Maternal and Child Health Services Title V Block Grant State Narrative for Arizona Application for 2014 Annual Report for 2012 Document Generation Date: Monday, September 16, 2013 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 ...................................................................................................................... 7 C. Needs Assessment Summary ................................................................................................. 7 III. State Overview ......................................................................................................................... 11 A. Overview ................................................................................................................................ 11 B. Agency Capacity .................................................................................................................... 28 C. Organizational Structure ........................................................................................................ 41 D. Other MCH Capacity ............................................................................................................. 44 E. State Agency Coordination .................................................................................................... 50 F. Health Systems Capacity Indicators ...................................................................................... 56 Health Systems Capacity Indicator 02: .................................................................................. 56 Health Systems Capacity Indicator 03: .................................................................................. 57 IV. Priorities, Performance and Program Activities ....................................................................... 59 A. Background and Overview .................................................................................................... 59 B. State Priorities ....................................................................................................................... 60 C. National Performance Measures ........................................................................................... 68 Performance Measure 01: ...................................................................................................... 68 Form 6, Number and Percentage of Newborns and Others Screened, Cases Confirmed, and Treated ................................................................................................................................... 71 Performance Measure 02: ...................................................................................................... 73 Performance Measure 03: ...................................................................................................... 76 Performance Measure 04: ...................................................................................................... 80 Performance Measure 05: ...................................................................................................... 84 Performance Measure 06: ...................................................................................................... 87 Performance Measure 07: ...................................................................................................... 91 Performance Measure 08: ...................................................................................................... 95 Performance Measure 09: ...................................................................................................... 98 Performance Measure 10: .................................................................................................... 101 Performance Measure 11: .................................................................................................... 104 Performance Measure 12: .................................................................................................... 108 Performance Measure 13: .................................................................................................... 111 Performance Measure 14: .................................................................................................... 114 Performance Measure 15: .................................................................................................... 118 Performance Measure 16: .................................................................................................... 121 Performance Measure 17: .................................................................................................... 124 Performance Measure 18: .................................................................................................... 127 D. State Performance Measures.............................................................................................. 130 State Performance Measure 1: ............................................................................................ 130 State Performance Measure 2: ............................................................................................ 133 State Performance Measure 3: ............................................................................................ 136 State Performance Measure 4: ............................................................................................ 139 State Performance Measure 5: ............................................................................................ 142 State Performance Measure 6: ............................................................................................ 145 State Performance Measure 7: ............................................................................................ 148 State Performance Measure 8: ............................................................................................ 151 E. Health Status Indicators ...................................................................................................... 154 Health Status Indicators 01A: ............................................................................................... 154 F. Other Program Activities ...................................................................................................... 155 2 G. Technical Assistance .......................................................................................................... 158 V. Budget Narrative ..................................................................................................................... 160 Form 3, State MCH Funding Profile ..................................................................................... 160 Form 4, Budget Details By Types of Individuals Served (I) and Sources of Other Federal Funds .................................................................................................................................... 160 Form 5, State Title V Program Budget and Expenditures by Types of Services (II) ............ 161 A. Expenditures ........................................................................................................................ 162 B. Budget ................................................................................................................................. 162 VI. Reporting Forms-General Information ................................................................................... 167 VII. Performance and Outcome Measure Detail Sheets ............................................................. 167 VIII. Glossary ............................................................................................................................... 167 IX. Technical Note ....................................................................................................................... 167 X. Appendices and State Supporting documents ........................................................................ 167 A. Needs Assessment .............................................................................................................. 167 B. All Reporting Forms ............................................................................................................. 167 C. Organizational Charts and All Other State Supporting Documents .................................... 167 D. Annual Report Data ............................................................................................................. 167 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 4 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, 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 5 departments, and nonprofit 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// /2014/ The BWCH website maintained a request for comments and feedback on the 2013 Title V application. Social media including Twitter was used to solicit public input as well. In addition, managers and leadership used public forums to remind attendees of the importance of providing feedback as this document helps determine the direction of maternal child health services in Arizona. Program Managers use site visits as an opportunity to listen to local community concerns. The MIECHV program continued to conduct community forums. //2014// 6 II. Needs Assessment In application year 2014, Section IIC will be used to provide updates to the Needs Assessment if any updates occurred. C. Needs Assessment Summary The Bureau of Women's and Children's Health (BWCH) continues to monitor changes to capacity and population. The Bureau as well monitors emerging issues as they relate to the MCH population and priorities including but not limited to safe sleep, prescription drug poisoning, obesity and teen pregnancy. Findings and reports are posted to the Bureau website and links to larger report updates are posted on Facebook and Twitter. Arizona seems to be coming out of the recession. According to the University of Arizona Eller College of Management, Arizona job growth continued in the first quarter of 2013, with seasonally adjusted state payrolls rising by 1.7% over the fourth quarter of 2012. The state added 46,100 jobs (1.9%) in the first quarter. That was faster than U.S. growth, which hit 1.5% in the first quarter on a year-over-year basis. The population has not changed significantly. The total number of births in 2012 is less than 1% higher than last year. Hispanic births increased only slightly. The state unemployment rate continued to gradually improve in the first quarter, reaching 7.9% on a seasonally adjusted basis; lower than 8.5% reached during the first quarter of 2012 and is similar to the national rate of 7.7%. http://azeconomy.eller.arizona.edu/aze13q3/fiscal_policy_weighs_on_growth.asp There was no further reduction to the ADHS budget during this legislative session. Funding has been added to the SFY 2014 budget for Mental Health First Aid education, to fund dental care and nutrition supplements for eligible people with kidney disease and funding for Medicaid (AHCCCS) was restored and expanded. This change in Medicaid eligibility will provide health coverage to an additional 300,000 low-income Arizonans (earning less than 133% of the federal poverty level) starting January 1, 2014. Additional funds were appropriated for Child Protective Services as well. There have been no significant changes to the system capacity for the Maternal Child Health program. The system continues to be strengthened by the increase in collaborative efforts. The BWCH is a part of the AMCHP Improving Birth Outcomes learning collaborative and has included our sister agencies, counties and the local community based organizations in that effort. The Preconception Health Task Force includes outside stakeholders. The Maternal Infant and Early Childhood Home Visiting program has developed a statewide system of early childhood home visiting now referred to 7 as StrongFamiliesAz. Arizona has not made any changes to the eight priorities selected during the last assessment. Most, if not all of them, require time to see change. A brief look at the state priority needs follows including assessment and some implementation activities include: Reduce Teen Pregnancy: Using Vital Statistics data, teen pregnancy is monitored carefully. Teen pregnancy has continued to drop. A closer review of the border shows that the border and non-border counties have seen a decline in teen pregnancy from 2005 to 2011 overall. Overall in 2011, there was no significant difference when comparing mother's area of residence by border and non-border counties. However, the rate of teen pregnancy among younger teens was slightly higher on the border counties compared to the non-border counties. Among older teens the teen pregnancy rate was lower in the border counties than in the non-border counties. The Bureau is initiating a study to more closely examine the reduction in teen pregnancies. Improve Healthy Weight: Arizona continues to monitor obesity. The Results of the 2011 Maternity Care Practices in Infant Nutrition and Care (mPINC) survey ranked Arizona as 16th in the country compared to 24th as indicated in the 2009 survey. WIC continues to monitor trends as well. The Office of Oral Health conducted the Arizona Healthy Smiles - Healthy Bodies Survey in 20092010. The survey collected heights and weights on third-grade students in public elementary schools across Arizona. Ninety-nine schools were randomly selected and 3,150 students participated across all 15 Arizona counties. The results were analyzed and released this past year. Among the key finding were: one out of every five Arizona third graders was obese, and almost 40 percent met the criteria for either overweight or obesity; overweight and obesity was strongly associated with the FRPM category. The ADHS continues to sponsor EMPOWER, a program addressing obesity in early care and education centers that incorporates physical activity and nutrition standards. Improve the health of Women Prior to Pregnancy: Arizona has implemented many of the strategies outlined in the 20102015 Bureau Strategic Plan including both supporting local infrastructure and increasing public awareness by incorporating preconception health education into many of the Bureau's contracts with county health departments and community based agencies. The use of preconception health materials by community health workers is being assessed in Health Start, as well as two other programs. The Arizona Women's Health Status report is being updated this year as well. Reduce the Rate of Injuries: Injuries are the leading cause of death among Arizonans between 8 the ages of 1 through 44. Unintentional injuries, suicides, and homicides ranked as the three leading causes of death among Arizonans between ages 15 through 44. In 2013, the Office of Injury Prevention published the Arizona Injury Prevention Plan. The report analyzed injury data, documented what is happening now in the state and developed plans to address the issue in the future. In July 2013 the OIP was reviewed by the Safe States State Technical Assessment Team. During 2012, the State Agency Coordination Team (SACT) developed a survey to assess the level of support/services sexual assault service providers across the state are receiving from state-wide organizations and whether the degree of support/services they are receiving is meeting their needs. Results of that survey are being discussed among the provider community. In 2013, Arizona completed the National Pediatric Readiness Assessment which is a multi-phase quality improvement initiative to ensure that all U.S. emergency departments (ED) have the essential guidelines and resources in place to provide effective emergency care to children as part of the EMS for Children's program. Seventy five of Arizona's seventy six hospital ED's completed the assessment. Improve Access to and Quality of Preventive Health Services for Children: Community focus groups have been held in 29 of the 31 communities targeted by the MIECHV grant as being most at risk. A facilitated discussion with community members identifies the strengths of the community that can be leveraged to address unmet needs. Community members describe referral patterns, current services and formal and informal networking. A home visiting model is chosen based on the specific characteristics of individual communities. In addition, focus groups in some communities have identified a common need to build capacity through workforce development, better communication and collaboration between service providers, cultural competency training and funding/sustainability planning. Analysis of immunization data shows an increase in personal exceptions. ADHS is studying this closely. BWCH will continue to monitor ACA implementation in order to better serve our clients. Improve the Oral Health of Arizonans: The Office of Oral Health (OOH) partnered with First Things First and the Arizona Dental Foundation to implement the 2013 Workforce Survey of Arizona Dentists. The primary purpose of the survey was to collect information on the availability and willingness of providers to provide quality low cost care to children under the age of five and to participate in a referral database. In addition, the survey collected information to compare results to the 2003/2004 Arizona Dental Workforce Survey. Work has begun to develop the 2013-14 Arizona Preschool Oral Health Status survey. Improve the Behavioral Health of Women and Children: The home visiting programs continue to 9 assess the behavioral health of women through the use of the Edinburgh Perinatal Assessment tool. During Maternal Mortality Reviews suicide was identified as a concern. The Team will now include a representative from the Division of Behavioral Health Services to look at the system. Reduce Unmet Need for Hearing Services: The Sensory Program in the Office of Children's Health captures the number of school aged children identified with a hearing loss. Additionally, the Office of Newborn Screening has a program manager dedicated to the follow up of infants who failed their initial hearing screen to ensure rescreening and if necessary timely entry into care. Promote Inclusion of CSHCN in all Aspects of Life: Focus groups were facilitated the Maricopa County Dept. of Public Health (MCDPH) as part of work on the Health in Arizona Policy Initiative (HAPI) to support children and youth with special health care needs birth -- 21 years (CYSHCN) through policy promotion. Input gathered from eight focus groups was used to inform the community needs assessment that MCDPH completed in April -- May regarding CYSHCN in Maricopa County. The target audiences for the groups were youth with SHCN, parents/caregivers of CYSHCN and agency providers serving CYSHCN. A presentation of findings from the MCDPH CYSHCN Community Assessment that Saguaro Evaluation Group, LLC completed is scheduled for July 17, 2013. Prepare CYSHCN for Transition to Adulthood: In an effort to assess capacity, OCSHCN developed the Arizona Children with Special Health Care Needs Transition Resource Guide. This document, currently posted on the Youth Transition webpage used 2009/10 NS-CSHCN data to provide a snapshot of youth transition in Arizona as compared to the rest of the nation. 