systems of care. OCSHCN will continue to educate its partners on the benefits of using telehealth videoconferencing capabilities for training. OCSHCN will collaborate with partners to ensure that the needs of CYSHCN and barriers to their participation are understood and addressed. OCSHCN will explore contracting with community based providers to increase the participation of CYSHCN in wellness programs through a new RFP, Health Advocacy for Children, Youth and Families. 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 2007 6 39.4 2012 41.2 2008 39 39.4 2009 40 39.4 2010 39 39.4 2011 41.2 35.6 SLAITS SLAITS SLAITS SLAITS 2013 41.2 2014 41.2 Final 2015 41.2 Final 2016 41.2 Notes - 2011 For 2011-2014, indicator data come from the National Survey of Children with Special Health Care Needs (CSHCN), conducted by the U.S. Health Resources and Services Administration and the U.S. Centers for Disease Control and Prevention in 2009-2010. Compared to the 2001 CSHCN survey, there were wording changes, skip pattern revisions, and additions to the questions used to generate this indicator for the 2005-06 CSHCN survey. There were also issues around the reliability of the 2001 data because of the sample size. The data for the 2 surveys are not comparable for NPM 6, and findings from the 2005-06 survey may be considered baseline data. However, the same questions were used to generate the NPM 6 indicator for the 20092010 survey. Therefore, the 2005-2006 and 2009-2010 surveys can be compared. All estimates from the National Survey of CSHCN are subject to sampling variability, as well as survey design flaws, respondent classification and reporting errors, and data processing mistakes. 64 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 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. a. Last Year's Accomplishments OCSHCN participated as an Arizona Community of Practice on Transition (AzCoPT) member. AzCoPT is a partnership of state agencies, families and YSHCN 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 young adults, families and representation from Arizona Departments of Education, Economic Security- Division of Developmental Disabilities, Health Services (Division of Behavioral Health Services and Office for Children with Special Health Care Needs) and the Navajo Office of Special Education and Rehabilitation Services Administration-Vocational Rehabilitation Program. AzCoPT provided guidance to parents, students, educators and state agency staff working with transitioning youth. Transition resources were provided at community fairs and conferences. AzCoPT presented a session on state agency processes and collaboration at Arizona's Eleventh Annual Transition Conference, "Imagine It, Plan It, Do It". OCSHCN funded scholarships for 66 youth/young adults with SHCN and their families to cover the cost of registration and lodging costs. OCSHCN worked with a Youth Leader with South West Institute and funded resource packets for the Youth Strand. OCSHCN participated as a informational vendor and distributed information and resources to over 200 families, educators, agency staff and young adults. The Building Partnerships for Quality Care (BPQC) contractors recruited, trained and compensated 3 youth to partner in ADHS specific activities including review of materials, website and to partner with staff during outreach events such as transition or health fairs. 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 partnered with Arizona's Developmental Disabilities Planning council to co-facilitate a presentation, "Similar Dreams, Different Approaches" through the Governor's Office on Equal Opportunity for 50 state agency staff including ADA Coordinators and Human Resource Specialists. The presentation included a family member who was also a community employer and highlighted disability awareness, employment opportunities and supports. OCSHCN participated at the Arizona Secondary Transition Mentoring Project (STMP) Conference and presented on health transition to approximately 70 special education teachers, administrators, sped administrators, and school psychologist. OCSHCN shared information and transition resources at the Arizona's Children's Executive Committee meeting and 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 of Arizona, APIPA-CRS, Division of Developmental Disabilities, health plans, families and providers. 65 Over 520 school nurses with the Arizona's School Nurse Consortium and School Nurses Association of Arizona conferences and the Developmental Disabilities Nurses Association 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 possible and that CYSHCN are prepared to direct their own healthcare as adults. Health care is stressed as an important aspect of selfdetermination. OCSHCN's Youth Advisor, Peter Graf, was instrumental in engaging young adults with SHCN from a community-based program to partner in the development of the House Bill 2103, Home Baked Goods & Confectionaries training video. The video which was posted on the ADHS website highlights employment opportunities for families of CYSHCN, youth and adults with developmental disabilities. OCSHCN staff, families and YSHCN partnered with AHCCCS on beta testing Arizona's Disability Benefits 101, new online tool available to assist individuals receiving federal and/or state assistance to assess the effect of various work/school scenarios on benefits, particularly healthcare. Table 4a, National Performance Measures Summary Sheet Activities 1. OCSHCN staff, families and YSHCN partnered with AHCCCS on beta testing Arizona’s Disability Benefits 101, new online tool available to assist individuals receiving federal and/or state assistance to assess the effect of various work/school scenarios 2. 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. 3. OCSHCN offers transition resources and training to other ADHS programs and state agencies, including AHCCCS programs. 4. OCSHCN is a member of the AzCoPT team and offers training to inform students, parents, educators, and others about state agency processes. 5. Health care is stressed as an important aspect of selfdetermination. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X X b. Current Activities AzCoPT provides guidance to families, students, educators and state agency staff working with transitioning youth. The AzCoPT is currently supporting the development of local transition teams that have identified themselves as ready to bring the community or school together around the issues of transition to adulthood Tucson, Flagstaff and Window Rock. OCSHCN partners with the Governor's Council on Spinal and Head Injuries on Arizona's TBI 66 Transitions Project providing best practice information on transition for CYSHCN. At the Navigating the SEAS of Transition, a conference for parents of youth with TBI, OCSHCN cofacilitated two sessions with emphasis on what parents need to know, how to be prepared to work effectively with the community-based agencies that can provide support to youth and families and understanding the rights transferred at age 18, options available when youth need additional assistance and support, and how and when to choose the appropriate options. OCSHCN is partnering with the Arizona Department of Education (ADE) on the planning committee for Arizona's Twelfth Annual Transition Conference, Facing the Future: Who's in Your Network? OCSHCN is using BPQC contract to compensate a Youth Advisor for their time and expertise as a co-trainer at the annual conference. OCSHCN is providing funding to ADE for scholarships to support the participation of up to 50 YSHCN, their families and attendant providers to cover the cost of registration and lodging costs. c. Plan for the Coming Year OCSHCN will continue to work closely with and support family and youth involvement within all lines of business including APIPA-CRS at UnitedHealthcare (UHC) Community Plans. UHC serves approximately 680,000 members with special needs, 44% of the state's special needs population including APIPA-CRS that serves approximately 25,000 CYSHCN. OCSHCN will participate in quarterly community networking partners' meetings hosted by UHC at the Disability Empowerment Center. The BPQC will continue to be used to recruit, train and compensate YSHCN to partner on ADHS specific activities as co-trainers, reviewers of materials, website and to partner with staff during outreach events such as transition or health fairs. OCSHCN will also work with other ADHS programs including the Division of Behavioral Health Services to develop and issue a new request for proposal to provide leadership development to YSHCN and their families as ADHS' BPQC contract is due to expire in 2014. OCSHCN will continue to identify and target youth centered community groups for outreach and policy program focused input in lieu of developing its own youth council. OCSHCN will continue to involve families, consumers and YSHCN in the development and review of curriculum and online training including the DB 101, a new online tool available to assist individuals receiving federal and/or state assistance to assess the effect of various work/school scenarios on benefits, particularly healthcare. OCSHCN will continue to expand representation of families and include youth to serve on the Arizona Leadership Education in Neurodevelopmental Disabilities (LEND) Advisory Group. OCSHCN will continue to serve as a member of AzCoPT and provide guidance to families, students, educators and state agency staff working with transitioning youth as well as continue supporting the development of local transition teams. OCSHCN will continue to provide funding to ADE for scholarships to support the participation of YSHCN, their families and attendant providers to cover the cost of registration and lodging costs. OCSHCN will explore the potential of partnering with ADHS' Bureau of Emergency Preparedness, Arizona's Developmental Disabilities Planning Council, Statewide Independent Living Council, and Department of Economic Security on developing emergency preparedness resources and tools for families of CYSHCN. Participation will be expanded to include families and YSHCN. OCSHCN will continue to provide education, trainings, technical assistance and resources on best practices for CYSHCN to 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 CYSHCN, pediatric to adult transition and navigating the system of 67 care. 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 2007 2008 2009 2010 2011 79.5 80 80 80 80 76.2 76.7 76 71.9 77.5 National Immunization Survey National Immunization Survey National Immunization Survey National Immunization Survey Final Final 2015 80 2016 80 Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2012 80 2013 80 2014 80 Notes - 2011 The confidence interval is + or - 5.8%. Estimates for 2010 are not recommended for comparison to years prior to 2009 because of the changes made in the way the Hib vaccine is now measured and the vaccine shortage that affected a large percent of children that were included in the 2009 and 2010 samples. The estimates are not directly comparable since they do not consider the brand type where some children may be counted as up to date with 3 doses but may require 4 doses to be up to date. 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 68 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 a. Last Year's Accomplishments The Bureau of Women's and Children's Health continued to provide Title V funds to support The Arizona Partnership for Immunizations (TAPI). TAPI's mission is to foster a comprehensive, sustained community program for the immunization of Arizonans against vaccine preventable disease, and achieves this through partnering in the community through standing working committees on Health Policy, Community Education and Provider Education. Examples of how TAPI impacted the immunization rates in Arizona are as follows: The TAPI home web page, www.whyimmunize.org which allowed parents to ask medical experts questions about vaccines and immunizations and find vaccines was kept updated to reflect the needs of the community and provider education page. Information was added to educate the community about a recent rise in the number of pertussis cases and prevention techniques. A child care page was added to provide resources for childcare centers about maintaining a healthy child care setting for children 0 to 5. In addition an employer page was added and partnerships were developed to better educate Arizona workforce about the important of providing immunization coverage for children's in health insurance and to provide information about maintaining a healthy work force. The website links to partner organizations web sites. TAPI's website, Facebook and twitter accounts are used for better outreach to partners and parents. English and Spanish parent education print flyers, "Is Your Child Protected?" and vaccine safety concern flyers were distributed. Additional materials updated and distributed in 2011 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 6) placemats for senior centers about vaccine for grandkids and across the lifespan. Over 75,000 educational pieces were distributed to schools, child care facilities, private providers, county health departments, community health centers, managed care organizations, hospitals, service organizations and WIC sites in 2011. 69 TAPI conducted eight regional immunization programs with the Vaccines for Children Program and the Arizona State Immunization Information System for providers statewide. 350 individuals from provider offices and health departments participated in the trainings. TAPI also partnered with ADHS/AIPO to educate healthcare providers on immunization educational tools at 10 professional conferences. In addition TAPI partnered with fire departments, county health and ADHS to train 500 participants from private offices, mass immunizers and fire departments about immunization delivery and community outreach for mass clinics during outbreaks and high volume seasons. 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. TAPI with ADHS and ASU, promoted a web based training program for provider offices on common immunization questions and best practices for outstanding immunization delivery. TAPI developed a curriculum for pediatric offices that have fallen below the national average for immunization coverage of their patient population. TAPI partnered with Medicaid plans to educate staff on best practices in immunizations and worked with 3 under performing provider offices to improve rates. TAPI also worked with two new offices to develop an immunization delivery system in their offices to provide vaccines for children. The Health Start Program educated pregnant and postpartum women about immunizations. The topic of immunizations was the second highest post-partum topic at family follow-up visits. Referrals are made to immunization clinics and social and behavioral health programs as needed. Approximately 93.3% of Health Start children were fully immunized and 6.7% were not fully immunized. The High Risk Perinatal Program (HRPP) Community Health Nurses and Project LAUNCH parent educators monitored the immunization status of the children enrolled in their program and continued to promote and facilitate immunizations. 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. Home Visiting programs monitor the immunization status of enrolled infants. 5. Bureau of Nutrition & Physical Activity coordinates statewide immunization record screening and referral by WIC staff to ensure proper timing of shots in WIC children. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X b. Current Activities 70 TAPI is continuing to print and distribute immunization materials to public and private providers throughout the state, and updating website, social media messages and print materials to keep current with established immunization recommendations and practices. TAPI is planning and conducting at least nine immunization workshops for staff of public and private clinics, medical offices, medics, schools and other VFC enrolled sites. TAPI is continuing educational programs for childcare centers on the importance of immunizations. TAPI is meeting with managed care plans to promote and institute methods to ensure local health departments are reimbursed vaccine administration costs for privately insured children. TAPI is working with immunization service providers to ensure immunization services are available in underserved areas. TAPI is developing educational materials for new parents and grandparents 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, HRPP Community Health Nurses and Project LAUNCH home visitors continue to monitor the immunization status of the children enrolled in their programs. The 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 plan and conduct at least nine 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 privately insured children. TAPI will work with immunization service providers to ensure immunization services are available in underserved areas ("pockets of need") - areas/locations identified where children lack access to immunization services. TAPI will continue to assist fire departments in developing new clinics in underserved areas, and develop materials for new parents in hospitals and childcare centers. TAPI will enlist the help of older adult organizations to help advocate for a healthy community by immunizing babies, teens, young adults and seniors to stop the spread of disease to our most vulnerable populations. Health Start Program will keep abrest of the most current immunization requirements and distribute to all contractors. A new immunization checklist will be required as part of the child's information in the client chart. The 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 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. Project LAUNCH parent educators will continue to confirm that children receive medical care and immunizations. The Bureau of Women's & Children's Health will work with TAPI and ADHS Immunization Program to help disseminate educational materials for new parents on the importance of adult pertussis vaccines in protecting babies. The Office for Children with Special Health Care Needs will work with TAPI and the ADHS Immunization Program on disseminating educational materials that are specific to children with special health care needs. The Bureau of Nutrition & Physical Activity will continue to train WIC staff to screen and refer WIC participants to receive the proper timing of the DtaP shots. The Office of Immunizations will continue to provide screening and referral training to WIC staff. A BWCH representative will continue to discuss the need for new mothers, fathers, grandparents 71 as well as hospital staff to be vaccinated for pertussis during Arizona Perinatal Trust site visits. 