10 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 11 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// /2014/ There was no significant change to the population by percentage, age group or county in 2012.//2014// US Census data indicates that the largest component of growth in Arizona over the last decade has been domestic migration, or people moving to Arizona from other states (49 percent). The next largest component of the population increase was the net natural increase, or the number of births minus the number of deaths. The net natural increase in Arizona accounted for 32 percent of the population growth during the last decade. The remaining growth (19 percent) was from the net international migration, or people moving here from other countries minus the number of people moving out. The rapid growth seen in Arizona as a whole has not been evenly distributed throughout the state. During the years between 1999 and 2009, growth rates in Arizona's 15 counties ranged from a low of two percent in Greenlee County (from 8,535 residents to 8,688) to a high of 89 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// /2014/ In 2012, there were 85,725 resident births, less than a 1% increase from 2011. //2014// 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 12 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// /2014/ In 2012, White Non-Hispanic births comprised 45 percent (38,395) of all births, while Hispanics comprised 39 percent (33,764) of all births compared to 45 percent (38,699) Non-Hispanic and 38 percent (32,399) Hispanic births in 2011. //2014// 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// /2014/ Private litigants continue to challenge in federal courts the fourth provision of SB 1070, the ‘show me your papers' section as it is being implemented in Arizona. //2014// 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 13 less than 1% to 1,271,867. //2013// /2014/ The total number of women of childbearing age increased 5 % to 1,340,296 in 2012. //2014// 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// /2014/ The composition of Arizona's population did not change substantially in the last year. //2014// 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 14 Arizona has consistently ranked lower in the nation per pupil spending compared to the U.S. The National Center for Education Statistics reported that Arizona spent $7,727 per student compared to the nation's average of $10,297 in fiscal year 2008. During the 2008 -2009 school year, Arizona had 586 school districts, including 349 charter holders. These districts housed 1,975 schools and 1,082,221 students in kindergarten through 12th grade. Over 10 percent of Arizona's K-12 students attend a charter school. Educational attainment for adults living in Arizona is similar to the United States. Overall, 84 percent of Arizona residents age 25 and older are high school graduates compared to 85 percent nationally. The most recent American Community Survey report shows that seven percent of adults in Arizona did not complete ninth grade and another nine percent have not graduated from high school. The National Assessment of Educational Progress (NAEP) is an assessment of what America's students know. In 2009, eighth grade students in Arizona public schools ranked 41st in NAEP reading scores. Thirty-two percent of Arizona eighth graders tested below basic skill level for their grade compared to 26 percent nationally. This represents an improvement over the reading levels reported in the previous five-year needs assessment, when 46 percent of Arizona 4th graders read below proficiency, compared to 38 percent in the rest of the nation. NAEP reading achievement varied considerably by race and ethnicity. Higher proportions of Native American, Hispanic, and Black public school students tested below the basic level in reading achievement, while Asian students were more likely to test at proficient or higher. In fiscal year 2008, 4 percent of students dropped out of public school from grade seven through nine. This represents an improvement over the dropout rates from the 2003-2004 school- year of 6 percent. The dropout rate for boys (4 percent) was somewhat higher than the dropout rate for girls (3 percent). However, the dropout rate among Native America students was twice the statewide rate. The Arizona Department of Education also tracks cohorts of students and measures the percent who graduate within four years. The graduation rate for the cohort that would be expected to graduate by 2007 was 73 percent. Girls were more likely to graduate within four years (78 percent) than boys (69 percent). However, the graduation rate varied considerably by race and ethnicity. Only 55% of Native Americans completed high school in four years, while 81% of White students graduated in four years. /2014/ High school dropout rates have not significantly changed. The rate increased from 4.3% in 2011 to 4.5% in 2012. //2014// 15 /2014/ Arizona has developed a significant focus on early childhood education. The Early Childhood Development and Health Board, known locally as First Things First, continues to invest heavily in a Quality Rating system for early care and education, scholarships for families unable to pay and professional development for early care and education teachers. This investment is funded through tobacco tax. //2014// 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 16 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 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// /2014/ Review of the current Kaiser Measure of State Economic Distress shows that Arizona's overall foreclosure rank is now 7th and there has been no change in the percent of monthly food stamp participation between October 2011 and 2012. Again Arizona showed improvement relative to the other states in the percent change in unemployment (38th). Arizona's unemployment rate as of May 2013 is 7.9 percent. //2014// 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 17 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// /2014/ More Arizonans live in poverty. The 2011 American Community Survey (ACS) showed 19 percent of Arizonans living in poverty (17.4 percent in 2010), an increase from previous years. Poverty among women increased to 19.7 percent, children under 18, 27.2 percent, American Indian and Alaskan Natives 40.2 percent and Hispanic or Latinos 29.6 percent. //2014// THE ARIZONA STATE BUDGET The majority of the Arizona state general fund is spent on education. Forty-two percent of the general fund goes to elementary and secondary education and another 13 percent is used for higher education. The next largest expenditures are Medicaid (16 percent) and corrections (11 percent). Rankings of Arizona spending relative to other states prior to the recent recession showed that Arizona spent more per capita on police and fire protection (rank = 11) and corrections (rank = 13), and less on highways (rank = 35), health and hospitals (rank = 37), public welfare (rank = 38), and local public schools (rank = 48). Figure 3.14 shows Arizona's state and local government expenditures as a percent of the national average for state fiscal year 2006-2007. Arizona's tax base depends heavily on income and sales taxes, which have been affected by the recession. A reduction in revenues generated by income and sales taxes, together with numerous tax cuts over the last 15 years, has resulted in a decline in state general fund revenues. State tax revenues have declined 34 percent in the past three years. Since the recession began in state fiscal year 2007, sales tax revenues have decreased 22 percent, personal income tax revenues have decreased 38 percent, and corporate income tax revenues have decreased 57 percent. In state fiscal year 2009, Arizona had the largest decrease (42.5 percent) in income tax in the nation. While the general fund used to receive $50 in revenue per $1,000 of personal income in the mid 1990's, it currently receives less than $30. A structural deficit was created as taxes were permanently reduced during years of high revenues without corresponding decreases in the budget. Even when the economy recovers and begins to 18 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. 19 • Stopped accepting new families in its child care assistance program in February, 2009 (denying assistance to more than 10,000 children.) Over the past three years, ADHS has dramatically reduced spending and staffing levels in an effort to bring spending in line with state revenues. Excluding the money that goes toward the matching funds that are required for Medicaid (AHCCCS), Behavioral Health and Children's Rehabilitative Services, the overall ADHS General Fund budget has been reduced by more than 47 percent during the past 3 years. Seventeen million dollars in operating budgets were cut during that time period, including the entire licensure budget of $10 million. Fiscal Year 2010 cuts include: • Suspended enrollment in Children's Rehabilitative Services for more than 4,000 children who are not enrolled in AHCCCS; • Reduced approximately 8,800 home visits to newborns discharged from neonatal intensive care, and enrolled in the High Risk Perinatal Program; • Suspended all prenatal block grants to county health departments for services to 19,000 women and children; • Eliminated the Hepatitis C and Valley Fever public health prevention programs; • Reduced county contracts for tuberculosis care by more than 50 percent; • Eliminated all state funding for children's vaccines; • Suspended remaining HIV surveillance contracts with Maricopa and Pima County; • Suspended remaining county grants for diabetes prevention; • Suspended all retinal and podiatry screenings for diabetics; • Suspended all grants to counties for public health personnel; • Reduced support for both Arizona Poison Control Centers by more than 50 percent; • 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. 20 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// /2014/ An attempt to reauthorize the one percent sales tax failed and the tax ended January 1, 2013. This has not however resulted in any additional cuts to programs affecting women and children. //2014// 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 government-sponsored 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 21 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 statesponsored, guaranteed issue health insurance program for small businesses and public servants. The Arizona Health Care Cost Containment System (AHCCCS), Arizona's Medicaid agency, oversees and administers the program. Since inception, HCG has undergone several substantial changes, the most notable occurring in 2004 when the Arizona State Legislature eliminated the state subsidy that had supported the program since 1999. Beginning in fiscal year 2005, the program has operated entirely from premiums paid by subscribers. Enrollment has continued to grow, more than doubling between 2004 and 2006, with March 2007 enrollment reaching 26,062 medical plan members. HCG also offers a dental and a vision plan, bringing the total enrollment in all plans to 45,521 and making HCG one of the largest state initiatives to provide health insurance for small businesses nationwide. Arizona Health Care Cost Containment System Arizona was the last state in the nation to implement a Title XIX Medicaid program. After much debate, the legislature rejected traditional fee-for-service financing arrangements in favor of an innovative plan for Medicaid managed care. The Arizona Health Care Cost Containment System (AHCCCS -- pronounced "access"), is today the state's Medicaid program, representing the single largest source of health insurance for Arizonans, providing coverage to over 1 million people. Currently there are over 52,000 AHCCCS-registered providers throughout the State, including approximately 80 percent of Arizona's physicians. The acute care program accounts for the greatest percentage (97 percent) of the AHCCCS population, and includes both Title XIX and Title XXI. The vast majority of Acute Care recipients include children and pregnant women who qualify for the federal Medicaid program (Title XIX). American Indians and Alaska Natives may choose to receive services through either the contracted health plans or the American Indian Health Program. The only other population not enrolled in a contracted health plan includes individuals who, because of immigration status, qualify for emergency services only. 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, 22 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 23 reductions to the amount of respite care available to families of children with special health care needs. //2012// /2012/ The Arizona Legislature passed a Medicaid Reform Package that will eliminate AHCCCS coverage for specific categories of people, including childless adults, people on a Medical Spend-Down Program, and parents earning 75% to 100% of federal poverty level. In total, an estimated 130,000 to 160,000 are expected to lose medical coverage during the next 12 months, pending federal approval. //2012// /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// /2014/ With the strong support of Governor Brewer, on June 17, 2013 AHCCCS (Medicaid) funding was restored. This will restore coverage for childless adults who are eligible for AHCCCS under the voter mandated Proposition 204. This will also include coverage for adults from 100-133% of the federal poverty level, beginning January 1, 2014. Additionally, preventive well exams have been restored. //2014// 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 cranial-facial disorders, tracheal-esophageal fistula, scoliosis, juvenile arthritis, muscular dystrophy, osteogenesis imperfecta, spina bifida, cystic fibrosis, sickle cell anemia, metabolic and endocrine disorders, neurofibromatosis, heart conditions, Hirschsprungs disease, hydrocephalus, glaucoma, neurosensory disorders, broncho pulmonary dysplasia, and many congenital anomalies. Members typically have more than one diagnostic condition, and are involved in multiple systems of care across childserving 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. 24 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 State-Only services, and approximately 4,000 members were disenrolled from CRS. Consequently, only members who are enrolled in an AHCCCS Health Plan remain enrolled. /2012/ The CRS program was moved from ADHS to AHCCCS in January 2011. Services for CRS members remain the same. //2012// General and Special Hospitals According to the Arizona Department of Health Services Division of Licensing Services, there were 64 general acute care hospitals in the State of Arizona in 2009, with 13,245 beds and 34 specialty hospitals with 2,433 beds. There are two children's hospitals, both of which are located in the Phoenix metropolitan area. In 2007, the state overall had 2 hospital beds per 1,000 population compared to the national average of 3 per 1,000. Arizona ranks 46 in the number of hospital beds per 100,000 population. Neonatal intensive care units and continuing care units are classified by the level of care they are capable of providing. In Arizona, while hospitals are licensed by the ADHS Office of Licensing, perinatal care facilities are certified by the Arizona Perinatal Trust, a nonprofit organization established in 1980 and dedicated to improving the health of Arizona's mothers and babies. The levels of neonatal care are built on the classification system of the American Academy of Pediatrics with some Arizona specific differences. The Level III facilities are the highest level and are capable of caring for all neonates, while Level I provides services for low-risk obstetrical patients and newborns, including cesarean section at 36 weeks gestation and greater, and In Hospital Birthing Centers, only found within Indian Health Service. In Arizona, there are currently nine Level III, six Level II EQ, fourteen Level II, nine Level I hospitals and two InHospital Birthing Centers. /2014/ As of June 2013, there are ten Level lll, seven Level llE, fifteen Level ll, eight Level l and two In Hospital Birthing 25 Centers certified by the APT. //2014// Disproportionate share hospitals (DSH) are hospitals that serve large numbers of Medicaid, lowincome, and uninsured patients. In the DSH program, a state makes a separate payment to a hospital in addition to its standard Medicaid reimbursement which is reimbursed by the federal government based upon the state's Medicaid matching rate. The American Recovery and Reinvestment Act of 2009 (ARRA) provided a temporary increase of about $3 million in Arizona's DSH allotment for Fiscal Years 2009 and 2010. However, due to state budget cuts, DSH payments were reduced by over $25 million in Arizona during Fiscal Year 2010. Professional Health Care Providers Arizona has 12,436 physicians, 58,441 registered nurses, and 3,633 dentists. The majority of physicians (87 percent), nurses (80 percent), and dentists (82 percent) practice in either Maricopa or Pima County. Federal regulations establish health professional shortage areas (HPSA) based on three criteria: the area must be rational for the delivery of health services, more than 3,500 people per physician or 3,000 people per physician if the area has high need, and healthcare resources in surrounding areas must be unavailable because of distance, over-utilization, or access barriers. As of May 2010, 63 areas in Arizona are federally designated as Primary Care HPSAs, 51 areas are designated as Dental HPSAs, and 6 areas are designated as Mental HPSAs. According to the Arizona Department of Health Services Bureau of Health Systems Development, Arizona has a shortage of 242 FTE primary care physicians. Federal regulations also establish medically underserved areas/populations (MUA/MUP) based upon four criteria: ratio of primary medical care physicians per 1,000 population, infant mortality rate, percentage of population below the federal poverty level, and percentage of population 65 years and older. As of May 2010, 49 areas in Arizona have federal MUA/MUP designations. Additionally, Arizona has developed its own designation system for identifying under-served areas. All federally designated HPSAs are automatically designated as Arizona shortage areas. 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. /2014/ As of January 2013, there are a total of 389 federally designated Health Professional Shortage Areas (HPSAs) consisting of 141 primary care, 154 dental, and 94 mental health designations, as well as 36 Medically Underserved Area (MUA) and 10 Medically Underserved Population (MUP) designations. Arizona needs a total of 699 full-time providers to practice in underserved areas (313 primary care, 250 dentists, and 136 psychiatrists) to eliminate these designations. It is 26 important to note that the data from 2010 reflected geographic and population HPSAs, and not the facility HPSAs. At that time designations were counted by hand. ADHS now utilizes the "HRSA in your state" website that lists the number of designations which include facilities.