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 2007 2008 2009 2010 2011 34 33 32 23.5 23 32.3 4361 134897 30.3 4151 137022 AZ Birth Certificates 25.3 3501 138280 AZ Birth Certificates 22.1 2910 131854 AZ Birth Certificates 18.4 2447 132814 AZ Birth Certificates Final Final 2015 16.5 2016 15 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 2012 18 2013 17.5 2014 16 Notes - 2010 The 2010 estimate is provisional until the 2010 Census releases total counts of 15-17 year old females in Arizona. a. Last Year's Accomplishments In 2011, the Bureau of Women's and Children's Health Teen Pregnancy Prevention Program (TPP) 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 five other tribes (Tohono O'odham San Lucy District, Fort McDowell, Hopi, White Mountain Apache, and Pascua Yaqui) were funded through a contract with the Inter-Tribal Council of Arizona. A total of 10,915 youth and 162 parents received services in 2011. 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. 72 Seven abstinence programs provided services with funding from Arizona lottery dollars. Projects focused on youth development/service learning and peer leadership as well as classroom instruction. From July 2010 through June 2011, 17,537 young people and 651 parents received services. In 2011, the Patient Protection and Affordable Care Act authorized funding for a comprehensive sex education initiative, the Personal Responsibility Program (PREP) and renewed funding for the Title V State Abstinence Program. Arizona's award was approximately $1 million for PREP and $1.2 million for Abstinence. Table 4a, National Performance Measures Summary Sheet Activities 1. Many TPP funded programs implement youth development/service learning focus and/or provide parent education related to talking with their teens about responsible sexual health and risk factors. 2. The Teen Pregnancy Prevention Program provides technical assistance to providers of teen pregnancy prevention services. 3. Programs reach high risk youth by developing successful partnerships with county juvenile probation offices in order to encourage participation among youth on probation. 4. Title V Teen Pregnancy Prevention Program contracts were awarded to community-based organizations. 5. The Teen Pregnancy Prevention Program provides abstinence education programming. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X b. Current Activities Arizona received approximately $1 million for comprehensive sex education initiative, the Personal Responsibility Program (PREP) and received $1.2 million for Abstinence renewed funding for the Title V State Abstinence Program. Eight PREP contracts were awarded to community-based organizations in high risk communities. To-date, 270 youth have received services. Four Title V contracts were awarded to community-based organizations. Grantees deliver programming to youth 12-18 years of age with an emphasis on African American, Hispanic, and American Indian youth residing in underserved or unserved geographic areas. To date, 7,006 youth and 76 parents have received services. ADHS became a Wyman Teen Outreach Program(r) (TOP) Replication Partner and trained two program staff as Certified Trainers of Trainers for the program. The program has certified 36 facilitators in TOP(r) and will certify another 30 facilitators. Arizona will also have over 20 TOP(r) Clubs implementing the curriculum across the state. The Program continues to use lottery dollars to fund 13 county health department projects and six tribal projects and seven abstinence programs. The TPP is working with Office for Children with Special Health Care Needs to address sexual health issues among this population. Two curricula, TOP(r) and Choosing the Best were selected as the most appropriate for the population and a 73 curricula supplement is being developed. 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 serve as match for the federal Abstinence Education Program. Federal dollars made available through health care reform will continue to fund the Title V Abstinence Education Program as well as the new Personal Responsibility Education Program (PREP). The Teen Pregnancy Prevention Program will continue to work with Office for Children with Special Health Care Needs to revise the TOP(r) and Choosing the Best teaching supplement curricula as needed. The program recently awarded a comprehensive teen pregnancy prevention contract to provide services to youth in the Adobe Mountain and Black Canyon Juvenile Detention facilities. Services will begin in June 2012. Close contract monitoring and technical assistance will continue to be provided by program managers to ensure programs are being implemented with fidelity. ADHS continues to coordinate with all federally funded Tier I and II agencies to best maximize our funding. The ACA Maternal, Infant and Early Childhood Home Visiting programs that are being implemented in Arizona: Nurse Family Partnership and Healthy Families will discuss family planning or birth spacing as a part of the home visits. 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 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? 2007 2008 2009 2010 2011 36.5 36.2 36.5 36.2 36.5 47.1 47.1 47.1 47.1 47.1 AZ Office of Oral Health survey AZ Office of Oral Health survey AZ Office of Oral Health AZ Office of Oral Health Final Final 74 Annual Performance Objective 2012 47.1 2013 47.1 2014 47.1 2015 47.1 2016 47.1 Notes - 2011 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 - 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. a. Last Year's Accomplishments During the 2010-2011 school year, the Arizona School-based Sealant Program provided dental screenings and referrals to 8,710 children attending eligible public schools. In addition, 5,020 children received 17,038 dental sealants. One rural county has had difficulties locating a dentist to participate in program activities due to lack of dental providers in the county. Lack of dental providers in rural areas is a barrier to expansion of the program 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 that at least 65% of the children are eligible for 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 has seen a plateau and there is evidence that there has been a decrease in the number of children served by the sealant program. This may be attributed to several factors including the increasing presence of "for profit" dental vans, and the reluctance of parents/guardians to sign consent forms. The Office of Oral Health completed a statewide oral health, BMI and asthma survey of over 3,100 third grade children in 2010, the Healthy Smiles Healthy Bodies Survey 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, 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 75 Surveillance System: http://www.cdc.gov/nohss/. Table 4a, National Performance Measures Summary Sheet Activities 1. Office of Oral Health contracts with local providers to provide dental sealants to high-risk children. 2. Office of Oral Health collaborates with key stakeholders to expand services. 3. The Office of Oral Health completed a statewide oral health, BMI and asthma survey called Healthy Smiles Healthy Bodies Survey and has begun sharing findings with partners. 4. New teledentistry sites being established through a HRSA workforce grant have expanded services throughout the state. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X b. Current Activities The Office of Oral Health continues to provide a school-based sealant program in five Arizona counties. In addition to collaborating with county health departments, the OOH is partnering with AT Still, School of Dentistry and Oral Health to implement a sealant program in underserved schools. This program is designed to provide sealant and referral services utilizing affiliated practice dental hygienists, dental faculty and dental students. Two schools are currently participating and an additional two are proposed for the next school year. New teledentistry sites being established through a HRSA workforce 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 Office of Oral Health will maintain Intergovernmental Agreements with counties, dental and dental hygiene schools to provide school-based dental screenings, referrals and sealants to children in lowincome schools. The focus will continue to be 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 will continue to seek to increase expansion in some of the most rural counties in Arizona by partnering with local community health centers. This partnership has the potential to reach children in many small; rural communities. 76 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 2012-2013 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. Teledentistry demonstration practice models working in sealant programs will continue to develop protocols to connect children with acute dental needs to dental providers. These models will document strategies and share lessons learned with other school-based sealant programs. The Office for Children with Special Health Care Needs will continue to 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. 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 2007 2008 2009 2010 2011 4 4 3.8 3.5 2.5 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 2.5 34 1368206 AZ Death Certificate Final Final 2015 2.4 2016 2.3 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 2012 2.4 2013 2.4 2014 2.4 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. 77 a. Last Year's Accomplishments The rate of motor vehicle fatalities in 2010 was 3.6 deaths per 100,000 children, a decline of 57 percent over six years from 8.4 deaths per 100,000 children in 2005. Motor vehicle crashes claimed 61 children's lives in 2010. There were zero deaths resulting from in utero injuries, allterrain vehicles, or dirt bikes. Eighty-nine percent of motor vehicle-related deaths were determined to have been preventable (n=54). Lack of vehicle restraints was identified as a preventable factor for 34 percent of motor vehicle crash fatalities (n=20). The Title V County Health and Prevention contracts began with two new goals. One of those goals is to reduce the rate of injuries, both intentional and unintentional. These contracts must use the Spectrum of Prevention. Their injury prevention activities included community education, building coalitions, changing organizational practices, and developing policies. Five out of six counties provided car seats and education on installation of car seats. They provided car seat technician training, certification and recertification. Yavapai County Health Department provided Safe Dates curriculum to approximately 500 students. Yavapai County Health Department conducted Teen Mazes including interactive information on motor vehicle crashes, driving under the influence of substance, and bullying. Both Coconino County and Gila County Health Departments distributed thumb rings with the message of "text it later". Navajo County Health Department began providing information on suicide prevention in High Schools. Gila County participated on a Suicide Prevention Coalition conducted by San Carlos Apache Tribe. Through Title V funding, the Health Start Program received and distributed to 13 contractors, 185 infant seats, 650 car seats and 260 backless boosters to Health Start clients and their families. Education and training was provided to over 800 clients and families regarding car seat safety and proper installation. 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, updating the Ride Safe Curriculum and offered a CEU training on using car seats for Arizona's Child Passenger Safety Technicians. The Injury Prevention Program also collaborated on a Road Safety Audit with Arizona Department of Transportation to improve pedestrian 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. 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. Title V funding enabled the Program to buy and distribute car seats and booster seats throughout the state to families. 4. Injury Prevention Program provides car seat safety technician training throughout the state including rural and tribal areas. 5. Title V funding suppported Teen Mazes in a rural county which included interactive information on motor vehicle crashes, driving under the influence of substance, and bullying. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X 78 b. Current Activities The Injury Prevention Program builds capacity for child passenger safety through providing certified training and continuing education for recertification. Courses are adding 40-50 more technicians throughout Arizona that will now have instructor support. With the recent signage of the booster seat law, the Office of Injury Prevention is focused on ensuring communities have information on booster seats. BWCH is using Title V funds to purchase booster seats for communities in need 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. The injury prevention activities of the Title V Prevention contracts included: education on car seats installation; car seat technician training, certification and recertification. Apache County Health Department developed a new Safe Kids Chapter. Yavapai County Health Department provided Safe Dates curriculum to approximately 500 students. Yavapai County Health Department conducted Teen Mazes including interactive information on motor vehicle crashes, driving under the influence of substance, and bullying. Navajo County Health Department began providing information on suicide prevention in High Schools. Gila County participated on a Suicide Prevention Coalition conducted by San Carlos Apache Tribe. 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 19th annual report will be produced in 2012 and will include information on the deaths that occurred in Arizona during 2011. 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) as well as monitoring the impact of the new booster seat law that goes into effect August 2, 2012. 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. MIECHV funded home visitors will provide car seat education to their families. The Injury Prevention Program will continue to build capacity in the state by training new car seat safety technicians. 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 2007 2008 2009 2010 2011 38 50 50 53 51 43.7 48.2 45.3 49.6 52 79 Numerator Denominator Data Source CDC National Immunization Survey CDC National Immunization Program 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 2012 53 2013 55 2014 57 CDC National Immunization Program CDC National Immunization Program Final Provisional 2015 60 2016 61 Notes - 2011 The CDC National Immunization Survey data for 2011 (2008 birth cohort) is provisional. The HP 2020 Goal is 60.6%. 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. a. Last Year's Accomplishments During FFY2011, the Arizona WIC program achieved a number of significant accomplishments. The Arizona WIC program had a rate of 65.0% for ‘ever breastfed' (CDC PedNSS 2010) and a target rate of 69.5%. The areas of outreach activities, training, and expanded access to services improved in FFY2011. Ninety seven WIC staff successfully completed the "Introduction to Breastfeeding" Learning Management System (LMS) class. This course is designed to provide a foundation for future breastfeeding education, as all staff members are required to complete a week-long breastfeeding course within six months of hire to satisfy employment probation requirements. One hundred fifty WIC staff from Arizona, American Samoa, CNMI, and Guam successfully completed "Breastfeeding Bootcamp." Breastfeeding Bootcamp is a 35-hour WIC-focused breastfeeding class developed by the ADHS Breastfeeding Coordinators. Upon completion, staff achieves the designation of "Local Agency Breastfeeding Authority" which enables them to conduct breastfeeding assessments, issue breast pumps, select food packages for breastfeeding 80 dyads, and other breastfeeding-related tasks. In October 2011, 27 Arizona WIC staff earned certification as new International Board Certified Lactation Consultants (IBCLCs). This raises the total number of Arizona WIC IBCLCs to 50. An additional six Local Agency staff members are taking the IBCLC exam this year. This effort is supported by eight exam review webinars conducted by State WIC staff. Arizona continued to offer professional education in breastfeeding at LATCH-AZ (LActation support To Collaborate for Health - AZ) meetings. Topics presented in FFY2011 included "BabyLed Breastfeeding," "Slow Weight Gain," "Pumps and Galactogogues," "How Mothers Think and Why It Matters," and "Medications and Mothers' Milk." The Arizona Breastfeeding Hotline continued to provide access to skilled lactation help 24 hours a day, seven days a week. The Bureau of Women's and Children's health continued to support two Hot Line lactation consultants who answer questions from 7:00 AM until 5:30 PM. Approximately 350 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. In 2011, one of the Hot Line Breastfeeding Consultants became ICBLC certified. The Arizona WIC Program continued to offer Peer Counselor Services in 12 of its Local Agencies, including Cochise County Department of Health, Coconino County Health Department, Gila County Health Department, Marana Health Center, Maricopa County Department of Public Health, Mariposa Community Health Center, Mohave County Health Department, Mountain Park Community Health Center, Pima County Health Department, Pinal County Health Department, Yavapai County Community Health Services, and Yuma County Health Services District. Each month, the program helps over 6,000 pregnant and breastfeeding women overcome their personal barriers to breastfeeding through the use of mother-to-mother support. A first statewide Breastfeeding Coordinator Meeting was held in April 2011. The meeting was mandatory for WIC Breastfeeding Coordinators and WIC Directors were also encouraged to attend. The agenda included a comprehensive review of Chapter 19, the breastfeeding chapter in the policy and procedure manual, networking, and the Loving Support Training (LST). As follow-up and to increase confidence using the LST platform, all participants were asked to train their WIC staff on at least one module of the LST within 60 days. ADHS continued to support breastfeeding by offering new mothers the opportunity to bring their infant to work for the first six months. For lactating women who do or do not wish to bring baby to work there is a dedicated room with two comfortable lounge chairs and a refrigerator where they can either feed baby, pump and/or store the breastmilk in privacy. BNPA will also be working with child care providers throughout the state in certifying centers and homes as Breastfeeding Friendly Child cares in alignment with the ADHS Empower program and the Let's Move Child Care initiative. Community Health Workers and Community Health Nurses continued to support breastfeeding in the home during home visits. Table 4a, National Performance Measures Summary Sheet Activities 1. Health Start Community Health Workers educate pregnant and postpartum women about breastfeeding. Pyramid Level of Service DHC ES PBS IB X 81 2. Baby Steps for Baby Friendly educates hospital staff on evidence based maternity care practices that support breastfeeding. 3. HRPP Community Health Nurses suport mothers of ill or premature babies to breastfeed. 4. Bilingual Certified Lactation Consultants answer the Pregnancy and Breastfeeding Hot Line during the business day. 5. A bilingual ICBLC answers the Pregnancy and Breastfeeding Hot Line after business hours and on weekends and holidays. 6. WIC conducts free lactation education and networking effects. 7. 8. 9. 10. X X X X X b. Current Activities The Hotline continues to be staffed by one bilingual Certified Lactation Consultant and one newly certified IBCLC. A registered nurse and advanced bilingual International Board Certified Lactation Consultant is available to answer all breastfeeding questions 24/7. Arizona Baby Steps to Breastfeeding Success training was completed with 3,000 nurses, physicians and WIC staff and is currently being converted to a Learning Management System (LMS) course for sustainability of the program. The course focuses on how changes in maternity care practices have a direct relationship on the initiation and duration of breastfeeding based on five of the ten Baby Friendly Hospital Initiative. The second statewide Breastfeeding Coordinator Meeting was held in April 2012. All home visitors continue to support breastfeeding in the home during home visits. BNPA continues to work with child care providers throughout the state. This fiscal year will conclude with a statewide breastfeeding summit as a collaborative effort the Bureaus of Women and Children's Health, Children with Special Health Care Needs and Nutrition and Physical Activity titled: The Woman behind the Breast: the Physical and Psychological Needs of the Breastfeeding Mother. The summit will also be the first of its kind in Arizona to focus on the emotional and physical needs of the breastfeeding mother with an inclusion of breastfeeding support for women with special healthcare needs. c. Plan for the Coming Year WIC will continue to offer the breast pump loan program through WIC local agencies statewide. Peer counseling services will be provided through selected local WIC agencies and all Peer Counselors will complete the revised Loving Support training. The Bureau of Nutrition and Physical Activity will continue to offer the 5-day Breastfeeding Bootcamp training to WIC agencies and breastfeeding community partners. BNPA will also continue to work with child care providers throughout the state in certifying centers and homes as Breastfeeding Friendly Child cares in alignment with the ADHS Empower program and the Let's Move Child Care initiative. The Hotline will continue to be staffed by one bilingual Certified Lactation Consultant and one newly certified International Board Certified Lactation Consultant (IBCLC) who will answer calls regarding breastfeeding during the workday in addition to the 24 hour availability of a bilingual ICBLC. 82 ADHS will continue to support breastfeeding by offering new mothers the opportunity to bring their infant to work for the first six months. For lactating women who do not wish to bring baby to work there is a dedicated room with two comfortable lounge chairs and privacy where they can pump and store the breastmilk. The Maternal, Infant and Early Childhood Home Visiting grant will fund a statewide professional development conference. A Breastfeeding workshop will be one of the available sessions. Health Start Community Health Workers and HRPP Community Health Nurses will continue to support breastfeeding in the home during home visits. The Maternal, Infant and Early Childhood Home Visiting visitors will also support new mothers in their desire to breastfeed. In an effort to educate all early childhood home visitors about the importance of breastfeeding as well as techniques, the Maternal, Infant and Early Childhood Home Visiting program will support a FTE in the Bureau of Nutrition and Physical Activity to develop breastfeeding trainings that can be utilized through the LMS platform. The proposed new Coordinator position will develop trainings for the Home Visiting program and related stakeholders, support the Hotline high risk breastfeeding calls, and provide ongoing technical assistance to hospitals, AzAAP, ArMA, APT, etc on all things breastfeeding support related. Performance Measure 12: Percentage of newborns who have been screened for hearing before hospital discharge. Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source 2007 2008 2009 2010 2011 97 97 98 100 100 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 97.4 84335 86599 AZ Early Hearing Detection and Intervention Progra Final Final 2015 2016 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? 2012 2013 2014 83 Annual Performance Objective 100 100 100 100 100 a. Last Year's Accomplishments Almost 98 % (97.8 %) of babies born in Arizona in 2011 received a hearing screen prior to discharge. All 47 birthing 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. The Newborn Hearing Screening Program continued to utilize the hospital scorecard which evaluates numbers of infants screened before discharge, pass and refer rates, outpatient return rates, refusals rates and completeness of demographic data on the mother. Outcomes include an overall improvement from 71.6% to 90.42% compliance with the quality indicators. OCSHCN and AzEHDI provided online training for 112 hospital-based hearing screeners. Arizona continued to use a video and public service announcements in English and Spanish to encourage parents to obtain the follow-up needed after an initial failed newborn hearing screen. More than 200 copies of the video were distributed throughout Arizona in 2011. Arizona Hands & Voices, Guide By Your Side (GBYS) visited four birthing hospitals in western AZ and two in northeastern AZ. Bilingual brochures describing GBYS Follow Through services for families were distributed at participating hospitals. The type of services offered varies by hospital and may include: Immediate follow-up with families whose infants fail the initial screen (parent can choose to opt out of being contacted); Follow up with families when infant is a "No Show" at an outpatient screen or diagnostic evaluation; Follow up with families after a failed outpatient screen; Interaction with guides only after the outsourced screening program has made multiple attempts to have a family return for further screening;Guide onsite at the screening hospital; Guide interaction only through phone and fax. A newsletter was launched in 2011 to educate and communicate with all of Arizona's healthcare providers and explain the relevance of EHDI's 1-3-6 goals for their practice. The newsletter provides tips to reduce the loss to follow up rate, resources for healthcare providers, and success stories from hospital screening programs and is widely distributed on the website and through local listserves. A pocket guide on infant hearing for healthcare providers was developed. The pocket guide is a comprehensive roadmap helping healthcare providers meet the goals of completing hearing screening by one month of age, diagnostic testing by three months of age and enrollment in early intervention services before six months of age. More than 11,000 pocket guides were distributed to Early Hearing Detection and Intervention (EHDI) partners: primary care providers, nurses, midwives, audiologists, early intervention programs, etc. In the past year the follow-up coordinator has been able to accomplish the following: Worked with GBYS to implement program at six hospitals; Established liaisons with discharge coordinators/case managers to track high-risk infants; Initiated follow-up with providers and parents of high-risk infants who failed the hearing screening to ensure appropriate follow-up; Updated brochures and resource lists provided to families at the time of screening (in English and Spanish); The parent hearing screening brochure was updated to include Joint Committee on Infant hearing (JCIH) best practice recommendations and to improve user friendliness ;Worked with EAR Foundation of Arizona (EFAZ), and GBYS to educate audiologists and encourage parents to schedule follow up appointments. In 2011, NBS completed the CDC Data Survey for screening year 2010. Broken down into three data sections -- screening, diagnosis and early intervention -- the strongest indicators of improvement were in the area of inpatient and outpatient screening. Of those documented as screened, an impressive 98% of babies received a screen within 30 days. However, a system 84 breakdown occurred between screening and diagnosis for infants who either failed an initial screen or had risk factors associated with hearing loss. There were approximately 600 infants lost to follow up (LTFU) between screening and diagnosis in 2009, and 389 in 2010; although incomplete, 2011 data suggests only a slight improvement in LTFU as many babies have no documented diagnosis and only 18% of those receiving a diagnosis did so within the three month milestone. Table 4a, National Performance Measures Summary Sheet Activities 1. Newborn Screening Program provides on-site technical assistance and training for hearing screening. 2. OCSHCN continues to support the online training of hospitalbased hearing screeners using the updated NCHAM Early Hearing Screening Training Curriculum that incorporates assessment tools and strategies for communicating screenings to parents. for he 3. OCSHCN directs families who lack services or coverage to healthcare, resources and family support. 4. NBS implemented the Fax Back Form to primary care physicians (PCP) to facilitate reporting. 5. The hearing screening database, Hi*Track, has been upgraded to a centralized platform. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X b. Current Activities This year NBS implemented the Fax Back Form to primary care physicians (PCP). Letters are no longer sent to PCPs; instead a fax back form is faxed to the PCP asking for hearing results and/or additional information as to where and when further testing will take place. The response rate is impressive. ADHS maintains 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 and especially those who are considered at greater risk. The hearing screening database, Hi*Track, has been upgraded to a centralized platform. All birthing hospitals now have direct, real time, secure access to upload screening results and demographic information on their patients and can view and edit notes from our case management team. Expanding public-private partnerships has enabled the program to increase visibility of the key messages related to hearing screening. The AAP, APT, Arizona Commission for the Deaf and Hard of Hearing and Hands & Voices each play an important role in reaching families and providers. OCSHCN continues to support the online training of hospital-based hearing screeners using the updated NCHAM Early Hearing Screening Training Curriculum that incorporates assessment tools and strategies for communicating screenings to parents. OCSHCN works with hospitals, 85 AzEHDI program, and providers to establish a telemedicine connection for hearing screening follow-up. 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 years old who are lost to follow up. This will be accomplished through our data integration efforts and parent outreach efforts and surveys to ensure that families have family centered 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. Effort will also be put into improving turnaround times for diagnostic evaluation and better reporting of hearing testing from audiologists. The NBS hearing screening program will explore the implementation of performance report cards for audiologists and other measures that will reduce cases lost to documentation. This will be implemented later this year and continue into 2013. As part of the data integration project funded by the CDC, new data systems will also be integrated. In partnership with the Arizona School for the Deaf and Blind, an Intergovernmental Agreement (IGA) is being written which will allow both entities shared access to patient information thereby reducing loss to documentation and improving follow-up for babies identified with hearing loss. A technical review is currently under way of the bloodspot and hearing screening databases to determine their potential to be included in a data exchange. Currently, the bloodspot database contains comprehensive information on providers and nursery levels, two key data elements not yet reliably found in the hearing database. Education and outreach in 2013 will include a focus on site visits to audiology offices and pediatric practices providing hearing screening services to families to ensure best practice standards are maintained, data is submitted and outcomes are monitored. The Sensory Program will continue to utilize Title V funding to train hearing and vision screening trainers, disseminate newsletters to all known schools, and continue to provide technical assistance to school health nurses. Community Health nurses and Health Start workers will review hearing screening results with parents. OCSHCN with NBS will continue to collaborate to ensure follow-up for children, beyond the newborn period, identified through screening sites participating in the T3 OAE programs. OCSHCN will continue to support the online training of hospital-based hearing screeners using the updated National Center for Hearing Assessment and Management Early Hearing Screening Training Curriculum. OCSHCN will continue to leverage the use of LMS to track and generate reports to AzEHDI partners for dissemination to hospital administrators. OCSHCN will explore the potential of using this online training as a professional development opportunity for Arizona home visitors. Performance Measure 13: Percent of children without health insurance. Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] 86 Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source 2007 16.5 17 2008 16.3 13.8 2009 16 16 2010 15.8 13.4 2011 13.1 15 US Census US Census U.S. Census U.S. Census 2013 14 2014 14 Final 2015 14 Final 2016 14 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 2012 14 Notes - 2011 The estimate is available at http://www.census.gov/hhes/www/hlthins/data/historical/HIB_tables.html(Table HIA-5) Notes - 2010 The estimate is available at http://www.census.gov/hhes/www/hlthins/data/historical/index.html (Table HIA-5) Notes - 2009 Because of ongoing budget shortfalls, Arizona has frozen enrollement in the state S-CHIP (KidsCare). The freeze and continuing recession may result in a greater proportion of children without health insurance during future reporting periods. 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 acute 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 (Arizona's Medicaid), KidsCare (Arizona's SCHIP), 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 2011, the Medical Services Project provided medical appointments to over 400 different children from 140 different referring schools. In 2011, the Medical Services Project developed new collaborative partnerships with New 87 Healthlinks for Kids, Walgreens, Delta Dental, Native Health, Mohave County Health Department, and East Valley Head Start. 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 30% of Health Start clients are without insurance. Project LAUNCH parent educators also assess the insurance status of their families and facilitate enrollment when possible or help the family to find other venues for health care like Federally Qualified Health Care Centers. Pregnancy & Breastfeeding/Children's Information Center Hotline assisted 15,090 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 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, Health Start Community Health Workers and LAUNCH parent educators educate the family on the importance of maintaining a medical home and assists families in accessing health insurance. 4. The Title V supported Children's Information Hotline helps families seeking health care to apply for AHCCCS or find community services. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X b. Current Activities The Medical Services Project continues to provide a network of physicians for uninsured children. The project is currently operating in seven Arizona counties with 268 referring schools. The primary care provider network consists of 28 active primary care providers, 17 active specialty care providers. The HRPP Community Health Nurses continue to assess the health insurance status of each 88 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. The Health Start Program and Project LAUNCH also review and assess the health insurance status of clients. Families are linked to medical resources available in their community and encouraged to establish a medical home. The newly implemented MIECHV home visiting programs ask about insurance status as well and try to help the family enroll. At the end of the last Legislative session KidsCare enrollment was frozen. In May of 2012, AHCCCS opened up enrollment for a limited number of children beginning with those already on the waiting list for KidsCare. 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 uninsured children to acute care services. 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 home visiting funded through the ACA MIECHV as well as families visited through Project LAUNCH will assist families to access insurance. The Health Start Program and Family Planning Programs will continue to ensure all eligible clients apply for insurance coverage through AHCCCS, the state's Medicaid agency. 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. 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 2007 2008 2009 2010 2011 35 36.9 34535 93555 34.5 37.3 38670 103755 AZ WIC Program database 34.5 30.2 31174 103089 AZ WIC Program 34.5 29.3 31182 106318 AZ WIC Program 34 28.9 30018 103873 AZ WIC Program Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 89 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 2012 28.5 2013 27 2014 26.5 Final 2015 26 Final 2016 25.5 Notes - 2011 Numbers reported from 2006-2010 were overestimated by error because it includes duplicate records. Years 2009, 2010 and 2011 have been updated with correct percentages. Numbers reported before 2009 includes duplicates, therefore are overestimating the percentage of kids with BMI at or above 85th percentile and are not comparable with numbers from 2009 and onward. Notes - 2010 Numbers reported from 2006-2010 are overestimated by error because includes duplicate records. The 2010 number reported as 35.8% (42255/117927) was corrected on Application 2013 to 29.3% (31182/106318). Notes - 2009 Numbers reported from 2006-2010 are overestimated by error because includes duplicate records. The 2009 number reported as 36.6% (41859/114502) was corrected on Application 2013 to 30.2% (31174/103089). a. Last Year's Accomplishments The Bureau of Nutrition and Physical Activity promoted healthier eating habits and lifestyles to WIC children and families by ensuring maternity care practices that support breastfeeding with the implementation of Arizona Baby Steps for Breastfeeding Success. The evidence-based maternity care practices were presented in 117 training sessions at 27 hospitals reaching more than 3,000 nurses, physicians, hospital staff members, and WIC staff as well as mentored 50 WIC staff, healthcare providers, and community partners to become International Board Certified Lactation Consultants (IBCLC) and provided Certified Breastfeeding Counselor training to 375 people. WIC also ensured access to nutritious foods through the implementation of the updated WIC food packages including more choices for fruits, vegetables and whole grains and provided $472.9 million in supplemental foods and an additional $20.9 million in fruits and vegetables to low income women and their children. In a joint effort between Arizona WIC and Arizona Nutrition Network, WIC raised awareness around Farmers' Markets with the Arizona: Fun, Fresh, Local farmer's market promotion video to increase awareness and access to healthy foods as a fun activity for WIC families. ADHS continued to enhance training and technical assistance for child care centers around the Empower initiative which empowers children (0-5) to live healthier lives by following ten standards supporting healthy eating, active living, and tobacco prevention. ADHS Office of Child Care Licensing continued to require childcare centers to offer meals family style, reduce juice consumption, and reduce screen time. Table 4a, National Performance Measures Summary Sheet Activities Pyramid Level of Service DHC ES PBS IB 90 1. ADHS has continued to enhance training and technical assistance around the Empower childcare initiative. 2. ADHS Office of Child Care Licensing continues to require childcare centers to offer meals family style, reduce juice consumption, and reduce screen time. 3. Arizona WIC is continuing the distribution of the emotionbased education materials for obesity prevention for WIC families. 4. WIC is expanding staff training and education around participant-centered weight counseling with WIC families. 5. 6. 7. 8. 9. 10. X X X X b. Current Activities ADHS has continued to enhance training and technical assistance around the Empower childcare initiative which empowers children (0-5) to live healthier lives by following ten standards supporting healthy eating, active living, and tobacco prevention. In February 2012, ADHS offered training to childcare providers statewide around the 10 Empower standards reaching 120 providers childcare facilities. First Things First Child Care Health Consultants attended the training and continue to incorporate Empower into the state Quality First system. ADHS Office of Child Care Licensing continues to require childcare centers to offer meals family style, reduce juice consumption, and reduce screen time. First Things First Child Care Health Consultants are incorporating Empower into their curriculum. Pima County child care consultants are providing technical assistance to child care centers. Arizona WIC is continuing the distribution of the emotion-based education materials for obesity prevention for WIC families, but is also expanding staff training and education around participantcentered weight counseling with WIC families. ADHS has incorporated obesity prevention into the department strategic map and obesity prevention has been identified as a winnable battle for department integration efforts. Integration of obesity prevention efforts across bureaus and programs to leverage impact and efforts continues to be a focus. c. Plan for the Coming Year ADHS Office of Child Care Licensing will continue to require childcare centers to offer meals family style, reduce juice consumption, and reduce screen time. In addition they will support centers that choose to become Empower centers to follow the ten standards supporting healthy eating, active living, and tobacco prevention. First Things First Child Care Health Consultants will continue to incorporate Empower into their curriculum. Pima County child care consultants will continue to provide technical assistance to child care centers. Arizona WIC will continue the distribution of the emotion-based education materials for obesity prevention for WIC families, and expand staff training and education around participant-centered weight counseling with WIC families. 91 The Statewide Home Visiting Task force will look to include nutrition and physical activity into early childhood home visiting curriculum. BNPA and its partners will update the EMPOWER program. As four of if its ten tenants are now in rule, there is an opportunity to enhance its ability to effect change in behavior. 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 2007 2008 2009 2010 2011 5 4.5 4.2 4 4 4.7 4826 102687 4.9 4859 99215 AZ Birth Certificates 4.8 4461 92616 AZ Birth Certificates 4.7 4063 87053 AZ Birth Certificates 4.3 3622 85109 AZ Birth Certificates Final Final 2015 3.2 2016 3.2 Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2012 4 2013 3.5 2014 3.5 Notes - 2011 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 - 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. 92 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. a. Last Year's Accomplishments For calendar year 2011, 8,221 women utilized Arizona Smokers' Helpline (ASHLine) services. Of these, 121 (or 1.47% 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 decreased from 2009 (16.1%) to 2010 (15%). Some of the reasons for this include; 1) ASHline's capacity has increased and BTCD launched a robust media campaign (both radio and TV) promoting ASHLine services, and 2) nicotine replacement therapies are covered for Arizona residents who are insured by AHCCCS (Title 19) 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 Title V County Health and Prevention contracts began with two new goals. One of those goals is to improve the Health of Women prior to pregnancy, which includes tobacco use prevention and cessation. These contracts must use the Spectrum of Prevention. Their preconception health activities included community education, building coalitions, changing organizational practices, and developing policies. Navajo County Public Health District offered courses in preconception health in high schools, gynecologists' offices, pediatrician offices, teen mazes, and public agencies. Women were screened related to tobacco use and referred to appropriate programs. The Health Start Program continued to provide the EveryWoman 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 ASHline's website www.ashline.org.to provide education on the health risks and steps to stop smoking. 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. The HRPP/NICP provided the EveryWoman Arizona Preconception Health Education materials to contractors which are being utilized during family follow-up visits with the postpartum clients. 93 Table 4a, National Performance Measures Summary Sheet Activities 1. BWCH bilingual Hotline staff refer pregnant women to ADHS tobacco education and cessation programs. 2. Health Start and Family Planning Programs provide training to contractors on tobacco cessation. 3. Breastfeeding program and tobacco prevention/cessation program are implementing methodology for referring new moms to the Arizona Smokers Helpline. 4. Three quit coaches were trained and designated to assist pregnant and breastfeeding mothers reach their goals to quit smoking 5. The Title V County grants promote tobacco education and preconception health activities. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X 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. The ASHLine changed its intake system and database to increase its support for pregnant and breastfeeding moms. Three quit coaches were trained and designated to assist pregnant and breastfeeding mothers reach their goals to quit smoking. Twenty WIC agencies were trained across Arizona on proactive referrals to ASHLine to increase support for pregnant and breastfeeding mothers who smoke. As a result of these trainings, there has been a 66 percent increase in the average number of pregnant and breastfeeding mothers referred to the ASHLine. The Title V County grants tobacco education and preconception health activities include community education, building coalitions, changing organizational practices, and developing policies. Six out of seven contracting counties are providing brochures and education about tobacco use and other preconception health topics in high schools, physicians' offices, pregnancy clinics WIC clinics, their own county buildings and other locations. Three counties are working to assist other organizations to develop worksite wellness plans including the prevention of smoking onsite. Two counties are working with schools to determine the need for policy change on topics such as tobacco tolerance. One county is working to develop policy against smoking in public housing. 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 Bureau of Tobacco Education and Chronic Disease; ASHLine. 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 2013. The Program will use the Basic Tobacco Intervention Skills for Maternal and Child Health Guidebook developed by the University of Arizona Health Care Partnership. Smoking questions will be added to the Health Start Alcohol Screening Tool and a Tobacco Cessation Brief Intervention handout will be developed to use with 94 clients to educate and to assist clients to move towards behavior change. 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 (ASHLine) is increasing outreach efforts to priority populations, like pregnant women, by partnering Community Health Centers statewide (CHC's). Rather than providing direct services to the clients, ASHline and BTCD are working to create a systemic change within all CHC's by working with the Arizona Association for Community Health Centers. The systemic change is a sustainable referral system created within CHC systems throughout the state. The Title V County Health and Prevention contracts will continue to include information on tobacco use in their preconception health activities. Their tobacco education and preconception health activities will continue to move up the Spectrum of Prevention to include community education, building coalitions, changing organizational practices, and developing policies. The HRPP/NICP will continue to provide the EveryWoman Arizona Preconception Health Education to contractors for family follow-up visits with the postpartum clients. Performance Measure 16: The rate (per 100,000) of suicide deaths among youths aged 15 through 19. Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source 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? 2007 2008 2009 2010 2011 13.5 8.5 38 444825 13 12.4 56 451910 AZ Health Status and Vital Statistics 12 10.7 49 456079 AZ Health Status and Vital Statistics 10 8.4 39 461582 AZ Health Status 8.2 10.1 47 464724 AZ Health Status Final Final 95 Annual Performance Objective 2012 9.8 2013 7.8 2014 7.7 2015 7.5 2016 7.4 a. Last Year's Accomplishments In 2011, the 18th Annual Child Fatality Report was produced, summarizing reviews of child deaths that occurred in Arizona during 2010. This marks the sixth year that the Child Fatality Review Program has reviewed 100 percent of child deaths that occurred in Arizona. During 2011, Child Fatality Review Teams reviewed the circumstances surrounding the suicides of 24 children that occurred during 2010. Fifteen (63 percent) of the suicides were among children 15 through 17 years, and nine children (37 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 Division of Behavioral Health Services provided information to BWCH program managers regarding behavioral health resources for women and children in the ADHS Zero to Five workgroup. That information was shared with our other colleagues and contractors. The Injury Prevention Program collaborated with the Division of Behavioral Health Services in developing web based training for emergency departments that cover several evidence based suicide risk and substance abuse screening tools. The intent is to train medical staff to screen patients at risk for suicide ideation and substance abuse. 