//2014// /2014/ Title V funds will be used to support surveillance of oral health workforce capacity. //2014// According to the American Medical Association Masterfile, there were 57,698 general pediatricians in the United States in 2007, representing about 8 pediatricians per 10,000 children age 0-17. Arizona has 914 general pediatricians, representing 5 pediatricians per 10,000 children age 0-17. The majority of pediatricians practice in Maricopa (68 percent) and Pima (22 percent) Counties. A recent survey of primary care pediatricians raised significant concerns about the adequacy of children's access to pediatric subspecialists, especially in rural communities. CYSHCN often require services provided by pediatric specialists and sub-specialists. An analysis of data on pediatric subspecialty practices nationwide estimated the size of the pediatric population that would be necessary to sustain a subspecialty practice. Depending upon the kind of subspecialty, estimates ranged from a low of 100,000 children per specialist to 200,000 children per specialist. By this estimate, there are only two areas in Arizona with pediatric populations large enough to support pediatric subspecialty practices: Maricopa and Pima Counties, which is where Phoenix and Tucson are located. There is also a shortage of pediatric physical, speech, and occupational therapists, which results in approximately one in four children with special health care needs in Arizona having an unmet need for these services, according to the 2005/2006 NS-CSHCN. /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 NSCSHCN.//2013// /2014/ In collaboration with First Things First, the Arizona Department of Health Services offers an incentives program to pediatric therapists providing early intervention services to young children in underserved regions of the state. Speech and language pathologists, occupational therapists, physical therapists, mental health specialists, and child psychologists, working in eligible service sites may participate in student loan repayment and/or stipend programs created to increase the number of early intervention service providers. Currently twenty-six therapists are participating in the Early Childhood Therapists Incentives Program and are serving children in nine regions of Arizona. //2014// Community Health Centers Community health centers were established in the 1960s by federal law to treat and provide primary care to all patients 27 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 one-time 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 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 28 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 29 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 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 30 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. 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. /2014/ One of the Hot Line Certified Lactation Consultants became an IBCLC. //2014// 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 31 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 infrastructurebuilding 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 32 federally funded Sexual Violence Prevention and Education Program reached 25,719 Arizonans with primary prevention education in the last fiscal year. The program worked with multiple stakeholders to develop the first state plan specific to the prevention of sexual violence. In 2009, BWCH accepted its first federal funding for direct services for victims of sexual assault. Capacity of Arizona's Title V Program to Provide Preventive and Primary Care Services for Children Medical Services Project To help improve access to care for children, BWCH provides Title V funding to the Medical Services Project. Administered through the Arizona chapter of the American Academy of Pediatrics, the Medical Services Project increases access to and utilization of primary care services for Arizona's uninsured children from low-income families. The Medical Services Project provides delivery of medical services in participating physicians' offices to children without health insurance and to those who do not qualify (or are in the process of qualifying) for public assistance. School nurses identify children who are eligible to participate in the Medical Services Project and facilitate their enrollment. To be eligible for the Medical Services Project a child must have no health insurance, must not be eligible for AHCCCS, KidsCare, or Indian Health Services; and must have a household income less than 185 percent of the federal poverty level. A network of physicians (pediatricians, family practice physicians, and specialists) provides care to children qualifying for the Medical Services Project for a fee of either $5 or $10 as payment-in-full 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 33 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 unfunded state mandate, BWCH dedicates Title V dollars to support the program. The Office of Oral Health contracts with county health departments to provide schoolbased 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. /2014/ The Workforce grant ended in 2012. Sustainability was built into the program from the beginning through collaboration with other state agencies. First Things First is funding teledentistry in Navajo County. //2014// 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 schoolbased sealant programs. /2012/ Funds have not been appropriated yet for any of the oral health initiatives included in the health care reform legislation. //2012// 34 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// /2014/ The Office of Injury Prevention now includes a second program manager. This position's responsibilities include Safe Kids Arizona, the safe sleep task force and professional development of home visitors about safety related issues. //2014// 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 comprehensive teen pregnancy prevention. County health 35 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 evidencebased home visiting programs. ADHS will continue to work with partners on development of infrastructure for home visiting in Arizona. //2012// /2014/ Arizona's Maternal, Infant, and Early Childhood Home Visiting Program has implemented home visiting programs and/or capacity building plans within communities that ranked as high risk based on several indicators. The evidence based models, Healthy Families or Nurse Family Partnership, have been implemented in 25 communities and 6 communities have received support for capacity building. Family Spirit is a promising practice tailored to the Native American culture and is being implemented within the White Mountain Apache Tribe. Arizona's early childhood home visitors have formed an alliance, StrongFamiliesAZ, out of the original MIECHV Task Force. The alliance works together on system building. Professional Development opportunities have been offered to home visitors throughout the state on the topics of breastfeeding, infant mental health, car seat safety, domestic violence, and an annual two day statewide home visiting conference covering multiple topics specific to the unique needs of home visitors. //2014// /2014/ In order to better provide preventive and primary care services for the maternal and child health population, ADHS is working to link data within the agency. Fully integrated with the hearing screening database, Vital Records demographic data is sent daily to Newborn Screening. The information includes NICU status, birth 36 weight or APGAR scores, and assigns a unique identifier if there is no medical record number. The algorithm sustains 90% and above matching rates. Elimination of duplicate records and/or incomplete records and accuracy of demographic information for babies who failed their hearing is the key for timeliness and effective follow up.//2014// 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, trachealesophageal 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 childserving 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 37 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 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 38 child has a special health care need can represent a challenge to one's cultural expectations. Every family has expectations about what life will be like when their baby is born. Assumptions are made about parents' job participation, daycare, healthcare, school, and the child's integration into everyday family life and ultimately transition to adult life and independence. Different cultures have different ideas about what the special healthcare means and what a family should do or not do. But families also must now renegotiate their every day expectations in ways that their culture did not prepare them. Institutions, such as healthcare, education, and work, are all designed with certain assumptions and rules for what is acceptable and how to participate. These assumptions and rules may present barriers to a person with special healthcare needs, who must constantly find ways to negotiate expectations. Sometimes personal adaptations are needed, but often full participation requires institutional change in terms of policies and practices. In order to ameliorate the harmful effects of failing to appreciate another's everyday reality, OCSHCN promotes cultural relativism. Activities are designed to promote an understanding that your experience of the world is only one of many possibilities, and you cannot judge a culture using the standards of your own culture. Activities are not so much oriented towards trying to understand the intricacies of every other potential cultural belief system, which can have the unintended consequence of stereotyping (which is an over-generalization about a group) but to sensitize staff towards listening for what others may be thinking and remaining open to hearing their points of view and adapting to it. Nowhere is it more critical to appreciate one's taken for granted assumptions than when a health care provider and a family must together decide on an appropriate course of treatment. The provider brings his or her own assumptions of what is necessary and good, which are influenced by their cultural expectations and training. They may have their own feelings about the child, and may be oriented towards a cure or amelioration of disability. The family's priorities could be different, but they are dependent upon the provider to help them to understand risks and possibilities of different treatment options. OCSHCN embeds cultural competence concepts into contract language and training, which go beyond requirements for reading level, interpretation, translation, and alternative formats, and include best practices for family-centered care, including people-first language and disability etiquette. Satisfaction surveys are conducted and analyzed to identify areas of strengths and opportunities for improvement. OCSHCN involves families and youth with special health care needs in policy and resource development, and makes translation and interpretation services available to other community partners. OCSHCN's cultural competence committee brings in regular speakers to address the unique perspectives of culturally diverse groups. 39 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 CDROMs on orientation to Culturally and Linguistically Appropriate Services (CLAS) standards. Additional courses on CLAS standards are in the process of development. ADHS is working on integrating CLAS standards into the orientation process required of all new employees. Health Start is designed on the principle that workers reflecting the neighborhoods in which they serve will be effective in identifying women in their community who need services. Health Start hires and trains lay health workers from targeted neighborhoods to provide outreach and services to pregnant women and new moms in their community. Project LAUNCH, provides evidence-based services for children ages 0-8 years and their families in neighborhoods in South Phoenix, which has a significant minority population. The program has as one of its guiding principles investing in the community to ensure cultural competence and sustainability by encouraging hiring staff and contracting with organizations from within those neighborhoods. The Office of Women's Health has implemented a social marketing campaign targeting African Americans around a message of preconception health. The campaign consists of radio spots, billboards, brochures, mood piece, website and Eblasts, 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. /2014/ The BWCH is assessing the degree to which contracts require cultural competency 40 training, the availability of TA to support cultural competency and the degree to which BWCH staff has been trained in cultural competency. //2014// /2014/ ADHS is working towards national public health accreditation in an effort to demonstrate the ability to deliver on the ten essential public health services and the three core functions at a high quality level. Currently, ADHS is working on completing the three prerequisites: a strategic plan, a state health assessment, and a state health improvement plan. ADHS will submit a Statement of Intent to PHAB this month. Through the accreditation process we are utilizing performance improvement tools to bring transparency to our work and demonstrate progress towards achieving targeted public health outcomes. Our ultimate goal is to strengthen our partnerships and our Agency functions to better meet the challenges of the future. //2014// 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 41 in the city of Phoenix. This location enhances collaboration between ADHS divisions as well as other state agencies. Structure of Bureau of Women's & Children's Health The organizational structure of the Bureau of Women's & Children's Health is comprised of four offices and two sections: Office of Women's Health, Office of Children's Health, Office of Oral Health, Office of Assessment & Evaluation, Injury Prevention & Child Fatality Section, and Business & Finance Section. An organization chart is attached. The Office of Women's Health provides leadership for planning, program development, and program management of initiatives and programs related to women. Programs include: teen pregnancy prevention, reproductive health services, sexual violence prevention and education, sexual assault services, family violence prevention and services/Rural Safe Home Network, Health Start, and First Time Motherhood. The office lead's the bureau's preconception health initiative and the Department's Women's Health Week activities. The Office of Children's Health provides leadership for planning, program development, and management of initiatives and programs related to children. Programs administered by this office include the Title V Community Health Grants, Pregnancy & Breastfeeding/Baby Arizona/WIC Hotline, Children's Information Center, High Risk Perinatal Program, Sensory Program, Medical Services Project for uninsured children, Project LAUNCH, and early childhood initiatives. The Office of Oral Health (OOH) provides leadership for planning, program development, and management of oral health initiatives. The office administers the school-based sealant program, fluoride mouthrinse program, and first dental visit by age one campaign. OOH provides technical assistance, training, and workshops for community fluoridation campaigns, and works to develop the current dental workforce by creating linkages with the Bureau of Health Systems Development scholarship and loan forgiveness programs. OOH administers a HRSA Oral Health Workforce grant which is developing teledentristry sites to provide oral health services to underserved populations. Injury Prevention & Child Fatality Review Section leads the Department's assessment of injuries and child fatality, as well as planning and program development for injury prevention. This section includes overseeing the state injury prevention plan, injury prevention advisory council, injury epidemiology, Child Fatality Review Program, Unexplained Infant Death Council, Emergency Medical Services for Children Program, and the Pediatric Advisory Council for Emergency Services. /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// 42 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 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. 43 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// /2014/ OCSHCN has added a program, Health Advocacy for Children, Youth and Families, which contracts with two community based organizations to increase participation in health and wellness activities for children and youth with special healthcare needs.//2014// 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 44 Director of the Division of Public Health Services, and has been with ADHS since 1992. Mr. Humble holds a Masters Degree in Public Health with an emphasis in environmental science. He has served as chief of the Office of Environmental Health and was the Assistant Director of Public Health Preparedness in ADHS. Jeanette Shea is the Assistant Director of Public Health Prevention Services in the Division of Public Health. Ms. Shea has served in many public health leadership positions, and was formerly the Title V and MCH Director. A Master's Degree in Social Work with specialization in planning, administration, and community development, combined with professional experience in case management and as a Medicaid policy specialist brought Ms. Shea to public health in 1990 as manager of the Teen Prenatal Express Program. Laura Nelson, MD, joined ADHS in September 2005 and currently serves as the Deputy Director for Behavioral Health Services. She was also recently appointed as ADHS Chief Medical Officer, and will be leading the agency in developing and implementing medical policy. Dr. Nelson previously served as the Associate Medical Director at the Arizona Department of Economic Security/Division of Developmental Disabilities. 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. /2014/ Furloughs ended in 2011. The agency has been able to begin hiring in a limited fashion. A temporary pay increase that went into effect in September of 2012 for state employees was made permanent with the SFY 2014 state budget. //2014// 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 45 V needs assessment and application processes. Sheila Sjolander has been the MCH Director and Bureau Chief of Women's & Children's Health since October 2005. She began her service with the Bureau of Women's & Children Health in 2001 as a manager overseeing several programs and leading the bureau's planning functions. Ms. Sjolander previously held strategic planning positions with the Wisconsin Department of Health Services and a workforce development agency in Oregon. She holds a Master's Degree in Social Work with an emphasis on planning and policy. Syed (Khaleel) Hussaini has led the Office of Assessment and Evaluation since January 2009. Dr. Hussaini has been an international consultant previously and has conducted several research and evaluation studies, including a 2007 evaluation of the Health Start Program which was published in a peer-reviewed journal. He received his Ph.D. in Sociology from Arizona State University. Doug Ritenour has served as the Bureau's MCH epidemiologist since January 2008. Mr. Ritenour has taken a lead role in producing data for the five-year needs assessment and Title V application, and presented data to the public at public input sessions. He holds a Masters in Public Health from Oregon State University. Toni Means serves as the Office Chief of Women's Health. Ms. Means has 18 years of progressively responsible program management experience, and has served in the Bureau of Women's & Children's Health since 1991. Ms. Means received a Masters in Business Administration in Health Care Management from the University of Phoenix. Mary Ellen Cunningham is the Chief of the Office of Children's Health. Ms. Cunningham has led the Bureau's High Risk Perinatal Program since 2005. Formerly with the U.S. Navy, Ms. Cunningham is a registered nurse with a Masters in Public Administration. Julia Wacloff joined the Office of Oral Health as Office Chief on July 6, 2009. Ms. Wacloff previously worked with Office of Oral Health as a consultant for 13 years. She holds a Master's degree in Dental Public Health and is a registered dental hygienist. She most recently served as an epidemiologist with the Centers for Disease Control and Prevention. Tomi St. Mars serves as the manager of the Injury Prevention & Child Fatality Section, and has lead the Department's injury prevention initiatives since August 2005. Ms. St. Mars is Arizona's representative to the State and Territorial Injury Prevention Directors Association, an active member of the Emergency Nurses Association (ENA) at the national and state level and is a 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 46 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// /2014/ Irene Burnton became the Chief of the Office of Children's Health. Previously Ms. Burnton was CEO of the O'Connor House, a nonprofit organization begun by retired US Supreme Court Justice Sandra Day O'Connor and as a member of the Governor's Executive staff where she managed the Children's Cabinet and the Office of Children, Youth and Families. She also was Director of the Governor's School Readiness Board where she worked with stakeholders to develop a multi-year state strategic plan that served as a blueprint for action on early childhood health and development. Dyanne Herrera was promoted to become the Chief of the Office of Assessment and Evaluation. Ms. Herrera was previously the Bureau's MCH epidemiologist. Prior to that Ms. Herrera served as a CDC/CSTE Epidemiology Fellow where she has worked on MCH capacity building in the border region. She 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. //2014// 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, 47 strategic planning, needs assessment, reimbursement design, and community outreach. In addition to serving as the CSHCN director for title V, she is the administrator of the Children's Rehabilitative Services Program. Michael S. Clement, MD, serves as the medical director for Children's Rehabilitative Services. Dr. Clement received his medical degree from the University of Utah in 1963. He holds a current medical license in Arizona, and is a board certified pediatrician. Dr. Clement has previously served as an assistant director at ADHS, the director of a county health department, the director of Ambulatory Services at Phoenix Children's Hospital, and as a consultant to the Arizona Perinatal Trust. He is a fellow of the American Academy of Pediatrics Cynthia Layne has served as the chief financial officer for OCSHCN since 2002. She is a certified public accountant, and has held positions as a financial consultant at AHCCCS and in the Auditor General's Office and in private industry before coming to ADHS. Jennifer Vehonsky is the division chief for policy and contract compliance. She has extensive experience with Medicaid program administration and policy development, and was formerly the Bureau Chief of Policy at ADHS/BHS and assistant to the legislative liaison at AHCCCS before joining OCSHCN. Stephen Burroughs is the division chief for Medical, Utilization, and Quality Management. Mr. Burroughs is a registered nurse with a Bachelor of Science in Nursing. He formerly held positions as quality director, quality manager, and risk manager for hospitals and managed care organizations. Margery Ault is the division chief of Consumer Rights for both OCSHCN and BHS. Ms. Ault holds a Juris Doctor, and has been the division chief of Consumer Rights since October of 2000. Ms. Ault brings to OCSHCN over 15 years of experience in managed health care operations for persons who have special health care needs. Judith Walker joined OCSHCN in 2002, and leads the Division of Member and Provider Services, Education and Advocacy. She has over 24 years as an educator on best practices regarding including children and youth with special needs in all aspects of life throughout the lifespan, and is a recognized leader in medical home, transition to adulthood, and community development. Ms. Walker led nationwide technical assistance on early intervention to parent training and information centers. She has testified on behalf of CSHCN at state and federal hearings on health care, early intervention, special education, and inclusion. She is also the parent of an adult with special health care needs. Lisa Anne Schamus leads the Division of Assessment and Evaluation. She holds a Master of Public Health with an emphasis in Epidemiology, and a B. A. in Spanish Literature. Ms. Schamus 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 48 Family Planning Council. Ms. Schamus has over 15 years experience guiding program development and improvement through in research and survey design, data analysis, needs assessment and program evaluation. Jennifer Jung is the Research Manager in OCSHCN. She has worked at ADHS for five years and has a Master of Science degree in Public Health. She has experience in epidemiological and health services research related to Women's and Children's Health as well as Children with Special Health Care Needs. She is skilled in designing reports and conducting data analyses using SAS. She maintains databases, performs data validation to ensure data quality, and establishes methodologies for analysis. Thara Maclaren manages special projects for OCSHCN, including overseeing survey activities. She holds a Bachelor of Science in Mathematics and a Master of Science in Economic Systems and Operations Research. Ms. Maclaren has worked in several industries including defense, utilities, education, and public health. She joined OCSHCN in June 2006, and her expertise in mathematical modeling, decision analysis, and experimental design supports program decisions and operations within OCSHCN. She contributed statistical support for the needs assessment process. Role of parents of CSHCN on staff: OCSHCN has a long history of involving parents of CSHCN and youth with special health care needs in program development and decision making. This is accomplished primarily by using families of CSHCN and YSHCN in paid consultant roles. There are several full time staff who are parents of CSHCN, including two of the division chiefs described above, and a few others, who did not choose to share their family information in this application. However, the following two people who play key professional roles in OCSHCN shared the following information. Marta Urbina serves as the Clinical Programs Executive Coordinator, chairs the cultural competency committee, and is responsible for information and referral. Ms. Urbina first learned the importance of understanding the multiple, complex systems of care when she became a parent in 1982. Her experience began with the neonatal intensive care unit and continued to community based supports and services that included early intervention, transition to preschool, navigating the special education system and transitioning to adult life. She immersed herself in her daughter's medical and educational needs and sought out training, workshops and conferences to learn to better advocate on her daughter's behalf until she could do so for herself. Ms. Urbina has worked at Raising Special Kids and the Division of Developmental Disabilities, with families of CYSHCN, adults living independently in their community, and with professionals that support them. Rita Aitken serves as a Title V outreach coordinator for OCSHCN. Ms. Aitken has two adult 49 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 50 Chapter of Academy of Pediatrics, and Ronald McDonald House among others. Participation in coalitions, networks, and associations has been a critical strategy in partnership development. Staff actively participates in groups such as the Arizona Public Health Association, Arizona Rural Women's Health Network, Arizona Asthma Coalition, Taskforce on Alcohol and Drug-Exposed Infants, Arizona School Nurse Consortium, Rocky Mountain Public Health Education Consortium, the Arizona Association of Community Health Centers, the Arizona Developmental Disabilities Network (consisting of the Institute for Human Development University Center of Excellence for Developmental Disabilities (UCEDD), Sonoran UCEDD, Arizona Developmental Disabilities Planning Council, Arizona Center for Disability Law, local oral health coalitions, and the Arizona chapters of the Dental Association and Dental Hygiene Association. ADHS also leads collaborative efforts to address specific public health issues. For example, ADHS coordinates an Injury Prevention Advisory Council that works on development and implementation of the state injury prevention plan. ADHS also coordinates the Pediatric Advisory Committee for Emergency Services, which helps facilitate accomplishment of performance objectives of the HRSA Emergency Medical Services for Children Program. The Unexplained Infant Death Council and State Child Fatality Review Teams address deaths of children and strategize around areas of preventability. The Office of Oral Health has established regional oral health workgroups to facilitate strategic planning for the state oral health workforce plan. Staff works with University of Arizona to develop services for children with neuro-developmental and related disabilities. In addition, ADHS has multiple partnerships in place with higher institutes of learning that provide education for the health professions. For example, staff participates on advisory boards, provide technical assistance and consultation on public health curricula, and mentor students. Most ADHS maternal child health programs contract with local organizations to carry out the mission of the programs. These organizations are primarily county health departments, non-profit human services agencies, and community health centers. Programs coordinate regular contractor meetings to provide educational opportunities, technical assistance, and opportunities for networking. Collaboration with other state agencies occurs on a regular basis. The Governor's Office for Children, Youth, and Families facilitates monthly meetings of the State Agency Coordination Team, which is comprised of all state agencies providing any kind of services related to domestic violence and sexual violence. The State Interagency Coordinating Council for Infants and Toddlers, which includes Department of Economic Security(DES)/Arizona Early Intervention Program (AzEIP), AHCCCS, 51 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// /2014/ BWCH has become an active participant of BUILD Arizona, a coalition of business leaders (Chamber of Commerce, Freeport McMoRan), philanthropy (Helios Foundation, Virginia Piper Charitable Trust), nonprofit executives, public sector representatives (Governor's Office of Education Innovation), educators, health and other practitioners working toward the shared goals of ensuring children, by age 5, have a solid foundation for success in school and that all children read at the highest level, based on their development and ability, in the third grade. //2014// /2014/ ADHS holds a two part data sharing agreement with DES to exchange both programmatic MIECHV data and securely exchange DES child abuse data. Each quarter, DES matches BWCH MIECHV enrollments to the CHILDS database so the program can report suspected, substantiated, and first-time child abuse as part of the federal MIECHV requirements.//2014// /2014/ BWCH monitors and utilizes maternal child health assessments completed by outside partners including First Things First, county health departments and advocacy groups. //2014// BWCH and OCSHCN collaborate with the Division of Behavioral Health Services (BHS) on the Arizona Children's Executive Committee which includes partners from Department of Economic Security, Department of Juvenile Corrections, Department of Education and the Administration of the Courts to ensure that behavioral health services are being provided to children and families. Staff collaborates on the Building Partnerships for Quality Care contract that funds two community organizations to involve family and youth partners in agency decision-making. 52 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 53 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 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. /2014/ The Bureaus of Women and Children's Health, Tobacco and Chronic Disease Prevention and the Office of Environmental Health work together on a ASTHO CQI demonstration project to develop a home visiting home safety assessment that included environmental concerns, lead and asthma triggers and referral to chronic disease self management for adults in the home as indicated as well as traditional injury concerns. Four county health departments piloted the tool. //2014// 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 54 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 InterTribal 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 55 and the Women's & Girls' Health Conference Planning Committee. BWCH also engaged city housing and employment agencies in planning of the women's health conference. //2012// /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// /2014/ The Office of Injury Prevention has convened a group of stakeholders and partners to work on a Safe Sleep Taskforce. The group plans to use the Collective Impact framework to address unsafe sleep practices. //2014// /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/adultsseniors.htm.//2013// /2014/ The Bureau of Women's and Children's Health is participating in the AMCHP Learning Collaborative Improving Birth Outcomes. In addition to ADHS leadership, the Team consists of representatives from the Governor's Office for Children Youth and Families, the Maricopa County Health Department and AHCCCS, Arizona's Medicaid agency. //2014// F. Health Systems Capacity Indicators Health Systems Capacity Indicator 02: The percent Medicaid enrollees whose age is less than one year during the reporting year who received at least one initial periodic screen. Health Systems Capacity Indicators Forms for HSCI 02 - Multi-Year Data Annual Objective and Performance Data 2008 2009 Annual Indicator 99.1 100.0 Numerator 58861 57283 Denominator 59373 57283 Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving 2010 100.0 39546 39546 2011 100.0 37247 37247 2012 100.0 37174 37174 56 average cannot be applied. Is the Data Provisional or Final? Final Final Narrative: In reviewing the updated data for the Health System Capacity Indicators, Arizona finds limited progress in access to care. Indicator #02 looks at the percent of Medicaid enrollees whose age is less than one during the reporting year who received at least one periodic screen. According to 2012 data provided by Arizona's Medicaid agency AHCCCS (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. This remains essentially unchanged from last year. What has changed however is the number of Medicaid enrollees. This decrease is less this past year than previous years. One of the important roles of early childhood home visitors is to help families to understand the importance of a medical home. Arizona's home visitors help families to enroll into a medical home. First Things First, Arizona's Early Childhood Development and Health Board funded through tobacco tax has committed over $700,000 to helping families enroll in insurance, either public or private. Arizona's maternal child health community in collaboration with child advocates will continue to guide eligible families to care and work to support families as new opportunities arise. Health Systems Capacity Indicator 03: The percent State Childrens Health Insurance Program (SCHIP) enrollees whose age is less than one year during the reporting year who received at least one periodic screen. Health Systems Capacity Indicators Forms for HSCI 03 - Multi-Year Data Annual Objective and Performance Data 2008 2009 2010 2011 Annual Indicator 84.0 82.1 100.0 100.0 Numerator 646 320 21 11 Denominator 769 390 21 11 Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Final Notes - 2012 Enrollment in the KidsCare Program has been frozen since January 1, 2010 due to lack of funding for the program. Currently there is a Kidscare waiting list for eligible children. 2012 100.0 10 10 Final A new children’s coverage program called KidsCare II became available for a limited number of eligible children from May 1, 2012 through December 31, 2013. The KidsCare II program reached its funding capacity (25,000) the week of September 3, 2012 and was frozen until further space becomes available. Beginning on November 1, 2012, AHCCCS reopened enrollment in the KidsCare II program and eligibility requirements for KidsCare II remained the same. Additionally, children on the wait list will be enrolled into the program if they meet the eligibility requirements for KidsCare II. Notes - 2011 Enrollement in Arizona's SCHIP (KidsCare) was indefinitely frozen in 2010 per legislative action. Notes - 2010 Enrollement in Arizona's SCHIP (KidsCare) was indefinitely frozen in 2010 per legislative action. 