1.5 CME hours are provided. The Title V County Health and Prevention contracts began with two new goals. One of those goals is to reduce the rate of injuries, both intentional and unintentional. These contracts must use the Spectrum of Prevention. Their injury prevention activities included community education, building coalitions, changing organizational practices, and developing policies. Navajo County Health Department began providing information on suicide prevention in High Schools. Gila County participated on a Suicide Prevention Coalition conducted by San Carlos Apache Tribe. Table 4a, National Performance Measures Summary Sheet Activities 1. Every year the Annual Child Fatality Report is produced, summarizing reviews of child deaths that occurred in Arizona. 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. Prescription drug drop-off event details and how-to develop a Prescription drop off community program tool-kit is available on the ADHS website. 5. The Injury Prevention Program is working with emergency departments to address the issue of opioid prescription abuse by establishing prescription guidelines for emergency departments. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X b. Current Activities 96 For 2011, 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. The program is working on developing a suicide investigation checklist for use by law enforcement when investigating suicides. Prescription drug drop-off event details and how-to develop a Prescription drop off community program tool-kit continues to be available on the ADHS website. The Injury Prevention Program is working with emergency departments to address the issue of opioid prescription abuse by establishing prescription guidelines for emergency departments. The Title V County Health and Prevention contracts continue to focus on two goals. One of those goals is to reduce the rate of injuries, both intentional and unintentional. These contracts must use the Spectrum of Prevention. Their injury prevention activities included community education, building coalitions, changing organizational practices, and developing policies. Navajo County Health Department began providing information on suicide prevention in High Schools. Apache County Health Department trained their Department staff in "Mental Health First Aid". 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 Injury Prevention Program will continue to collaborate with the Division of Behavioral Health Services and medical professional organizations to establish statewide guidelines on prescription drug abuse for health care providers/prescribers. The Title V County Health and Prevention contracts will continue to focus their two goals. One of those goals is to reduce the rate of injuries, both intentional and unintentional. These contracts must use the Spectrum of Prevention. Their injury prevention activities include community education, building coalitions, changing organizational practices, and developing policies. Navajo County Health Department will continue to provide information on suicide prevention in High Schools Performance Measure 17: Percent of very low birth weight infants delivered at facilities for high-risk deliveries and neonates. 97 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 2007 2008 2009 2010 2011 82 82.5 83 91 91.5 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 87.8 889 1013 AZ Birth Certificates Final Final 2015 93.5 2016 94 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 2012 92 2013 92.5 2014 93 Notes - 2011 The 2011 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 - 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. 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 98 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 2011, 816 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. The Licensed Midwife Program reviewed quarterly reports from licensed midwives for any infants that were below 3000 grams. If the infant was below that weight the Program contacted the midwife who delivered the infant to determine if there were problems with either the delivery or the pregnancy. The Health Start program continued 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. The Arizona Perinatal Trust maternal fetal medicine physicians reviewed transport logs on site visits to identify where transports should have happened sooner and provide guidance to the sending facility. Table 4a, National Performance Measures Summary Sheet Activities 1. High Risk Perinatal Program transportes high risk pregnant women to appropriate level of care regardless of ability to pay. 2. HRPP requires every contracted hospital to use HRPP contracted transport providers ensuring the highest quality care. 3. High Risk Perinatal Program promotes public awareness of availability of transport. 4. The Arizona Perinatal Trust maternal fetal medicine physicians continue to review transport logs on site visits to identify education opportunities. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X b. Current Activities The maternal transport component of the 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 99 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. The Arizona Perinatal Trust maternal fetal medicine physicians continue to review transport logs on site visits to identify where transports should have happened sooner and provide guidance to the sending facility. c. Plan for the Coming Year The maternal transport component of the High Risk Perinatal program (HRPP) will continue funding for a centralized Information and Referral Service. This 1-800 telephone line will continue to offer toll free 24/7 consultation services by board certified Maternal Fetal Medicine (MFM) specialists throughout Arizona to providers caring for pregnant women who presented with high risk factors. Providers will be able to continue to make one telephone call to be connected with this service. If a transport is deemed necessary, the board certified Maternal Fetal Specialists will determine the availability of the appropriate level of perinatal bed and authorize and provide medical direction for the transport regardless of the woman's ability to pay. The MFM will continue to utilize the perinatal screen of the EMSystem, a web based program with real time information of perinatal bed availability in Arizona, including high risk labor and delivery and NICU beds. The program plans to continue to fund all uncompensated care associated with the transport itself of pregnant women to Level II Enhanced Qualification or Level III perinatal centers. The HRPP will continue to visit hospitals and providers to educate them about the availability of the transport system. The Arizona Perinatal Trust maternal fetal medicine physicians will continue to review transport logs on site visits to identify where transports should have happened sooner and provide guidance to the sending facility. Due to significantly reduced state funding, Title V funds will continue to 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. Two counties do not currently have NICP contractors. 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 2007 2008 2009 2010 2011 79 79 80 81 83 77.6 79.4 80.3 81.9 83.3 100 Numerator Denominator Data Source 79683 102687 78738 99215 AZ Birth Certificates 74331 92616 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 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 2012 84 2013 85 2014 86 71331 87053 AZ Birth Certificates 70953 85190 AZ Birth Certificates Final Final 2015 87 2016 88 Notes - 2010 The HP 2020 Goal is 77.9%. 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 2011, Health Start provided educational services to 3,770 unduplicated enrolled clients. The program provided a total of 12,478 home and/or office visits. The program increased outreach to the most vulnerable populations, Native Americans and African Americans, in targeted communities to focus on new prenatal enrollments. Approximately 41% 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. Over 90% of clients had a baby within normal birth weight. The proportion of very low birth weight infants born to Health Start clients was approximately 1% and low birth weight was 9%. The Office of Oral Health (OOH) continued to print and distribute educational materials related to the importance of good oral health during pregnancy and to promote dental care before, during and after pregnancy. These materials were distributed to the Baby Arizona, Health Start and Preconception Health programs. OOH also provided technical assistance and educational materials on oral health and premature, low-birth weight infants for external partners and organizations that work with young families and pregnant women. The ADHS Midwife Licensing Program reviewed data from 681 quarterly reports turned into the Department by midwifes with notation of any who began care after the first trimester to determine 101 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 732 callers to have presumptive eligibility for Baby Arizona in 2011. Table 4a, National Performance Measures Summary Sheet Activities 1. The Office of Oral Health educate internal and external partners on the relationship of oral health and pregnancy risks. 2. Health Start Community Health Workers educated pregnant and postpartum women about the importance of early prenatal care. 3. Bilingual Hotline staff prescreened callers for Baby Arizona. 4. Bilingual Hotline staff refer pregnant women who would not quality for Medicaid to providers offering sliding scale rates. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X b. Current Activities The Office of Oral Health (OOH) is available to provide education and technical assistance to dentists on treatment protocols during pregnancy. OOH provides information to health care workers and pregnant women through programs such as Health Start, Baby Arizona and Preconception Health as well as external partners, on the importance of oral health during pregnancy. Oral health training is being provided to the Health Start Program's Community Health Workers and training is projected for Healthy Families visiting nurses for fall of this year. 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. Nurse Family Partnership and Healthy Families home visitors funded through the Maternal, Infant and early Childhood Home Visiting program will assist pregnant women into care when necessary. 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. 102 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, Health Start, Healthy Families and the Maternal, Infant and Early Childhood Home Visiting Nurse program to enhance oral health education and provider training. OOH will promote incorporation of oral health messages into health education provided to women of child bearing age and the 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. Nurse Family Partnership and Healthy Families home visitors funded through the Maternal, Infant and early Childhood Home Visiting program will continue to assist pregnant women into care when necessary. 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. The ADHS Midwife Licensing Program will continue to review data from 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. 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. Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective 2007 2008 2009 2010 2011 10.6 103 Annual Indicator Numerator Denominator Data Source Is the Data Provisional or Final? Annual Performance Objective 2012 10.6 2013 10.6 2014 10.6 11.8 302 2557 Youth Risk Behavior Survey Final 11.4 326 2856 Youth Risk Behavior Survey Final 2015 10.6 2016 10.6 Notes - 2011 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: 9.7-13.3%) 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 The Rural Domestic Violence Services Network (RDVSN) program includes seven domestic violence shelters in Arizona. This program is supported by federal Family Violence Prevention and Services Act funding. The seven shelters provided 236 healthy relationship presentations and/or workshops to a total of 5,516 youth and teens in rural communities. Topics included Domestic Violence 101, Safe Dating How to Break Up Safely, Warning Signs of Teen Dating Violence, Self-Esteem, Cycle of Violence, Power and Control, Bullying and Cyber Stalking. Fortynine youth ages 12-17 self-reported being a victim of intimate partner violence. The Centers for Disease Control (CDC) funded Sexual Violence Prevention and Education Program (SVPEP) provided sexual violence prevention single/multi-sessions across three counties. The target population included school staff, family and community members, Latino/a, Native American, Lesbian, Gay, Bisexual, Transgender and Queer, incarcerated youth, and staff of alcohol-serving establishments. From November 1, 2010 until October 31, 2011 the programs reached a total of 18,289 participants in 264 single/multi-session presentations. Subjects in the multi-sessions workshops presentations included: 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. The funded programs received twenty-four disclosures (selfreported) incidents of sexual assault from elementary school-age children through adulthood. The SVPEP program worked to develop effective evaluation tools for the programs that are being funded. Throughout 2011, ADHS/SVPEP gathered data to determine the core components of bystander intervention training in alcohol-serving establishments. The greatest finding for both groups was that alcohol/drug facilitated sexual aggression/ rape should be a core component in staff and patron training. The Office of Violence Against Women, (OVW) through the Department of Justice (DOJ) funded the Sexual Assault Services Program (SASP) to provide counseling and accompaniment aimed at rural counties. The target population includes adult, youth, and child victims of sexual assault; family and household members of such victims; and those collaterally affected by the victimization, except for the perpetrator. Collaterally affected victims are children, siblings, spouses or intimate partners, grandparents, other affected relatives, friends and neighbors. In 2011, ADHS maintained three contracts in rural counties. This allowed the continued funding of outreach, hotlines, and counseling services within three counties and several rural communities. They were also able to outreach and provide services to disabled individuals; as well as offer bilingual hotline services, expand their capacity to serve more clients and conduct a weekly non- 104 therapeutic, drop-in, support group, the Cafecito, to help victims/survivors break their isolation and learn about self-esteem and coping skills. Arizona has been able to maintain accessible and effective crisis intervention, court accompaniment and advocacy to primary and secondary victims of sexual assault. In 2011, a total of 315 victims/survivors and 36 collaterally affected received services. Arizona received a Project Connect grant which made it possible to address intimate partner violence and reproductive and sexual coercion by educating twelve county health department family planning clinics about domestic violence and the importance of screening clients. Three agencies registered as pilot sites and were provided in-depth training. Health Start staff attended training on Project Connect and learned how to effectively screen for domestic/dating violence. The Relationship Assessment Tool was implemented in the Health Start Program as part of the Community Health Worker home visits. During site visits the Program manager monitored that each client was screened for domestic/dating violence and that appropriate referrals were provided as needed. The BWCH conducted a scan/inventory of existing prevention programs for adolescents that include efforts related to promoting healthy relationships and violence prevention. BWCH staff collaborated with the ADHS Division of Behavioral Health and the Governor's Office for Children, Youth and Families on the development of the survey tools. Table 4b, State Performance Measures Summary Sheet Activities 1. Sexual Violence Prevention and Education Program provides education in key areas of preventing sexual violence 2. Sexual Assault Services Program provides counseling, outreach and accompaniment aimed at rural counties for victims/survivors of sexual assault; and those collaterally affected by the assault. 3. The Rural Domestic Violence Services Network provides awareness presentations to adults, youth targeted presentations and community awareness activities in rural Arizona. 4. The SVPEP program works to develop effective evaluation tools for the programs that are being funded. 5. Health Start staff attended training on Project Connect and learned how to effectively screen for domestic/dating violence. 6. Health Start contract staff is providing the Relationship Assessment Screening Tool to all enrolled Health Start Clients. 7. Bureau of Women's & Children's Health will continue to work with other programs throughout ADHS and external partners to identify opportunities to further integrate violence prevention into existing programs. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X X X b. Current Activities RDVSN agencies provided presentations, events, and/or workshops to 2,048 youth in 2012. Three Teen Mazes were held educating over 600 youth in each rural community. These fun interactive events educate teens on topics of health and wellbeing. 105 From November 1, 2011 until April 2012 SVPEP agencies have given 282 single/multi session presentations to a total of 7,861 attendees. We have started piloting the evaluation tools with several funded agencies. SVPEP has continued to provide education in key areas of preventing sexual violence. In three locations in Arizona, the ADHS/SVPEP is conducting a second round of focus groups involving alcohol-serving establishments. The first round of focus groups, in 2011, envisioned the creation of a statewide standardized bystander model as the most effective strategy to reducing sexual aggression in alcohol serving establishments. ADHS is exploring that concept and we are excited to involve several alcohol-serving establishments and community leaders in this project. Yavapai County is providing education about healthy and abusive dating relationships using a Safe Dates course. Health Start revised the policy and procedure manual and the community health worker training manual to incorporate the information provided during the Project Connect training. Health Start contract staff is providing the Relationship Assessment Screening Tool to all enrolled Health Start Clients. 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. Seven 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 and will begin to pilot evaluation tools which will cover key messages of primary prevention of sexual violence. The program will pilot a curriculum for bystander intervention training for participating alcohol-serving establishments. The Sexual Assault Services Program will continue to provide counseling, outreach and accompaniment in three rural counties. Health Start will coordinate with the AzCADV (Arizona Coalition against Domestic Violence) to provide continued training to Health Start staff on the Project Connect -- Futures Without Violence education. Health Start will collect the surveys and create a data base to analyze the survey tool results in an effort to inform future program issues and development. 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. 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. Bureau of Women's & Children's Health will continue to work with other programs throughout ADHS and external partners to identify opportunities to further integrate violence prevention into existing programs. Yavapai County will continue to provide education about healthy and abusive dating relationships using a Safe Dates course. 106 Beginning January of 2013, all Title V clinics will be contractually obligated to screen for domestic violence and reproductive coercion. 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 2007 2008 2009 2011 27 27.7 652 2354 Youth Risk Behavior Survey (2009) 27.7 652 2354 Youth Risk Behavior Survey (2009) Final 24.8 666 2687 Youth Risk Behavior Survey (2011) Final 2014 25.5 2015 24.9 2016 24 Is the Data Provisional or Final? Annual Performance Objective 2010 2012 26.5 2013 26 Notes - 2011 Arizona overweight=13.9% and obese=10.9%. U.S. overweight=15.2% and obese=13.0%. 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% 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 In FY2011, through the Communities Putting Prevention to Work (CPPW) grant the Bureau of Nutrition and Physical Activity completed development of the Active School Neighborhood Checklist. Fifty schools used the online assessment tool when applying for Safe Routes to School funding to increase the number of students walking and biking to school. Also through CPPW, BNPA facilitated the completion of the School Health Index and the establishment of School Health Advisory Councils in 48 elementary, middle, and high schools to implement healthier school programs and policies. Through the Arizona Nutrition Network, BNPA provided education on healthy eating and physical activity to low income students in 440 schools. BNPA increased the number of youth qualifying for the Presidents Active Lifestyle Award (PALA) from 20% in 2009 to 48% in 2011 with a total of 43,088 youth at highest risk for becoming sedentary, participating in an evidence-based physical activity program. 107 The Title V County Health and Prevention contracts began with two new goals. One of those goals is to improve the health of women prior to pregnancy. These contracts must use the Spectrum of Prevention. Their activities included community education, building coalitions, changing organizational practices and developing policies. All contracted counties provided information on nutrition, physical activity and chronic disease prevention which includes reducing obesity. Counties provided education to WIC staff on the importance of preconception health, obesity prevention and chronic disease prevention. Counties began imbedding preconception health, obesity prevention and chronic disease prevention into their other programs. Through the Title V County Health Prevention contracts, Maricopa County developed a policy unit. This unit began partnering with other agencies. They began working with the Livable Communities Coalition (LCC) to design an advocacy agenda and a toolkit to promote the incorporation of concepts of healthy community design into cities' general plans. In addition, Maricopa County worked with the Maricopa County Wellness Council on a Healthy Vending Policy. A pilot test was conducted in three locations. Maricopa County was funded by the Tohono O'odham Nation to create a Public Health School Ambassador Program for parents. The program began to train interested parents in school districts on the basic principles of public health and how parents can create needed change in their schools. The Public Health Ambassador program empowers parents to make a difference in the health of their children while their children are at school. Table 4b, State Performance Measures Summary Sheet Activities 1. BNPA provides education on healthy eating and physical activity to low income students. 2. Through Title V Community Grants counties imbed preconception health, obesity prevention and chronic disease prevention into their other programs. 3. The ADHS Bureau of Nutrition & Physical Activity continues to work with the Arizona Department of Education to support the federal Coordinated School Health grant. 4. ADHS has chosen ‘Promote Nutrition and Physical Activity to Reduce Obesity’ as a part of the Strategic Plan. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X b. Current Activities The ADHS Bureau of Nutrition & Physical Activity continues to work with the Arizona Department of Education to support the federal Coordinated School Health grant. School health activities are targeting school age youth and BNPA provides technical assistance to school districts to help them implement their school wellness policies and create model policies. ADHS continues integration efforts with the Bureaus of Women's & Children's Health, Nutrition & Physical Activity, Tobacco & Chronic Disease, and Health Systems Development around obesity prevention messaging and programming. ADHS is finalizing a Memorandum of Understanding between ADHS, the Arizona Department of Economic Security, the Arizona Department of Education, and First Things First that will support consistent common messaging around obesity prevention across government departments. 108 The Title V County Health and Prevention contracts continue to include community education, building coalitions, changing organizational practices and developing policies. Counties continue to imbed preconception health, obesity prevention and chronic disease prevention into their other programs. The LCC and Maricopa County are working to target the cities of Avondale, Mesa, Phoenix and Tempe to include wellness in community design. In addition they are expanding the Healthy Vending Policies throughout County owned buildings. c. Plan for the Coming Year ADHS will continue to enhance department-wide strategies to reduce and prevent obesity throughout Arizona consistent with the ADHS strategic map and winnable battles. BNPA will finalize the bureau Strategic Plan for 2012-2016 guided by the efforts identified in the department wide strategic plan. The Winnable Battles, along with other strategic objectives, will be areas BNPA staff will work on to improve health and wellness for all Arizonans. Priority efforts continue to be around obesity prevention, with integration around the "whole person" approach consistent with behavioral and environmental approaches that are mindful of weight stigmatization and bias. Messaging will support healthy eating and active living strategies and working across systems to leverage impact. Title V County Health and Prevention contracts will continue to include community education, coalition building, changing organizational practices and developing policies. All contracted counties will provide information on nutrition, physical activity and chronic disease prevention including obesity. Counties will continue to imbed preconception health, obesity prevention and chronic disease prevention into their other programs. 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 2007 2008 2009 2010 2011 32.5 32 31.5 31 31 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 Final 32 2013 30 2014 29.5 2015 29 2016 29 Is the Data Provisional or Final? Annual Performance Objective 2012 30.5 AZ Vital Records Provisional Notes - 2011 The 2009 birth cohort data with linked birth-death was not ready for analysis by the time of submission of the 2013 application. The 2011 estimate will be updated when the analysis is completed. 109 Notes - 2010 The 2008 birth cohort was used in this analysis. Notes - 2009 The 2007 birth cohort was used in this analysis. a. Last Year's Accomplishments Child Fatality Review Program issued an annual report in November 2011, with recommendations for prevention of infant deaths. The Child Fatality Review Program and Arizona Unexplained Infant Death Council continued to promote use of updated Infant Death Investigation Checklist. Bureau of Women's & Children's Health focused activities for prevention of infant deaths based on the results of the data analysis including infant safe sleep messaging. 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. Following the April 2011 release of the Arizona Preconception Health Strategic Plan 2011-2015, BWCH convened a Preconception Health Implementation Task Force to monitor and assist with achieving the action steps developed for the three strategic goals;1) Public Awareness 2) Healthy Behaviors and 3) Access and Quality of Preconception Healthcare. The task force consists of representatives from county health departments, community health association, director of OB/GYN department for a Medicaid Health Plan, ADHS staff from the Bureau of Nutrition and Physical Activity and the Division of Behavioral Health. Each meeting consists of updates from each member regarding their work related to increasing consumer and provider awareness about preconception health or providing preconception health care. The results and implementation of the LiveitChangeit.com campaign were presented during the June 2011 National Preconception Health Summit. The Title V funded County Health and Prevention contracts addressed preconception health. Their preconception health activities included community education, building coalitions, changing organizational practices, and developing policies. Six out of seven contracting counties provided brochures and education about preconception health in high schools, physicians' offices, pregnancy clinics WIC clinics, teen mazes, their own county buildings and other locations. Maricopa County Department of Public Health developed a policy unit. This unit partnered with Livable Communities Coalition to design an advocacy agenda and toolkit to promote the incorporation of the concepts of healthy community design into the cities general plans. They also worked with the Arizona State University to bring together a variety of health and wellness experts to design a model plan to increase access to healthy and fresh foods in Arizona. MCDPH is working collaborating with others to develop a Food Policy Council in Goodyear. MCDPH worked with other associations to promote joint use agreements. These organizations introduced a senate bill to help decrease the risk of liability for schools that open their recreational grounds during non-instructional time. This was signed into law by the Governor during the session. The goal is to increase community access to physical activity. The Policy staff worked with their health department's Wellness Council on developing a healthy vending policy. The MCDPH also received a grant to assess food procurement policies within Maricopa County Government. 110 Coconino County Public Health District developed a resource directory of preconception health care providers in Williams Arizona. ADHS home visiting programs continued to educate families about safe sleep. During Arizona Perinatal Trust site visits the BWCH representative monitors hospital safe sleep policies and practice. Table 4b, State Performance Measures Summary Sheet Activities 1. Child Fatality Review Program promotes use of the Infant Death Investigation checklist. 2. Child Fatality Review Program produces annual report on infant and child deaths, including recommendations for prevention. 3. ADHS programs promote use of folic acid and multivitamins. 4. Title V County Health projects are implementing preconception health strategies at multiple levels of spectrum of prevention. 5. BWCH promotes preconception health materials and strategies. 6. BWCH convenes a Preconception Health Implementation Task Force to monitor and assist with achieving; public awareness, healthy behaviors and access and quality of preconception healthcare. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X X b. Current Activities The Preconception Health Strategic Plan task force continues to meet to focus on implementation of the strategic plan. The Chief of the Office of Women's Health is a member of the CDC's Preconception Health Consumer Workgroup, which allows Arizona to be an active partner in national efforts to promote preconception health. The Preconception Health Implementation Task Force completed and distributed the Arizona Women's Health Status Report in January 2012 as a means of using data to look at women's health not only from a preconception health perspective but a life course perspective. The Empire State Public Health Training Center has free online preconception health training for community health workers that Health Start Community Health Workers and Community Health grantees complete. A reproductive life plan has been developed for use in Arizona and distributed to Health Start and Community Health grantees. The content utilized information from North Carolina's Are You Ready booklet and the Florida Department of Health Services Healthy Start A Community Health grant. ADHS partnered with the Arizona Perinatal Trust and The March of Dimes to take up the Association of State and Territorial Health Officer's challenge to reduce prematurity by 8% by 2014. 111 The Emergency Medical Services for Children is working on the pediatric designation system for emergency departments. There are currently 9 hospitals verified this year. This represents 12% of Arizona's EDs. c. Plan for the Coming Year 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. Women will continue to be screened related to preconception care and referred to appropriate programs. Child Fatality Review Program will issue the 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 the 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 BWCH will work with our county health departments and other partners to facilitate the implementation of the CDC Preconception Health social marketing campaign in Arizona. The BWCH, the Preconception Health Implementation 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. The HRSA funded EMS for Children program will continue with the implementation of a voluntary pediatric designation process for hospital emergency departments using the American Academy of Pediatrics Arizona Chapter as the designating body. This program received a demonstration grant to expand the project to include rural and tribal health facilities. ADHS will continue to partner with the Arizona Perinatal Trust and The March of Dimes to promote the importance of eliminating elective inductions before 39 weeks, preconception health and safe sleep as we work to reach the Association of State and Territorial Health Officer's challenge to reduce prematurity by 8% by 2014. State Performance Measure 4: Emergency department visits for unintentional injuries per 100,000 children age 1-14. Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator 2007 2008 2009 2010 2011 7477 7477 7476 7000 7400 6,681.6 92588 1385725 6,835.2 90940 1330464 7,077.9 95037 1342722 7,558.6 96070 1271006 7,436.0 95181 1279995 112 Data Source AZ Hospital Discharge data AZ Hospital Discharge data AZ Hospital Discharge Data Final AZ Hospital Discharge Data Final 2013 7100 2014 6950 2015 6800 2016 6650 Is the Data Provisional or Final? Annual Performance Objective 2012 7250 Notes - 2011 If the 2011 the rate of emergency department visits for unintentional injuries was 7,436 per 100,000 and the population in this age group was 1,279,999 children; If we had met the preformance objective of 7400 per 100,000 children age 1-14 years, approximately 461 visits would have been prevented. Notes - 2010 If the 2010 the rate of emergency department visits for unintentional injuries was 7558.6 per 100,000 and the estimiated children in this age group was 1,271,006; If we had met the preformance objective of 7000 per 100,000 children age 1-14 years, approximately 7,100 visits would have been prevented. 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 provided technical assistance in establishing three special needs child passenger safety sites; this resource now gives families a place to have their car seat check or will provide a seat if the family is unable to afford a seat. Twelve Hope Car Beds were provided to tertiary pediatric hospitals for those children who require being transported in a supine position. Additionally, over 3,000 child safety seats were distributed to rural and tribal communities. The program stepped up use of social media and provides safety "Tweets" on a weekly basis. In 2008, Arizona's Emergency Medical Services for Children Program began work on establishing a pediatric designation system for hospital emergency departments. This system's purpose is to identify minimum training and equipment a hospital needs to care for a pediatric patient. A three tiered criteria was developed and approved by stakeholders. This was released in Fall 2011. The program has contracted with the American Academy of Pediatrics, Arizona Chapter to be the certifying body. 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 to correct the situation, thereby reducing risk and the potential for preventable emergency room visits. The Title V County Health Prevention contracts worked in all levels of the Spectrum of 113 Prevention. These contracts have provided activities around community education, building coalitions, changing organizational practices, and developing policies. Projects address a variety of injury issues, including poison prevention, safe sleep, and motor vehicle safety. The Title V funded Early Childhood Education/Child Care Health Consultant in Pima County provided 150 encounters in preschools which include assessment, consultation, and recommendations regarding playground safety. The 18th 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. All ADHS Home Visitors conduct home safety assessments. 2. Safe Kids provides certified child passenger safety training. 3. EMSC assists in pediatric emergency department 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 2012, the Emergency Medical Services for Children continues to work on the pediatric designation system for emergency departments. There are currently 9 hospitals verified. This represents 12% of Arizona's emergency departments. These ED's will see approximately 250,000 children in 2012. The Office of Injury Prevention will be hosting an emergency department stakeholders meeting to discuss unintentional poisoning and prescription drug abuse. The anticipated outcome is guidelines that ED's will be able to utilize. The Title V County Health Prevention contracts are continuing to grow through the levels of the Spectrum of Prevention. These contracts are increasing 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. 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 114 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. ADHS was awarded a Robert Woods Johnson Quality Improvement grant to standardize home safety checklists for all home visitors. c. Plan for the Coming Year The HRSA funded EMS for Children program will continue with the implementation of a voluntary pediatric designation process for hospital emergency departments using the American Academy of Pediatrics Arizona Chapter as the designating body. This program received a demonstration grant to expand the project to include rural and tribal health facilities. 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 Safe Native American Passengers Program. The Injury Prevention Program and Advisory Council will update the 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 continue to monitor 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 continue increasing 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. The High Risk Perinatal Program, CHNs will continue to conduct environmental risk assessments on every home visit. 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. 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. These programs will conduct environmental assessments of the families' homes to identify injury risk. Project LAUNCH will continue to provide training for staff and community providers in evidence based 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. This coming year BWCH utilize a standardized home visiting safety assessment tool developed through the Robert Wood Johnson CQI grant. This assessment will be used by the two home visiting programs in the Bureau of Women's and Children's Health with the hope that the Early Childhood Task Force will eventually adopt the tool for all of Arizona's early childhood home visitors. This is with the understanding that model developers would have to agree and approve the tool. 115 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 Objective Annual Indicator Numerator Denominator Data Source 2007 2008 2009 2011 45 41.7 24748 59309 AZ Birth and Fetal Death Certificates 43.8 24330 55589 AZ Birth and Fetal Death Certificates Provisional 44.2 24449 55265 AZ Birth Certificates Final 2014 46.5 2015 48 2016 48.5 Is the Data Provisional or Final? Annual Performance Objective 2010 2012 45.5 2013 46 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. The 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 5,181 women who received an initial or annual exam in 2011, 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 2011, 47% of clients served were under 25 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 Neonatal Intensive Care Unit. Arizona received a Project Connect grant from the Family Violence Prevention Fund that made it possible to improve 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 Chief of the Office of Women's Health has been invited to participate on the CDC's Preconception Health Consumer Workgroup. This allows Arizona to be an active partner in national efforts to promote preconception health and health care. In addition, Arizona will be able to disseminate and utilize current marketing strategies for increasing public awareness of 116 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 leads preconception health initiatives within ADHS. 4. Title V County Health projects implement preconception health strategies at multiple levels of spectrum of prevention. 5. All ADHS home visiting program discuss reproductive health and reproductive life plans with their clients. 6. BWCH works 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. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X 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. The "Every Woman Arizona Are You Ready" reproductive life plan booklets were distributed to Health Start contractors for use with their clients and any woman with a negative pregnancy test. The 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. The Chief of the Office of Women's Health participates 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 coalitionbuilding, organizational practices, and policy development. Each home visiting program discusses reproductive health and reproductive life plans with their clients. MIECHV funding will help to support professional development for home visitors around preconception health and reproductive life planning. c. Plan for the Coming Year 117 The Reproductive Health/Family Planning Program (RHFP) will continue to provide Title V funding to county health departments and Maricopa Integrated Health Systems to offer services to underserved populations. The program will continue to focus on women at or below 150% of the federal poverty level. The program will continue to seek out locations where underserved clients can be reached. In coordination with the Arizona Coalition Against Domestic Violence, ADHS will assist in the training of family planning providers to screen women for domestic violence in the clinic setting. The Health Start Program will continue to 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 continue to enhance interconception education, particularly regarding appropriate birth spacing, among home visiting programs and WIC program. 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 2007 2008 2009 2010 2011 42.9 240529 560823 AZ Medicaid 47.3 281134 594701 AZ Medicaid Final 2015 52 48 47.9 285371 596114 AZ Medicaid Final 2016 53 Is the Data Provisional or Final? Annual Performance Objective 2012 49 2013 50 2014 51 a. Last Year's Accomplishments The Office of Oral Health continued to work 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. As a result of the trailer loan program, in 2011, the Central Arizona Shelter Services (CASS) officially launched their "Caries Prevention Program" serving children in the Murphy School District community. Through this program, ten dental clinics for underserved populations have been established throughout the state. Through a HRSA Workforce Grant, the Office has been 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 overall goal of the teledentistry grant is to promote and develop enhanced dental teams (utilizing teledentistry practice, affiliated practice and other strategies) to improve workforce capacity, diversity and flexibility for providing oral health services to underserved populations and areas. 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. 118 Through a HRSA Workforce grant, the Office of Oral Health continued to support pilot teledental sites in rural Arizona communities including Northern Arizona University (NAU) School of Dental Hygiene, one tribal site and one site targeted at Head Start children in rural areas. In April of 2011, the OOH partnered with the Arizona Dental Association and the Arizona Dental Hygiene Association to conduct the first ever American Indian Oral Health Summit in Arizona. Outcomes of the Summit resulted in the acquisition of a DentaQuest Foundation grant to build on an American Indian Coalition of tribal members and stakeholders. The coalition conducted a series of six round tables with tribal members across the state. The round tables were designed to provide an opportunity to inform Tribal Leadership who were not able to attend the Summit about the Summit proceedings and outcomes. In February 2011, the OOH in collaboration with the Arizona Health Start Association, the Arizona Pediatric Dental Association, and the Arizona Department of Health Services launched the Arizona Dental Home Initiative (DHI). The state launch convened DHI leaders and key stakeholders to develop a plan to achieve the DHI goal of ensuring that local children have a dental home in which they receive comprehensive, continuously accessible, coordinated, and family-centered dental services. The 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. 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 2011, the Medical Services Project provided dental services to 25 individual children. The Office of Oral Health continued to administer a state-wide School-based Fluoride Mouthrinse Program (FMR) for children attending eligible schools. Eligible schools are those with a 50% or greater enrollment in the National School Meal Program located in communities with sub-optimal fluoride levels in the community drinking water. Last year, 23,099 children participated in the program. Table 4b, State Performance Measures Summary Sheet Activities 1. The Office of Oral Health works closely with the Arizona Health Care Cost Containment System in identifying opportunities to increase access to preventive services for eligible enrollees. 2. The Office of Oral Health continues the dental trailer loan program for communities and non-profit organizations in underserved areas. 3. The Office of Oral Health maintains Intergovernmental Agreements with counties to provide school-based dental screenings, referrals and sealants to children in low-income schools. 4. The Office of Oral Health administers a state-wide School- Pyramid Level of Service DHC ES PBS IB X X X X 119 based Fluoride Mouthrinse Program (FMR) for children attending eligible schools. 5. The Office of Oral Health provides training to childcare providers and early childhood teachers. 6. 7. 8. 9. 10. X b. Current Activities The office is working the Southwest Telehealth Resource Center to identify opportunities for collaboration. The goal is to identify linkages with telehealth resources that may be applied to teledentistry activities. Teledentistry grant activities have established 4 Regional Oral Health Coordinators in 10 of Arizona's 15 counties; developed 4 new or expanded Regional Oral Health Coalitions; completed 4 regional needs assessments and 4 regional oral health improvement plans. Partnerships have implemented 5 enhanced dental team practice models. The Grant has integrated enhanced dental team strategies into 3 health initiatives for increasing access to care and dental homes for children ages 0-5 years, Head Start children, and tribal populations. The Office of Oral Health is developing contracts with the Inter-Tribal Council of Arizona (ITCA) and the Sells Area Dental Service Unit to provide technical assistance and equipment for a teledentistry demonstration practice model. Additional partnerships with the ITCA include providing Train the Trainer materials on oral health. The Office of Oral Health provides technical assistance to communities to respond to water fluoridation threats. Technical assistance is provided in the form of scientific consultation, links to fluoridation resources and identification of local and national experts. This year the enrollment in the FMR program deceased to 16,237 children. OOH is currently conducting a program evaluation to address this. 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 of 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. The Office of Oral Health will continue to conduct evaluation activities with school nurses who participate in the Arizona School-based Fluoride Mouthrinse Program. Evaluation activities will be used to measure participant satisfaction, program efficiency and direct efforts for program improvement. 120 The Office of Oral Health is working with the Central Arizona Dental Society to implement an "Arizona Dental Mission of Mercy" event scheduled for December 2012. This event will provide free dental services to approximately 2,000 underserved. 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 OOH will work with other MCH programs in the Bureau of Women's and Children's Health to enhance integration of oral health strategies into existing programs, such as Health Start, MIECHV funded home visiting and WIC. The OOH is partnering with First Things First, the Arizona Early Childhood Development & Health Board to expand their early childhood oral health program. The partnership is developing a sustainability model to implement a pilot fluoride varnish program for children ages birth through five. 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. State Performance Measure 7: Percent of women age 18 years and older who suffer from frequent mental distress. 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 2007 2008 2009 2010 10.2 375 3686 AZ BRFSS 11.9 385 3239 AZ BRFSS 11.9 385 3239 AZ BRFSS 2013 10 2014 9.5 Is the Data Provisional or Final? Annual Performance Objective 2012 10.5 Provisional 2015 9 2011 11 11.7 404 3451 AZ BRFSS Final 2016 8.5 Notes - 2011 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?" 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 121 BWCH selected this as a 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 continued 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 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 continued 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. 4. BWCH promotes mental wellness among women through preconception health materials and women's health week activities. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X 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. Community Health Workers educated all clients on the postpartum warning signs of depression and perinatal mood and anxiety disorders. HRPP/NICP CHNs 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 NICU. 122 Each CHN agency contracted with HRPP/NICP has developed a list of referral resource service providers for the community they serve. The CHNs educate their clients on warning signs of postpartum depression as well as perinatal mood and anxiety disorders. All home visitors funded through MIECHV will screen their clients with the Edinburgh. BWCH promotes mental wellness among women through preconception health materials and women's health week activities. The 2012 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. The ADHS 2013-2017 Strategic Priorities includes integration of physical and behavioral health. 