57 Narrative: In Health System Capacity Indicator #03, 100 percent of SCHIP enrollees whose age is less than one received at least one periodic screen, but the number of children served has remained at a historic low. In 2009, as a result of the severe economic downturn Arizona froze enrollment in KidsCare, Arizona's SCHIP program. Eligible children were put on a waiting list. In April 2012, funding was found to open enrollment, called KidsCare ll, for 22,000 children. Children on the waiting list were eligible to enroll with the possibility of enrolling additional children if there was space. This program will end December 31, 2013, however as beginning January 1, 2014 families with incomes of up to 400% of FLP may be eligible for premium subsidies for commercial coverage in the Federally Facilitated Marketplace. In April 2012, the advocate community worked hard to let families know of the new opportunity for KidsCare ll. Additionally, one of the important roles of early childhood home visitors is to help families to understand the importance of a medical home. Arizona's home visitors help families to enroll in KidsCare. First Things First, Arizona's Early Childhood Development and Health Board funded through tobacco tax has committed over $700,000 to helping families enroll in insurance, either public or private. Arizona's maternal child health community in collaboration with child advocates will continue to guide eligible families to care and work to support families as new opportunities arise. 58 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 59 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 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; 60 each is of equal importance. /2014/ While continually assessing the state of maternal child health in Arizona, the Bureau has continued to focus on the original eight priorities. //2014// 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 populationbased 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. /2014/ The Teen Pregnancy Prevention Program continues to ensure local contractors use evidence based curriculum for programs. Additionally, work has begun with the Arizona Mexico Commission Health Committee to share best practices to address teen pregnancy on both sides of the border. //2014// 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 populationbased 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 Index (BMI) at or above the 85th percentile, and the state performance measure on the percent of high school students who are 61 overweight or obese. /2014/ Arizona's 2011 Maternity Care Practices in Infant Nutrition and Care (mPINC) scores improved from 16th in 2009 to 24th. MIECHV is funding a position to educate and support home visitors about breastfeeding. In June 2013, the Division of Public Health Prevention Services was awarded a CDC grant: State Public Health Actions to Prevent and Control Diabetes, Heart Disease, Obesity and associated Risk Factors and Promote School Health. Work continues on the Health in Arizona Policy Initiative (HAPI) to align state and local policies with the goals of the National Prevention and Health Promotion Strategy. //2014// 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 priority-setting 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 interpregnancy interval of 18-59 months. Lastly, health status indicators related to low birth weights will also serve as indicators of preconception health. /2014/ Preconception wellness education and support is incorporated into home visiting, family planning, and teen pregnancy prevention. Additionally, grants to counties include policy and coalition building around preconception health as a priority. An updated Arizona Women's Health Status Report will be released that tracks trends in women health indicators. //2014// PRIORITY 4: REDUCE THE RATE OF INJURIES, BOTH INTENTIONAL AND UNINTENTIONAL, AMONG ARIZONANS. 62 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 populationbased 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. /2014/ BWCH continues to work on the Bars project. Currently 27 alcohol-serving employees have completed two sessions totaling 5 hours of training. The MIECHV program will support training to increase the number of car seat safety technicians statewide. As part of the prescription drug initiative, we are working to increase the number of drug drop boxes in communities which will help with decreasing access to prescription drugs by young children, adolescents and teens. //2014// 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 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 63 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 low-birth 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. /2014/ The statewide system of early childhood home visiting has made working to enroll the family/child into a medical and dental home a priority. Home visitors also check immunization and hearing screening records during the visit. //2014// 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. /2014/ Arizona third graders have a significant burden of oral disease with 75% having tooth decay experience and 40% with untreated tooth decay; levels that are far above the U.S. Department of Health and Human Services' Healthy People targets for 2020. The prevalence of dental sealants for Arizona third graders is 47% which is closely reaching the Healthy People 2020 target of 50%. Additional capacity to reach preschool children has been added through a partnership with ADHS and FTF to implement a fluoride varnish program in WIC immunization clinics //2014// PRIORITY 7: IMPROVE THE BEHAVIORAL HEALTH OF WOMEN AND CHILDREN. 64 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. /2014/ In 40% of Arizona's maternal deaths, the woman tested positive for illicit drugs and/or alcohol at the time of autopsy. As a result, the Division of Behavioral Health Services has been asked to become a part of the Maternal Mortality Review Team. Additionally, the Office of Injury Prevention brought together personnel from EDs to discuss the growing concern of patients spending prolonged periods of times in EDs waiting for psychiatric beds. In this legislative session $250,000 was appropriated for Mental Health First Aid, an evidence-based interactive 12hour course designed to teach people a five-step process to help a person in crisis or who may be developing the signs and symptoms of mental illness. //2014// 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 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 65 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 five-year goal for this measure is to reach 90% by 2013. /2014/ Through OCSHCN's contract with the EAR Foundation of Arizona (EFAZ), EFAZ updated the T3 OAE Birth to Three Training module for screeners and trainers. A revised OAE reporting form was disseminated to UA T3 program and a survey of training needs for early childhood programs was begun. OCSHCN with the State's Interagency Coordinating Council (AzEIP-ICC) developed and disseminated a survey for providers of hearing screening to assist in identifying areas of need and gaps in services. E-learning platform for standardized training using the NCHAM Newborn Hearing Screening Training Curriculum continues to be promoted //2014// 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. /2014/ OCSHCN developed the Arizona Children with Special Health Care Needs Transition Resource currently posted on the Youth Transition webpage using 2009/10 NS-CSHCN data to provide a snapshot of youth transition in Arizona as compared to the rest of the nation. A Transition! What's Health Got To Do With It? brochure in English and Spanish was also developed to provide families and youth practical tips and resources to move from 66 adolescence into adulthood. The Arizona's Community of Practice on Transition (AzCoPT), actively disseminates OCSHCN materials at all outreach and training events including Partners in Transition trainings and the annual Arizona Department of Education Transition Conference. //2014// 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. /2014/ Using Title V funding, OCSHCN supports the focus on inclusion of CYSHCN and their families in the Health in Arizona Policy Initiative (HAPI) and provides technical assistance to the Local Health Agencies to increase local capacity to implement preventative health policy, system and environmental changes within the strategic areas of procurement, worksite wellness, school health, clinical care and healthy communities. OCSHCN works with the Arizona University Center on Disabilities' Consumer Advisory Council that promotes full inclusion of all persons in meaningful life activities. Two contracts were also awarded to community based organizations to increase the inclusion of CYSHCN in health and wellness activities including education on physical activity, nutrition and injury prevention and health advocacy for their families. //2014// /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 67 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, HighRisk Perinatal Community Nursing, and Children's Information Center. BWCH Strategic Plan is attached.//2012// 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 2008 2009 2010 2011 2012 100 100 100 100 100 100.0 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 100.0 131 131 AZ Office of Newborn Screening Final Final 2016 100 2017 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 2013 100 2014 100 2015 100 a. Last Year's Accomplishments The Office of Newborn Screening utilized a framework of education, screening improvement and partnerships to ensure Arizona's newborns that screen positive receive appropriate follow up. The paired message - Blood Spot and Hearing education to hospitals, community health centers and provider offices - continued in 2012 with the partnership of The EAR Foundation of Arizona (EFAz) and Arizona Department of Health Services-Office of New Born Screening (ONS). Materials distribution included; updated pocket guide, Newborn Screening Essentials and Newborn Screening Dispelling Myths sheets and site-specific data reports. For 2012, the total number of specimens unsatisfactory for testing was reduced to below 1%. 68 The updated website (www.aznewborn.com ) now appeals to a wider audience by being more graphically oriented and is also designed to more effectively reach a younger demographic. A social media presence has also been created and includes Twitter, Facebook, and blogs related to NBS. Lab improvements in 2012 include the initiation of a long overdue review, evaluation and adjustment of the laboratory cutoffs. This adjustment is expected to improve the positive predictive values for disorders and the sensitivity and specificity of the individual tests. Improvements will result in fewer false positives and by extension help minimize family stress and anxiety. This process began with the tandem mass spectrometry (MSMS) disorders. Newborn Screening Laboratory and QI staff attended the week long Tandem Mass Screening training at Mayo Clinic to learn improvement strategies for reducing presumptive positive screens and to refine a protocol, which identifies interfering agents such as TPN/starter Amino Acids, resulting in fewer abnormal results being reporting on NICU babies. In the interest of minimizing delays in the identification of life threatening disorders, improperly collected samples are now reviewed to determine if any part of the sample could be used for priority tests. Previously, such a sample would have been rejected in its' entirety and testing would have waited until a new sample was submitted. This new procedure has already resulted in early identification of three confirmed cases. Also, the sample receipt and transfer process was evaluated and modified and our method for Galactosemia testing was changed. Finally, a dramatic increase in equivocal results for CF DNA tests that resulted in many delays in reporting was investigated and tracked down to a faulty piece of equipment. The equipment was replaced and a dramatic reduction in equivocal results quickly followed. The Newborn screening program developed a NICU Workgroup comprised of several Neonatologists from levels III and IIE hospitals around the state to determine feasibility of implementing serial blood spot screening for the special care-NICU infant. The goal was to reduce and or eliminate late-identified or missed confirmed cases for NICU graduates. The workgroup developed a protocol to include an algorithm and FAQ, determined the 5 pilot hospitals and implemented serial screening. Hospital Care Coordination was responsible for improved screening outcomes including; timing of collection, shipping and handling, collection methods, and reporting. This took place at selected hospitals in collaboration with nursing leadership, laboratory, medical director, risk management and clinical educators. Training was conducted with staff nurses, lab technicians, and hearing screeners to ensure that these practices were appropriately integrated. Arizona's early childhood home visitors continued to review NBS results with parents and provide education and referral information. The High Risk Perinatal Nurses continued to be available to find infants where efforts to contact then family have been unsuccessful for follow up. 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 continues to expand collaboration with key stakeholders. 3. Newborn screening has continued to educate parents about the need for second screens. 4. The Community Health Nurses educated families about the Pyramid Level of Service DHC ES PBS IB X X X X 69 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, work 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. 10. X X b. Current Activities Arizona participated in the National Center for Hearing Assessment and Management Physician survey to determine understanding and usage of the EHDI system. These findings will drive outreach and education activities for providers for the remainder of 2013 and 2014. Site visits using the paired newborn screening message was targeted to regions with high loss to follow-up, and incomplete or abnormal results based on data review. A data review was conducted to examine the causes of late-identified CF cases reported. Target messages were developed based on CLSI standards and distributed to the neonatologists, Neonatal Nurse Practitioners and Pediatricians. Cystic Fibrosis age at treatment in Arizona has been reduced to 14 days compared with standard guidelines of 28 days. Ongoing partnerships with state and national agencies and workgroups are at the core of continued quality improvement for laboratory practice as well and include Arizona's Genetics Services Advisory Committee, MSGRCC and the National Newborn Screening and Genetic Resource Center (NNSGRC), where yearly laboratory totals and all conformed bloodspot cases are submitted for national review. AZ NBS is partnering with The Newborn Screening Technical assistance and Evaluation Program (NewSTEP) to send ten confirmed cases so that definitions and standards can be developed and adopted nationally. As part of this project, Arizona is participating in the REDCAP data repository for NewSTEPS c. Plan for the Coming Year The NCHAM Physician survey will be used to target selected physician practices for education, training and outreach. The paired newborn screening message will continue providing individualized practice data and assist in the coordination among physicians, midwives, community health centers, hospitals and audiologists. Community and provider meetings will be held to target the Native American population and service providers to improve screening, diagnosis, reporting and entry into early intervention and services. Selected regional meetings will be held to improve communication and coordination of care. Tele-Intervention exploration activities will continue to be assessed for the feasibility of integration of services. We will continue to refine our MSMS protocols and lab procedures to reduce presumptive positive screens and transition the use of secondary markers to all MSMS disorders. Arizona will continue our partnership with the CF centers in Tucson and Phoenix and review data to exam the causes of late-identified CF cases. We will also continue to distribute the target messages developed from CLSI standards to the neonatologists, Neonatal Nurse Practitioners and Pediatricians. Our partnership with the High Risk Perinatal Program to work with hospitals during Arizona Perinatal Trust (APT) site visits will continue. The Office of NBS prepares a report on the 70 hospital's NBS results and this is reviewed during the APT site visit. As well, provider education to families on the importance of the second screen and diagnostic services will continue. Outcomes will include elevating parent participation and expanding the paired message of newborn bloodspot and hearing screening within the Mountain States Region. We will continue to develop systems to improve outcomes through coordinated outreach with local and national organizations like the AZ American Academy of Pediatrics (AAP) and the Arizona Perinatal Trust. We will continue to develop and utilize EHDI Pals for improved diagnostic services for families. We will also 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. Finally we will evaluate progress on sharing data with AzEIP and ASDB for improved entry into Early Intervention. Arizona's early childhood home visitors and Child Care Health Consultants will continue to monitor NBS results for the children they visit and continue to provide education to families on the importance of follow up and intervention. 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 beta- 87274 2012 (A) Receiving at least one Screen (1) (B) No. of Presumptive Positive Screens (C) No. Confirmed Cases (2) No. 83934 % 96.2 No. 106 No. 6 (D) Needing Treatment that Received Treatment (3) No. % 6 100.0 83934 96.2 796 59 59 83934 96.2 22 0 0 83934 96.2 3 2 2 100.0 83934 96.2 1013 7 7 100.0 83934 83934 83934 96.2 96.2 96.2 164 358 170 25 0 0 25 0 0 100.0 83934 96.2 7 0 0 100.0 71 ketothiolase deficiency Tyrosinemia Type I Very LongChain Acyl-CoA Dehydrogenase Deficiency 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 83934 96.2 94 0 0 83934 96.2 6 2 2 100.0 83934 96.2 8 1 1 100.0 83934 83934 96.2 96.2 8 66 1 0 1 0 100.0 83934 96.2 17 1 1 100.0 83934 96.2 3 1 1 100.0 83934 96.2 7 2 2 100.0 83934 96.2 17 2 2 100.0 83934 96.2 17 0 0 83934 96.2 2 0 0 83934 96.2 44 0 0 83934 96.2 9 8 8 100.0 83934 96.2 150 8 8 100.0 83934 96.2 11 5 5 100.0 83934 96.2 2 0 0 83934 96.2 0 0 0 83934 96.2 17 0 0 72 (Mutase Deficiency) S-Beta Thalassemia Pap test Hearing Pregnancy Test 83934 96.2 5252 574361 20004 4 1 1 100.0 0 12573 6326 0 1484 0 0 1484 0 100.0 Performance Measure 02: The percent of children with special health care needs age 0 to 18 years whose families partner in decision making at all levels and are satisfied with the services they receive. (CSHCN survey) Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2008 54 53.6 2009 55 53.6 2010 54 53.6 2011 57.4 66.2 SLAITS SLAITS SLAITS SLAITS 2012 57.4 66.2 153623 231913 SLAITS 2013 67 2014 67 2015 67 Final 2016 67 Final 2017 67 Notes - 2012 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 - 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 73 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. a. Last Year's Accomplishments OCSHCN used the Building Partnerships for Quality Care (BPQC), AZ's unique contract that supports leadership development through recruitment, training and compensation of families of children and youth with special health care needs (CYSHCN) and consumers who serve as Family and Youth Advisors, to participate in focus groups, program and policy development, strategic planning, workgroups, performance improvement committees, advisory boards, educational trainings, hiring panels, curriculum development and review, program evaluation, cotrainers at conferences or workshops and providing leadership development/mentoring to other families and youth as they assume leadership roles within ADHS or other child serving agencies. This contract supported family and youth involvement in policies, program and practices that affect the UnitedHealthcare Community Plans (UHC), Arizona Physicians IPA-Children's Rehabilitative Services (UHC-APIPA-CRS) delivery system, telemedicine services and administration of social service funds. The UHC-APIPA-CRS Ombudsman and OCSHCN staff met quarterly to further develop partnership opportunities. These included the ongoing exchange of program updates; reinforced the importance of the family perspective in the service delivery system by creating opportunities for families to participate in focus groups; review of member notices, resource materials and training including participation on conference calls with UHCAPIPA-CRS Clinic Liaisons to discuss resources and technical assistance OCSHCN may provide to families and providers promoting the availability of family and youth involvement contract that helped support CRS' family involvement initiatives and Raising Special Kids' (RSK) role as AZ's Family to Family Health Information Center and Arizona Chapter for Family Voices. OCSHCN supported family feedback through an online survey hosted on the AHCCCS website regarding the Children's Rehabilitative Services redesign. OCSHCN collaborated on the Flagstaff CRS 25th Anniversary, Show Low Therapy Conference, Community Partner Initiative Meetings, APIPA-DDD Member and Family Health Plan Information Exchange. Family Advisors reviewed and developed additional content in the 2012 AZ Medical Home Care Coordination Manual. Family participation was well received in ADHS' Zero to Five Workgroup, Home Visiting Task Force, Project LAUNCH and NBS Emergency Planning. The ADE Resource Guide for Supporting Children with Life-Threatening Food Allergies & Delivery of Specialized Health Care and OCSHCN's Hospital to Home: Caring for Children with Medically Fragile Health curriculum was vetted by Family Advisors. Family and Youth Advisors co-trained in AZ's Annual Coalition for Military Families Symposium, Department of Education Transition Conference and American Indian Maternal and Child Wellness Forum. Veronica James was recruited as OCSHCN's Outreach Family Advisor on the Hopi Nation to facilitate linkages between State and local American Indian community. Eight Family and Youth Advisors were recruited to participate in the Health in Arizona Policy Initiative (HAPI) with the Local Health Agencies. Two health policy trainings were held for ADHS and Local Health Agencies as well as key external stakeholders from the children's and adult disability community. The first training was targeted county and state health department staff and the second training was targeted primarily towards community and statewide partners for a total of 225 individuals. Training sessions focused on what makes a strong population health policy, inclusion of CYSHCN in public policy, community design, clinical care, ACA and population health interventions. Each attendee was provided a flash drive with both national and state resources on identifying and implementing health policy within their respective environments. OCSHCN supported RSK's provision of family-centered care training to 79 medical, dental and 74 nursing students and coordinated 59 resident-in-training home visits with 59 Family Faculty (host families) and 59 CYSHCN. Training took place in the homes of families of CYSHCN to better acquaint the health care professionals 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 over 300 families with information, support and guidance on navigating the systems of care. 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, 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. Pyramid Level of Service DHC ES PBS IB X X X X X X b. Current Activities On April 3, 2013, AZ's Medicaid Program, AHCCCS awarded one statewide Children's Rehabilitative Services (CRS) contract to one managed care company, UHC Community Plan to provide integrated physical and behavioral health services to AHCCCS enrolled children with CRS-qualifying conditions beginning Oct. 1, 2013. OCSHCN works closely with the Ombudsman and using the BPQC contract to support family/youth involvement in review of member notices, resource materials, training and development of an advisory body. OCSHCN partners on the 2013 AZ Partners in Preparedness Conference, "Bridging the Gaps in Whole Community Planning" to ensure that the functional needs of the whole community are met in a disaster or emergency. Family/youth are compensated through the BPQC contractor. OCSHCN supports the focus on inclusion of CYSHCN and their families in the Health in Arizona Policy Initiative (HAPI) and provides technical assistance to the Local Health Agencies so that they can increase local capacity to implement preventative health policy, system and environmental changes within the strategic areas of procurement, worksite wellness, school health, clinical care and healthy communities. OCSHCN supports Veronica James' involvement on the Hopi Nation with focus on CYSHCN and their families. As a result, the Hopi Health Center facilitates use of its telemedicine room for meetings between State and local partners for information sharing and training promoting families in decision-making. 75 c. Plan for the Coming Year OCSHCN will continue to work closely with UHCCP who will be serving over 45% of Arizona's residents with special health care needs including Acute Medicaid, Medicaid Long Term Care, CRS, Developmental Disabilities and Medicare Dual Special Needs Plan. Of these, approximately 25,000 CYSHCN are enrolled in the UHCCP-CRS. As a result of this new health integration model starting on October 1, 2013, OCSHCN will explore additional opportunities for development of family and provider engagement within UHCCP-CRS and the delivery of training for staff, members and providers related to best practices for CYSHCN and their families. OCSHCN will continue to partner with ADHS' Bureau of Emergency Preparedness, AZ's Developmental Disabilities Planning Council, Statewide Independent Living Council and Department of Economic Security (DES) on the outcomes of 2013 Arizona Partners in Preparedness Conference focused on meeting the needs of CYSHCN and their families in a disaster or emergency, developing emergency preparedness resources and tools. OCSHCN will continue to support the focus on inclusion of CYSHCN and their families in the Health in Arizona Policy Initiative (HAPI) and provide technical assistance to the Local Health Agencies so that they can increase local capacity to implement preventative health policy, system and environmental changes that integrate CYSHCN and their families. OCSHCN will continue to provide education, trainings, technical assistance and resources on best practices for CYSHCN to health plans, school nurses, therapists, other child serving agencies and providers on cultural competence as it relates to chronic health conditions, families as decision-makers, medical home and care coordination, pediatric to adult transition and navigating the system of care. OCSHCN will continue to involve families, consumers and YSHCN in the delivery of the AZ DB 101, a new online tool available to assist individuals receiving federal and/or state assistance to assess the effect of various scenarios on benefits, particularly health care. Learning how to make decisions with families as partners is the focus of resident/physician training conducted in the homes of families and CYSHCN to better acquaint them on day-to-day life issues related to SHCN will also be supported in part through the BPQC contract. Family and youth participation will be expanded to represent Arizona's cultural, geographical and tribal diversity. OCSHCN will explore supporting consumer involvement in the Az Employment and Disability Partnership whose vision is to that Arizonans with disabilities have the opportunity to capitalize their potentials, achieve their economic goals, contribute to and be included in their communities, and individually maximize quality of life through employment. OCSHCN will also explore the 20 DES sponsored Community Network Teams that identify gaps in local human services to further promote family involvement in all levels of decision-making. 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 2008 41 40.4 2009 41 40.4 2010 40 40.4 2011 47.1 36.1 SLAITS SLAITS SLAITS SLAITS 2012 47.1 36.1 81306 225115 SLAITS 76 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 2013 47.1 2014 47.1 2015 47.1 Final 2016 47.1 Final 2017 47.1 Notes - 2012 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 - 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. 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. a. Last Year's Accomplishments OCSHCN staff and the UnitedHealthcare Community Plans, Arizona Physicians IPA, Children's Rehabilitative Services (UHC-APIPA-CRS) Ombudsman have met quarterly and supported family and youth involvement in policies, program and practices that affect the UHC-APIPA-CRS delivery system, telemedicine services to Yuma patients through June 30, 2013 and administration of social service funds. Partner meetings helped further develop partnership opportunities that included ongoing exchange of program updates, participation on conference calls with Clinic Liaisons to discuss the availability of OCSHCN's family and youth involvement contract that helped support APIPA-CRS' family involvement and Raising Special Kids' (RSK) role as Arizona's Family Voices Chapter and Family to Family Health Information Center. OCSHCN partnered with UHC-APIPA-CRS and RSK on regional Collaborative Therapies 77 Conferences for families to access information on services, communication strategies and familycentered care. The Arizona Telemedicine Program made specialty services available to 243 CYSHCN unique Yuma APIPA-CRS members. Specialty clinics included pediatric orthopedics, neurology and neurosurgery. OCSHCN and RSK also 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 in English and Spanish hosted on the AHCCCS website regarding the Children's Rehabilitative Services redesign. The medical home model was integrated into all published materials, trainings and presentations offered to 748 medical staff, 919 educators, 262 school nurses who served over 12,000 CYSHCN, 662 therapists and social services staff, 35 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. As a member of the Arizona Early Intervention Program-Interagency Coordinating Council for Infants and Toddlers, OCSHCN partnered in the development of team based family model with respect to importance of coordination of care. OCSHCN funded medical residency training to 59 residents and physicians who participated in training and home visits through RSK's contract. OCSHCN partnered with RSK to integrate mental health with existing physical health curriculum in the physician residency training. An evaluation workgroup comprised of 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. As a result, OCSHCN overview and contact information was incorporated into the physician residency training curriculum. OCSHCN used its family, consumer and youth involvement contract to recruit, train and compensate families, consumers and youth for their time and experience to partner with ADHS on specific time-limited projects. The American Academy of Pediatrics (AAP) Emergency Information Cards in English and Spanish were distributed to 1,396 families and 2,791 professionals through individual contacts, trainings and community outreach. OCSHCN joined the Arizona AAP Care Coordination Learning Community where ideas, challenges, documents, and healthcare systems barriers are identified and resources shared. OCSHCN piloted its new online training curriculum, Breaking the Diagnosis, focusing on family and physician interaction and communication around difficult diagnoses. Home visitors from the Bureau of Women's and Children's Health Start Program reviewed, assessed and provided recommendations on training content and ease of use of the new eLearning platform. Arizona's MH Care Coordination (MHCC) Manuals CDs were distributed to 2,791 physicians, providers, families, school nurses, therapist and others. The MHCC Manual's letters of medical necessity were vetted by Arizona's School Nurse Consortium and School Nurses Organization of Arizona and hosted on the OCSHCN website. A survey monkey solicited ongoing input on improving the manual's content. OCSHCN collaborated with Division of Behavioral Health Services' Family Involvement Subcommittee, focusing on health care integration, and shared information on medical home, MHCC Manual and AAP's Emergency Information Card in English and Spanish. 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, Pyramid Level of Service DHC ES PBS IB X X 78 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 health care professionals, health plans, 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 materials and videos to community partners on behalf of CYSHCN. 6. OCSHCN funds the Arizona Telemedicine Program that provides network management and video conferencing services for educational and administrative uses. 7. 8. 9. 10. X X X X X b. Current Activities On April 3, 2013, AZ's Medicaid Program, AHCCCS awarded a statewide CRS contract to UnitedHealthcare Community Plan to provide integrated physical and behavioral health services to 25,000 AHCCCS enrolled children with CRS-qualifying conditions beginning Oct. 1, 2013. OCSHCN is currently working closely with the Ombudsman and using the BPQC contract to support family/youth involvement in review of member notices, resource materials, training and development of an advisory body. OCSHCN supports the focus on inclusion of CYSHCN and their families in the Health in Arizona Policy Initiative (HAPI) and provides technical assistance to the Local Health Agencies so that they can increase local capacity to implement preventative health policy, system and environmental changes within the strategic areas of procurement, worksite wellness, school health, clinical care and healthy communities. OCSHCN is working with Magellan Health Services in conjunction with Jewish Family & Children's Services to develop Train-the-Trainer session for up to 16 transition facilitators that mentor/coach over 190 transition-age youth to use the "My Health Organizer", adapted from OCSHCN's Health Care Organizer. Each YSHCN would receive support on using their own expandable organizer with tabs for care coordination, dental/oral health, emergency planning, legal options, medical history, insurance, prescriptions, school and immunizations. Adaptations will be made based on youth and facilitator feedback. 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 revise training content to reflect patient-centered medical home consistent with the Patient Protection and Affordable Care Act (ACA) and explore the roles physicians play in examining social determinants of health in order to assess and treat patients with a more holistic approach. OCSHCN will continue to use the family, consumer and youth involvement contract to recruit, train and compensate families, consumers and youth for their time and experience to partner with ADHS on specific time-limited projects. OCSHCN's continued participation in the Central Arizona ACA Coalition workgroups will leverage 79 additional opportunities to educate and inform families, providers, educators, social workers, and other health professionals about the importance of a medical home to support meeting the needs of CYSHCN and their families. OCSHCN 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 including how to communicate their needs/preference and how to identify aspects of a medical home. 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 including health integration of physical/behavioral 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 continue to partner 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 reaching out to Mercy Maricopa Integrated Care, the new Regional Behavioral Health Authority for Maricopa County starting October 1, 2013 that will be providing integrated physical and behavioral health services. OCSHCN will continue working with ADHSDivision of Behavioral Health Services staff to coordinate resource sharing so that families of CYSHCN, providers and other related professionals access the most current information available about medical and health homes. 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 2008 59 58.1 2009 59 58.1 2010 58 58.1 2011 62 52.9 SLAITS SLAITS SLAITS SLAITS 2012 62 52.9 121804 230201 SLAITS 2013 62 2014 62 2015 62 Final 2016 62 Final 2017 62 Notes - 2012 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, 80 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 - 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. a. Last Year's Accomplishments OCSHCN's Building Partnerships for Quality Care (BPQC) contract supported family and youth involvement in policies, program and practices that affected UnitedHealthcare (UHC), Arizona Physicians IPA-Children's Rehabilitative Services' (UHC-APIPA-CRS) delivery system, telemedicine services and administration of social service funds. The CRS Ombudsman and OCSHCN staff met quarterly to further develop partnership opportunities that included ongoing exchange of program updates, 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 AZ Medicaid Program - AHCCCS website regarding the CRS redesign, review of member notices, resource materials and training including 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. OCSHCN provided information and training on the Pre-Existing Condition Insurance Plan (PCIP) including 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. OCSHCN worked with the Bureau of Women's and Children's Health (BWCH), 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. Families and providers received OCSHCN's Making the Most of Your Healthcare resource with information in English and Spanish on how to use public/private health plan, member and provider services, member handbooks, and offer guidance on negotiating rates with doctors and supported families' whose children are uninsured and underinsured with resources to prescription discount programs, federally funded qualified CHC, PCIP and charitable foundations. Over 1,700 electronic/hard copies were distributed in trainings, outreach and community events. It was also incorporated into NICU packets disseminated by RSK. OCSHCN funds supported the CHN Program to assess and support 500 older siblings in families who expressed concerns about the development of an older child. OCSHCN also distributed information about KidsCare II when AHCCCS reopened enrollment. Families were informed about the application processes for Supplemental Security Income (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 81 identified by the Newborn Screening Program and for others who did not qualify for Medicaid. 