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 aid training statewide. The Health Start Program Manager will continue to attend the 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. Health Start will develop an expanded alcohol survey tool which will add smoking and drug questions and will develop supplemental brief intervention materials for use by the Community Health Workers. 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 will continue to participate in the development of a DBHS Adult System of Care Strategic Plan that is focused on the integration of mental health and physical health. All home visitors funded through MIECHV will screen their clients with the Edinburgh. HRPP/NICP CHNs 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 NICU. Each CHN agency contracted with HRPP/NICP will develop 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 continue to 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 123 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 2007 2008 2009 2011 79 77.7 2829 3643 AZ Early Hearing and Detection 77.9 2110 2710 AZ Early Hearing and Detection 85.4 2346 2747 AZ Early Hearing and Detection Final 86.3 2292 2655 AZ Early Hearing and Detection Final 2013 83 2014 85 2015 86 2016 86 Is the Data Provisional or Final? Annual Performance Objective 2010 2012 81 a. Last Year's Accomplishments The Arizona Newborn Screening Program (NBS) along with the EAR Foundation of Arizona (EFAz) are improving the loss to follow up and the system of screening beyond the newborn period. NBS efforts to improve loss to follow up following the newborn screen are also covered under Performance Measure 12. 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. Efforts have also been undertaken to improve screening for out of hospital births including those by midwives. Efforts to increase the opportunities for screening beyond the newborn period have been successful in the past year. More than 20 programs serving families 6 months to 2 years of age reported screening results with more than 5000 babies screened between June 2011 and March 2012. This allowed identification of children who were lost to follow up from the newborn screen, screening of some missed babies and identification of late onset and progressive hearing losses. OCSHCN partnered with EFAz and the University of Arizona Cooperative Extension T3 program to develop curriculum to provide standardized training to screeners and screening program providing services to families with children between 6 months and 3 years of age. These programs include Head Start, Arizona Early Intervention Program, Community Health Centers and Home Visiting Programs. A significant effort has also been made to ensure that health care providers are informed about screening results and are aware of the requirement that they report to the Department of Health any hearing screening or testing completed on a baby up to two years of age. 124 In 2011, the ADHS Sensory Program used Title V funding to contract with the University of Arizona Train the Trainer (T3) Program to provide vision screening training in addition to hearing screening. During school year 2010-2011, 19 new T3 hearing and vision screening trainers were trained and approximately 760 hearing screeners were trained. Table 4b, State Performance Measures Summary Sheet Activities 1. OCSHCN partners with UA to develop curriculum to provide standardized training to screeners and screening program providing services to families with children between 6 months and 3 years of age. 2. OCSHCN and AzEHDI offer online training for hospital-based hearing screeners and working on updating training with assessment tools and how to communicate screenings to parents. 3. HRPP Community Health Nurses and Health Start Community Health Workers review hearing screening results with parents. 4. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X b. Current Activities OCSHCN and AzEHDI through the EFAz are working on developing the infrastructure to support additional screening. This infrastructure includes partnering with the University of Arizona T3 program to provide standardized training through trained trainers. The EFAz is in the process of implementing the new birth to three curriculum. Ten new trainers have completed the didactic portion of the training and 4 have completed all parts of the program to become trainers including the hands-on and master training observation. 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. HRPP Community Health Nurses and Health Start Community Health Workers continued to review hearing screening results with parents. ADHS Bureau of Women and Children's Health (BWCH) are working with home visiting programs to determine how programs can enhance review of hearing screening. BWCH continues to provide midwives the Arizona Parent Kit to distribute to parents who choose home birth. During this school year 535,001 students were screened and 1,259 were identified with a hearing disorder for the first time. The Sensory Program monitors school compliance with the Arizona Hearing Screening Rules, loans hearing screening equipment to schools upon request and is also responsible for ensuring this equipment has been properly calibrated and repaired if needed. c. Plan for the Coming Year OCSHCN will continue to partner with the EAR Foundation of Arizona and NBS to support ADHS' follow-up efforts. OCSHCN will be working with EAR Foundation of Arizona and other EHDI 125 stakeholders to build infrastructure for screening beyond the newborn period including providing both short term and long term loaner equipment where needed in the community. HRPP Community Health Nurses and Health Start Community Health Workers will continue to review hearing screening results with parents. ADHS Bureau of Women and Children's Health (BWCH) will continue to 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 will continue to direct families to the EAR Foundation of Arizona's HEAR for Kids program for hearing aids, cochlear implant batteries, repairs and audiology testing for children. E. Health Status Indicators Reviewing the 2011data, ADHS is concerned about the disparity between border versus nonborder motor vehicle mortality and morbidity. Health Status Indicators 03C measures the death rate per 100,000 from unintentional injuries due to motor vehicle crashes among youth aged 15 through 24 years. Health Status Indicators 04C measures the rate per 100,000 of nonfatal injuries due to motor vehicle crashes among youth aged 15 through 24 years. The death rates from motor vehicle injuries and the rate of non-fatal injuries continued to decline in 2011, except among 15-24 years old which showed an increase in non-fatal injury and unintentional injuries due to motor vehicle crashes during 2011. The death rate for unintentional injuries due to motor vehicle crashes among youth aged 15 through 24 years had declined each year during the grant reporting period until 2011 when there was a slight increase (13.7 per 100,000) compared to the rate in 2010 (12.2 per 100,000). The rate of nonfatal injuries due to motor vehicle crashes for youth aged 15 through 24 years old increased slightly in 2011. Compared to 2010 (137.6 per 100,000) the rate in 2011 (144.5 per 100,000). Closer review of the data show the rate of injury due to motor vehicle crashes has been higher in border communities than nonborder communities. According to Arizona Vital Records, general (not only 15-24 year old) mortality for unintentional motor vehicle traffic events has decreased since 2005. However the decrease was by 30% for border counties and 39% for non-border counties. There was no significant difference between the border counties and non-border counties for 2010. Non-fatal emergency room discharges for unintentional motor vehicle traffic events (again for all ages) have decreased since 2005, by 20% for border counties and 19% for non-border counties. There was no significant difference between the border counties and non-border counties in 2010. Non-fatal inpatient discharges for unintentional motor vehicle traffic events have decreased since 2005, by 26% for border counties and 36% for non-border counties. While morbidity and mortality among the 15 to 24 cohort must be and in great part is being addressed, the disparity between border and nonborder needs further review. ADHS believes this presents an opportunity to reach out to other border communities, on both sides of the border. ADHS is helping to organize a meeting of border state MCH directors. At the same time discussions are planned with health representatives from the border communities in Mexico and 126 Arizona. For the 15-24 year old cohort, the Title V Community Health Grant program continues to fund several counties to implement education in high schools about driving while under the influence of alcohol. The grants also encourage the counties to look toward policy changes to address this concern by advancing up the spectrum of prevention; moving from education classes to community policy changes. Going forward, we hope the increased collaboration with neighboring states on both sides of the border will help to direct policy and program change to address motor vehicle safety as well as other public health issues. 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. /2013/ /2013/Pediatric orthopedics, neurology, neurosurgery and metabolic services are in place. There is no current telemedicine for hearing screening. //2013 // 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. /2013/ Between October 1, 2010 September, 2011 the Rural Safe Home Network provided 23,565 shelter nights to 313 women, 305 children, and 1 man and non-residential domestic violence services to an additional 3,741 women, 264 men, and 1635 children.//2013// 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 127 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// /2013/ Between November 1, 2010 and October 31, 2011, the program reached 24,063 unduplicated Arizonans with multi-session workshops of primary prevention of sexual violence and education.//2013// Toll-Free Hotlines 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. 128 /2013/ The EMSC program has successfully implemented a pediatric designation process for emergency departments. An additional grant will help rural and tribal hospitals to become certified. //2013// 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. /2013/ Arizona's State Early Childhood Comprehensive Systems Grant is being implemented through the Early Childhood Development and Health Board. The State Systems Development Initiative now resides in the Bureau of Health Status and Vital Statistics. //2013// G. Technical Assistance The ADHS Office of Oral Health requests additional training assistance to create and enhance coordination between ADHS and other state and non-state agencies to promote oral health priorities. There is a need for enhance integration of oral health interventions into other health programs. 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. BWCH requests technical assistance with identification of health promotion curricula that can be applied to children and youth with special health care needs. This is one of the areas of need identified as a result of issuing the new Health Advocacy for Children, Youth and Families RFP. Having evidence-based curricula would be important as we work to promote health and wellness activities/projects within a population whose primary focus has been on addressing only the chronic health needs. BWCH requests technical assistance in developing a border coalition of MCH Directors. 129 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 2011 Budgeted Expended 7090511 5925733 FY 2012 Budgeted Expended 7065379 FY 2013 Budgeted Expended 6941708 612223 1542969 1920000 1420000 7734184 6438295 7625192 7693086 0 0 0 0 31969534 17170668 7472018 7472018 0 0 0 0 47406452 31077665 24082589 23526812 74092038 88008425 53932696 61382212 121498490 119086090 78015285 84909024 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 2011 Budgeted Expended FY 2012 Budgeted Expended FY 2013 Budgeted Expended 1819821 1627665 3713835 3632356 3739081 3216317 5608571 5523094 6097680 6039081 9393274 9573184 33794776 18747418 3845832 3306713 130 Special Healthcare Needs e. Others 1499676 1107998 1158238 1163887 f. Administration 455418 339186 362839 327578 g. SUBTOTAL 47406452 31077665 24082589 23526812 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 93713 100000 100000 c. CISS 0 0 0 d. Abstinence 0 1260250 1302706 Education e. Healthy Start 0 0 0 f. EMSC 130000 130000 130000 g. WIC 0 45136403 42599706 h. AIDS 0 0 0 i. CDC 0 0 0 j. Education 0 0 0 k. Home Visiting 0 0 12045184 k. Other FAMILY 1868628 1766500 1813619 VIOLENCE ORAL HEALTH 384092 384000 384000 WORKFORC PREP 0 1099600 1103821 PROJECT 900000 900000 900000 LAUNCH RAPE PREV ED 640456 624000 624000 SEXUAL 282410 198000 198555 ASSAULT SVCS STATE INJURY 127358 180500 180621 SURVEIL MI&EC HOME 0 1893443 0 VISITING NGIT FASD227669 250000 0 SAMHSA WOMENS HLTH 0 10000 0 CONF 1ST TIME 500000 0 0 MOTHERHOOD CRS 68937712 0 0 Form 5, State Title V Program Budget and Expenditures by Types of Services (II) I. Direct Health Care Services II. Enabling Services III. PopulationBased Services IV. Infrastructure FY 2011 Budgeted Expended 35021005 19413542 FY 2012 Budgeted Expended 4350018 FY 2013 Budgeted Expended 4355595 2306163 1988925 3583506 3459392 4748460 4264542 10765807 10657349 5330824 5410656 5383258 5054476 131 Building Services V. Federal-State Title V Block Grant Partnership Total 47406452 31077665 24082589 23526812 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// /2013/The state's match and overmatch continues to exceed the 1989 maintenance of effort. The budgeted amounts are based on previous year's projections and do not correlate well with the actual budgeted amount because of the unpredictability of the actual award amount and program changes that occur. //2013// 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 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 132 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 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 inter-governmental 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 133 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 inter-governmental 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 high-risk infants, and Reproductive Health services for women. Indirect Administrative Costs: $362,839//2012// /2013/The estimated Title V allocation for Arizona, FFY2013, is $6,941,708. For FFY 2013, 34.75% ($2,412,068) of the Title V Block grant will be allocated for preventative and primary care needs for children and adolescents; 31.71% ($2,201,513) will be allocated to children with special health care needs; 28.82% ($2,000,549) will be allocated for women, mothers, and infants and 4.72% ($327,578) will be budgeted for administrative costs. It is projected that there will be $1,420,000 unobligated funds from our FY2012 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 2013, the state's match and maintenance of effort includes State General, Lottery, Dental Sealant funds. The $9,692,844 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 $15,165,104 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, Abstinence Education Grant Program, Personal Responsibility Education Program, Women Infants and Children, Maternal Infant and Early Childhood Home Visiting Program, and Project Launch. Core Public Health Infrastructure - $2,578,754: Bureau of Women's and Children's Health (Part A & B): $1,377,846 will support the Department's birth defect registry, management service, information technology automation, assessment evaluation and epidemiologic analysis, Child Fatality services, Midwife Licensing, the Empower Program, injury prevention and preconception health, including policy and organizational strategies. Office for Children with Special Health Care Needs (Part C): $1,200,908 will support administrative initiatives, education, training, support services, advocacy and outreach. A Health Advocacy for Children, Youth and Families RFP was issued andthe Office is in the process of awarding community based organizations for projects that will address Title V Priorities. OCSHCN will also fund ADHS' new Population Health Policy IGAs with county health departments that focus on inclusion of CYSHCN within policy, system, and environmental change in Arizona and the 9th Annual Native American Disability Summit. 134 Population-Based Services: $859,798 is budgeted for initiatives that include the Sensory Program, Pregnancy and Breastfeeding Hotline, Breastfeeding Consultation, Immunizations, Early Childhood, Oral Health services for children, injury prevention and preconception health, including raising public awareness and providing community education. Enabling and Non-Health Support: $1,363,383 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: $1,812,195 will support hospital, physician, transport, community nursing services for high-risk infants, and Reproductive Health services for women. Indirect Administrative Costs: $327,578//2013// 135 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. 136