1,044 letters were mailed to SSI applicants under age 21 informing them about medical coverage and programs or services 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 needs such as prescription medications and therapy services. OCSHCN informed 748 medical staff, 919 educators, 262 school nurses who touch 12,000 CYSHCN, 662 therapists and social services staff, 35 health plan staff and other community partners of eligibility requirements and services available to CYSHCN. OCSHCN supported the BWCH-CIC and CHN Program through funding and training about public and private health insurance options, services and programs for CYSHCN. OCSHCN presented on health resources including SSI, AHCCCS, and PCIP at the Arizona's Department of Education Twelfth Annual Transition Conference, Arizona's School Nurse Consortium and School Nurses Association of Arizona conferences. Charitable funds were identified such as the UHC -Children's Foundation and Arizona Funeral, Cemetery and Cremation Association, Foundation for Children through school nurses that help families offset medical costs. Over 300 contacts were tracked in the call log and barriers were identified by families in accessing services and health insurance. Arizona's Navigating the System of Care online training hosted on the OCSHCN webpage was highlighted as a resource in all training, community outreach and through one-on-one referrals. Table 4a, National Performance Measures Summary Sheet Activities 1. OCSHCN develops resources and training materials, offers training and education to providers, community partners, family support organizations, families and youth about working with private and public health plans. 2. OCSHCN assists and encourages families and youth to apply for the AHCCCS programs. 3. Maintain systems with other state agencies and ADHS offices, community partners, family organizations and the Social Security Administration to help link families of CYSHCN to services and resources. 4. OCSHCN provides information and technical assistance to help families understand eligibility requirements, learn how to apply for services and understand their rights and responsibilities. 5. OCSHCN refers CSHCN to the EAR Foundation of AZ for hearing aids, cochlear implant batteries, repairs and audiology testing. 6. OCSHCN works with the CIC Hotline, CHN, school nurses and others to educate families on potential sources of health care coverage. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X X 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 82 navigate the system of care. On October 1, 2013, as a result of the Patient Protection and Affordable Care Act (ACA), Arizonans will be able to use the federally facilitated exchange or Marketplace to shop for and enroll in a health insurance plan. To help inform families of the importance of health insurance and how to access and use the exchange, OCSHCN participates in the Central Arizona ACA Coalition with representatives from the CMS, AHCCCS, AZ Department of Economic Security, St. Luke's Health Initiatives, Maricopa Integrated Health Systems, health plans, as well as family advocacy and support organizations. The Coalition receives education and information as the health care Marketplace is implemented in Arizona; collects and analyzes community statistics to determine best methods to reach target audiences; identifies partners to assist with community education; and assists in disseminating Marketplace information. Workgroups are being formed to focus on one or more of these areas. OCSHCN uses national sources to provide resources and training on the federally facilitated exchange to families, providers, educators, social workers, school nurses, other child-serving agencies and ADHS programs. c. Plan for the Coming Year OCSHCN will continue to work with 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 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, 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 federally facilitated exchange, through the ACA and charitable foundations. In January, 2014, as a result of the Patient Protection and ACA, Arizonans will be able to obtain health insurance through a federally facilitated exchange or Marketplace. OCSHCN will explore the potential of becoming Certified Application Counselors to provide assistance to families applying for Medicaid, CHIP, and plans sold through the new insurance exchange, as well as provide information on premium tax credits and cost-sharing reductions. As a result of OCSHCN's ongoing partnership with the Central Arizona ACA Coalition, staff will continue to participate in of the Coalition and workgroups with representatives from the CMS, AHCCCS, AZ Department of Economic Security, St. Luke's Health Initiatives, Maricopa Integrated Health Systems, health plans, and family advocacy and support organizations. OCSHCN will continue using national sources to provide informational resources and training on the federally facilitated exchange to families, providers, educators, social workers, school nurses, other child-serving agencies and ADHS programs. OCSHCN will continue to inform and educate school nurses, providers, therapists and social service staff and other community partners on eligibility requirements, application process and services available to CYSHCN through outreach events, trainings, and conferences. OCSHCN will continue to support the CIC Hotline and the CHN through funding and training about health insurance options, charitable funds, services and programs for CYSHCN. OCSHCN will explore revising Arizona's Navigating the System of Care online training hosted on the OCSHCN webpage to reflect the changes within the systems of care impacting CYSHCN and their families. OCSHCN will explore the AZ Department of Economic Security sponsored Community Network Teams to further inform and educate them on the availability resources for CYSHCN and their families including health insurance. The approximate 20 Community Network Teams identify gaps 83 in local human services and work to focus all available resources on eliminating those gaps. 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 2008 87 86.5 2009 87 86.5 2010 86 86.5 2011 89.1 59.7 2012 89.1 59.7 SLAITS SLAITS SLAITS SLAITS SLAITS 2013 89.1 2014 89.1 2015 89.1 Final 2016 89.1 Final 2017 89.1 Notes - 2012 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 - 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 84 Indicator data comes from the National Survey of CSHCN, conducted by HRSA and CDC, 20052006. Compared to the 2001 CSHCN survey, there were revisions to the wording, ordering and the number of the questions used to generate the NPM05 indicator for the 2005-2006 CSHCN survey. The data for the two surveys are not comparable for PM #05. a. Last Year's Accomplishments OCSHCN worked closely with UnitedHealthcare (UHC) Community Plan served 44% of Arizona's residents with special health care needs, approximately 680,000 members, across the lifespan including Acute Medicaid, Medicaid Long Term Care, CRS, Developmental Disabilities (DD) and Medicare Dual Special Needs Plans. Of these, approximately 25,000 CYSHCN were enrolled in the UHC-APIPA-CRS. OCSHCN partnered at community and outreach events with information about how OCSHCN and UHC-APIPA-CRS continued to work together to support families in decision-making, transition to adulthood, navigating the system of care and medical home. OCSHCN participated at the DD Member and Family Health Plan Information Exchange, Annual Back-to-School Health and Safety Fair and Community Partner Initiative (CPI) meetings. CPI meetings brought community partners together to identify the strengths and challenges of offering an integrated, community-based, coordinated system of care for AZ residents with disabilities and SHCN. This partnership complemented common concerns and issues regarding the need for collaboration to reduce duplication and streamline activities to ensure that a continuum of resources, information, care and access to services are available to the people and communities we collectively serve. OCSHCN staff responded to over 300 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. 1,044 letters were mailed to families of SSI applicants informing them of services for which they might be eligible in their community. OCSHCN funded the Ronald McDonald Houses in Phoenix and Tucson. The houses enabled 293 out-of-town families to stay near their hospitalized CYSHCN receiving needed treatment or surgeries for an average of 7 days. OCSHCN also supported 36 children that received respite and palliative care hours provided at Ryan House. A new contract with AZ's Department of Economic Security (DES) was established to implement the Lifespan Respite Care's short-term respite care for families/caregivers of CYSHCN. Through DES' Lifespan Respite Care, respite care was provided over 11,000 hours of respite to over 300 CYSHCN who did not otherwise qualify for state or federally funded disability programs. Training was coordinated through a contract with RSK that provided family-centered care training to 79 medical, dental and nursing students and coordinated 59 resident-in-training home visits with 59 Family Faculty (host families) and 59 CYSHCN focused on the day-to-day life issues related to children and youth with special health care needs (CYSHCN). Staff trained 262 school nurses, who served over 12,000 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, childserving 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 AZ's School Nurse Consortium and School Nurses Organization 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. OCSHCN supported 8 Family and Youth Advisors to participate in the HAPI with the Local Health Agencies to implement preventative health policy, system and environmental changes in the strategic areas of procurement, worksite wellness, school health, clinical care and healthy communities. Two health policy trainings were held for ADHS and Local Health Agencies as well as key external stakeholders from the children's and adult disability community. The first training 85 targeted county and state health department staff and the second training targeted primarily towards community and statewide partners for a total of 225 individuals. Training sessions focused on what makes a strong population health policy, inclusion of CYSHCN in public policy, community design, clinical care, ACA and population health interventions. Attendees received a flash drive with both national and state resources on identifying and implementing health policy within their respective environments. Table 4a, National Performance Measures Summary Sheet Activities 1. OCSHCN staff identifies services for which CYSHCN may be eligible, guide families on application processes and help them understand their rights in school, healthcare and community settings. 2. OCSHCN offers training to school nurses and early care providers on strategies to support CYSHCN to participate in school and early care settings in the least restrictive and most inclusive environment. 3. OCSHCN represents ADHS on the AzEIP-ICC, and keeps them informed on changing aspects of the system of care for CSHCN. 4. OCSHCN funds Ronald McDonald Houses to enable out-oftown families to stay near their hospitalized CSHCN. 5. OCSHCN partners with Special Olympics Arizona (SOAZ) and others to promote inclusion of CSHCN of all ages in wellness activities such as nutrition, physical activity and injury prevention. 6. 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. 7. OCSHCN funds the Ryan House to provide respite and pediatric palliative care in a home-like setting for CYSHCN and their families. 8. OCSHCN funds AZ Department of Economic Security to enable families/caregivers of CYSHCN to receive short-term respite. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X X X X X X X X b. Current Activities On April 3, 2013, AZ's Medicaid Program, AHCCCS awarded UHC Community Plan-CRS contract to provide integrated physical and behavioral health services to AHCCCS enrolled children with CRS-qualifying conditions beginning Oct. 1, 2013. OCSHCN works closely with the Ombudsman and using the BPQC contract to support family/youth involvement in review of member notices, resource materials, training and development of an advisory body. UHCCPCRS' new integrated care model will improve AZ's community-based services for approximately 25,000 Medicaid enrolled children. As a member of the AzEIP-ICC, OCSHCN is a partner in education and dissemination of the new team based model with respect to importance of coordination of care and is keeping them informed on changing aspects of the system of care for CYSHCN. OCSHCN's Health Advocacy contractors compile and maintain a provider registry comprised of community-based health, education and social services resources linking families to needed referral sources. 86 OCSHCN supports the focus on inclusion of CYSHCN and their families in the Health in Arizona Policy Initiative (HAPI) and provides technical assistance to the Local Health Agencies to increase local capacity to implement preventative health policy, system and environmental changes within the strategic areas of procurement, worksite wellness, school health, clinical care and healthy communities. Several HAPI contractors are working on developing resource guides unique to CYSHCN. c. Plan for the Coming Year OCSHCN will continue to work closely with the UnitedHealthcare Community Plan-Children's Rehabilitative Services' (UHCCP-CRS) Ombudsman through the transition from a "carve-out" to an integrated health care model beginning in 10-1-13. OCSHCN will explore additional opportunities within all lines of business in the development of family and provider engagement and the delivery of training for staff, members and providers related to best practices for CYSHCN such as families in decision-making, transition to adulthood, navigating the system of care and medical home. OCSHCN will also continue to use its family, consumer and youth involvement contract to support leadership development through recruitment, training and compensation of families of CYSHCN, consumers and youth that serve as Family/Youth Advisors to participate in focus groups, program and policy development, strategic planning, workgroups, performance improvement committees, advisory boards, educational trainings, hiring panels, curriculum development and review, program evaluation, co-trainers at conferences or workshops and providing leadership development/mentoring to other families and youth as they assume leadership roles within ADHS or other child serving agencies. This contract will continue to support family and youth involvement in policies, program and practices that affect UHCCP-CRS' delivery system to ensure that families of CYSHCN, members, providers and community stakeholders have the most current information about the CRS integrated health model. OCSHCN will continue to participate as a member of the AzEIP-ICC for Infants and Toddlers actively involved in the team based model with respect to importance of coordination of care and will continue to keep them informed on changing aspects of the system of care for CYSHCN. OCSHCN's Health Advocacy contractors will continue to compile and maintain a provider registry comprised of community-based health, education and social services resources to facilitate linking families of CYSHCN ages 3 -- 21 to needed referral sources. OCSHCN will continue to support the focus on inclusion of CYSHCN and their families in the Health in Arizona Policy Initiative (HAPI) and provides technical assistance to the Local Health Agencies to increase local capacity to implement preventative health policy, system and environmental changes within the strategic areas of procurement, worksite wellness, school health, clinical care and healthy communities. Community-based resource guides developed through this initiative will be linked within the OCSHCN webpage. OCSHCN will explore the AZ Department of Economic Security sponsored Community Network Teams to further inform and educate them on the availability resources for CYSHCN and their families including health insurance. The approximate 20 Community Network Teams identify gaps in local human services and work to focus all available resources on eliminating those gaps. 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. 87 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 2008 39 39.4 2009 40 39.4 2010 39 39.4 2011 41.2 35.6 SLAITS SLAITS SLAITS SLAITS 2012 41.2 35.6 30347 85151 SLAITS 2013 41.2 2014 41.5 2015 42 Final 2016 42.5 Final 2017 43 Notes - 2012 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. 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. 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. 88 a. Last Year's Accomplishments Arizona's Community of Practice on Transition is an interagency state leadership team comprised of young adults, family organizations and representatives from Departments of Education, Economic Security- Division of Developmental Disabilities, Health Services - Division of Behavioral Health Services, Office for Children with Special Health Care Needs, Navajo Office of Special Education and Rehabilitation Services Administration-Vocational Rehabilitation Program. As a state level partner, OCSHCN incorporates the importance of health transition as part of youth transition planning. AzCoPT promoted collaboration and coordination for transition planning, professional development and youth and family involvement to improve school and post-school outcomes by providing guidance to parents, students, educators and state agency staff working with transitioning youth. Transition resources were provided at community health events, transition fairs and conferences. AzCoPT presented a session on state agency processes and collaboration at Arizona's Twelfth Annual Transition Conference, Facing the Future: Who's in Your Network? During the conference a young adult co-presented with OCSHCN staff a session on "Transtion, What's Health Got to do With It?" OCSHCN funded scholarships for 77 YSHCN, their families and attendant care providers to cover the cost of registration and lodging costs. OCSHCN also participated as an informational vendor and distributed information and resources to over 800 families, educators, agency staff and young adults. OCSHCN hosted a 2-day broadcast of the 13th Chronic Illness and Disability Conference: Transition from Pediatric to Adult-Based Care co-sponsored by Baylor College of Medicine for community partners and ADHS programs. OCSHCN was granted approval to post the conference extensive resource listing on OCSHCN's proposed youth transition webpage. OCSHCN's family and youth involvement contract, BPQC, supported Family and Youth Advisors to partner in ADHS specific activities including review of materials, website and during outreach events such as transition or health fairs with staff. The AzCoPT supported the development of local transition teams that have identified themselves as ready to bring the community/school together around the issues of transition to adulthood in Tucson, Flagstaff and Window Rock. AzCoPT team members identified themselves as local transition team "ambassadors", technical advisors bridging information and resources from the local to the State team. ADHS Public Health Services launched the Health in Arizona Policy Initiative (HAPI), collaborative leveraging resources across ADHS to maximize environmental approaches to achieve health outcomes. As a result, inter-governmental agreements were established with Local Health Agencies to increase local capacity to implement preventative health policy, system and environmental changes within the CDC grant strategic areas of procurement, worksite wellness, school health, clinical care and healthy communities. OCSHCN supported the inclusion of CYSHCN in their activities with funding through Title V funding. Best practices on transition were promoted through OCSHCN's development of two new resources, Transition! What's Health Got To Do With It? brochure and AZ CSHCN Transition Resource using the 2009/10 National Survey of Children with Special Health Care Needs. Over 200 school nurses received training promoting 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 self-determination. Arizona's Navigating the System of Care online training hosted on the OCSHCN webpage was highlighted as a resource in all training, community outreach and through one-on-one referrals. OCSHCN staff and families partnered with AHCCCS on beta testing the AZDB 101, new online 89 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. Young adults with SHCN review contracts, policies, curriculum, training, resources and OCSHCN website and are members of the cultural competence committee. 2. OCSHCN and the Governor’s Council on Spinal and Head Injuries partner by helping youth transition to adult health care, understand their rights and responsibilities, and learn how to access community support system 3. 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. 4. OCSHCN offers transition resources and training to other ADHS programs and state agencies, including AHCCCS programs. 5. OCSHCN is a member of the AzCoPT team and offers training to inform students, parents, educators, and others about state agency processes. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X X X b. Current Activities AzCoPT provides guidance to families, students, educators and state agency staff working with transitioning youth and currently supporting additional local transition teams to which an AzCoPT Ambassador is assigned. OCSHCN works closely with two HAPI contractors, Mohave and Maricopa County Departments of PHS to establish a new Youth Coalitions focusing on the needs of YSHCN within their needs assessment process. OCSHCN's transition resources are being utilized to promote increased understanding of what transitioning YSHCN and their families face when moving to the adult system of care. OCSHCN partners with the Governor's Council on Spinal and Head Injuries on Arizona's TBI Transitions Project and the Brain Injury Alliance through regional conferences scheduled in Tucson, Phoenix and Prescott with OCSHCN presenting on AZ DB 101, an online tool to assist individuals receiving federal and/or state assistance to assess the effect of various work/school scenarios on benefits such as health care. OCSHCN participates on the AZ Department of Education's 13th Annual Transition conference and funds scholarships to support the participation YSHCN, their families and attendant providers to cover the cost of registration and lodging. OCSHCN also supports the 2013 Arizona Partners in Preparedness Conference, "Bridging the Gaps in Whole Community Planning" to ensure that the functional needs of the whole community, including CYSHCN and their families, are met in a disaster or emergency. 90 c. Plan for the Coming Year OCSHCN will continue to work closely with UHCCP to serve more than 45% of Arizona's residents with SHCN across the lifespan including Acute Medicaid, Medicaid Long Term Care, CRS, Developmental Disabilities and Medicare Dual Special Needs Plan. Of these, approximately 25,000 CYSHCN are enrolled in the UHCCP-CRS. As a result of the new health integration model starting on October 1, 2013, OCSHCN will explore additional opportunities for development of family and youth involvement within all lines of business using the family, consumer and youth involvement contract to recruit, train and compensate YSHCN to partner on ADHS specific activities such as focus groups, program and policy development, strategic planning, workgroups, performance improvement committees, advisory boards, educational trainings, hiring panels, curriculum development and review, program evaluation, co-trainers at conferences or workshops and providing leadership development and mentoring to other families and youth as they assume leadership roles within ADHS or other child serving agencies. OCSHCN will continue to serve as a member of AzCoPT and promote co-leading the group with a family member or young adult. In conjunction with AzCoPT, OCSHCN will continue to provide guidance to families, students, educators and state agency staff working with transitioning youth and supporting the development of local transition teams. The Annual Transition Conference scholarships to support the participation of YSHCN, their families and attendant providers to cover the cost of registration and lodging costs will continue to be supported. OCSHCN will continue to partner with ADHS' Bureau of Emergency Preparedness, AZ's Developmental Disabilities Planning Council, Statewide Independent Living Council, and Department of Economic Security on the outcomes of 2013 Arizona Partners in Preparedness Conference, "Bridging the Gaps in Whole Community Planning" focusing on meeting the needs of CYSHCN and their families in a disaster or emergency as well as developing emergency preparedness resources and tools. Family and YSHCN participation will be expanded to represent Arizona's cultural, geographical and tribal diversity. OCSHCN will also explore supporting consumer involvement in the Arizona Employment and Disability Partnership whose vision is to that Arizonans with disabilities have the opportunity to capitalize their potentials, achieve their economic goals, contribute to and be included in their communities, and individually maximize quality of life through employment. An OCSHCN website Youth Transition page will continue to link to resources on managing your own health care, physical activity, health care transition, AZDB 101, and Got Transition? along with other state and national resources and continues to be developed. OCSHCN will continue working with Magellan Health Services in conjunction with Jewish Family & Children's Services to develop Train-the-Trainer session for up to 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 2008 2009 2010 2011 2012 80 80 80 80 80 76.7 76 71.9 77.5 70.7 91 Numerator Denominator Data Source National Immunization Survey National Immunization Survey National Immunization Survey Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2013 75 2014 75 2015 80 National Immunization Survey National Immunization Survey Final Final 2016 80 2017 80 Notes - 2012 The confidence interval is + or - 8.6%. Estimates for 2012 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. 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. a. Last Year's Accomplishments The Bureau of Women's & Children's Health (BWCH) provided Title V funding to help 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 92 disease, and achieves this through partnering in the community through standing working committees on Health Policy, Community Education and Provider Education. The TAPI home web page www.whyimmunize.org which allows parents to ask medical experts questions about vaccines and immunizations and find vaccines, was kept updated to reflect the needs of the community. 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. Two additional websites were added and linked to make information on vaccine preventable diseases and immunizations accessible to the community. The page www.tapi.org was added to the www.whyimmunize.org site for providers to have direct access to support materials for immunization delivery. In addition, www.stopthespreadaz.org was linked to county immunization clinics, with information regarding pertussis and flu and where to locate vaccines. English and Spanish flyers, "Is Your Child Protected?" and vaccine safety concern flyers were revised and distributed. Additional materials updated and distributed in 2012 included: 1) A parent education flyer to help overcome 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 and teens; 3) posters and flyers on Pertussis vaccine information; 4) flyers for childcare centers on the importance of tracking immunization records using ASIIS; 5) teen parent education flyers and post cards; 6) placemats for senior centers about vaccine for grandkids and across the lifespan; and 7) a flyer was designed and distributed for families about the importance on immunizations 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 2012. TAPI has developed and used a social media plan for better outreach to new parents and supporting organizations and uses partner organizations web sites as a tool to educate the community about immunization resources. The TAPI's website, Facebook and twitter accounts are used for better outreach to partners and parents. TAPI conducted eight regional immunization programs with the Vaccines for Children Program and the Arizona State Immunization Information System for providers statewide. 450 individuals from provider offices and health departments participated in the trainings. The programs emphasized the importance of using resources such as reminder/recall cards and parent education flyers. TAPI also partnered with ADHS/AIPO to educate healthcare providers on immunization educational tools at 10 professional conferences. TAPI partnered with the ASU School of Nursing in a training seminar for graduate level community nursing students to instill the value of community partnerships in immunization. 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. This year TAPI partnered with AHCCCS insurance plans to educate staff on best practices in immunizations. AHCCCS (Arizona's Medicaid) conducts an immunization assessment every other year and in 2012 indicated increased exemption rates in the AHCCCS kids under 5. TAPI has trained all of the health plan provider reps on immunization best practices to share with the offices during site visits. All BWCH early childhood home visitors monitored the immunization status of the children enrolled in their program and continued to promote and facilitate immunizations. Approximately 92% of Health Start children were fully immunized and 8% were not fully immunized. 93 Table 4a, National Performance Measures Summary Sheet Activities 1. TAPI designs, prints and distributes immunization materials for parents and providers 2. TAPI works with managed health care plans to promote ontime immunizations for enrolled children/adolescents 3. TAPI conducts educational/training programs to improve immunization practices 4. TAPI continues programs and partnerships that promote childhood immunizations 5. Home visitors educate pregnant and postpartum women about the importance of immunization and monitor the immunization status of enrolled infants. 6. Arizona WIC participants are screened and referred for proper timing of the DtaP. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X X X X X b. Current Activities TAPI continues to use traditional and social media for outreach and education. Arizona has faced significant changes to vaccine funding and is working with partners to identify new approaches to fill service gaps and to develop messaging for parents and providers to ensure that no children are denied immunizations. TAPI is working with immunization service providers to ensure immunization services are available in underserved areas and developing educational materials on the importance of adult pertussis vaccines in protecting babies. Other MCH programs continue to monitor immunization status. Health Start CHWs, HRPP Nurses and home visitors funded through the Maternal, Infant and Early Childhood Home Visiting grant continue to monitor the immunization status of the children enrolled in their programs and continue to promote and facilitate immunizations. 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. Utilizing Title V funds, in 2013 ADHS commissioned a study by the University of Arizona to analyze the increase in personal belief exemptions. Additionally, the BWCH reached out to AMCHP and HRSA to ascertain how other states were addressing this issue. Work continues in the agency and with partners to address findings, both procedural and educational. The Office of Immunizations hosted a "Twitter Chat" as a means of addressing this issue. c. Plan for the Coming Year A Task Force of ADHS, TAPI and other partners will continue to work collectively to address the high immunization exemption rates. Plans include focus groups, surveys and community discussions. TAPI will continue to meet 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 providers to ensure immunization services are available in underserved areas. 94 TAPI will continue to revise and update website, social media, and print materials as needed to keep current with established Immunization recommendations and practices. TAPI will assist fire departments in developing new clinics in underserved areas, and develop materials for new parents in hospitals and childcare centers. 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. The Health Start Program will obtain the most current immunization requirements and distribute to contractors. A new immunization checklist will be required as part of the child's information in the client chart. 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 Community Health Workers will continue to provide education on the importance of immunizations for the whole family and will direct them to immunization providers and other resources within their community. The HRPP Community Health Nurses will continue to monitor the immunization status of the children enrolled in their program and continue to promote and facilitate immunizations. Additionally, the alliance of early childhood home visitors funded through MIECHV, StrongFamiliesAz, will provide professional development opportunities to all of Arizona's home visitors about immunizations as well as link the StrongFamiliesAz.com web page to the TAPI web page. 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. 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 2008 2009 2010 2011 2012 33 32 23.5 23 18 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 18.5 2430 131429 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 95 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2013 17.5 2014 16 2015 16.5 Final Final 2016 15 2017 15 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 Arizona's teen pregnancy rate continues to decline. In 2012, the Bureau of Women's and Children's Health Teen Pregnancy Prevention Program (TPP) funded 13 Arizona county health departments, the Navajo Nation, and five other tribes (Tohono O'odham San Lucy District, Fort McDowell, Hopi, White Mountain Apache, and Pascua Yaqui) through a contract with the InterTribal Council of Arizona with lottery revenue to provide abstinence plus programming to youth. Programs also provided parent/teen communication education to parents. Additionally, through federal Personal Responsibility Education Program (PREP) funding, BWCH TPP funded 8 community-based organizations to provide abstinence plus programming including life skills training to youth. A total of 9,848 youth and 149 parents received services in 2012. 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 and foster care group homes in order to encourage participation among youth on probation, in detention centers and living in group homes. Seven abstinence programs provided services with funding from Arizona lottery dollars with an additional 3 programs providing services through Title V federal funding. Projects focused on youth development/service learning and peer leadership as well as classroom instruction. Additionally, the federally funded programs also created youth advisory groups to assist with the development of successful programming. Programs also provided parent/teen communication education to parents. A total of 26,983 youth and 873 parents received services in 2012. In 2012, the Teen Pregnancy Prevention Program began collaborating with the Arizona Mexico Border Health Commission to address teen pregnancy along the Arizona/Mexico border. The teen pregnancy prevention team along with the Sonoran Department of Public Health held a meeting in November 2012 to outline potential areas for programs operating along both the Arizona and Sonoran borders to collaborate. Staff outlined potential collaborative projects which included a Binational Teen Health Facilitator Certification Program with youth from Sonora and Arizona that would be provided by the Mariposa Community Health Center, as well as conducting quarterly Binational Teen Pregnancy Prevention program meetings to share best practices and plan activities that would benefit programs on both sides of the border. ADHS home visiting programs; Health Start, the High Risk Perinatal Program and an alliance of Arizona's home visitors developed as a result of Maternal, Infant and Early Childhood Home Visiting funding address birth spacing with clients. 96 Table 4a, National Performance Measures Summary Sheet Activities 1. The Teen Pregnancy Prevention Program provides a youth development/service learning program to Juvenile Probation Youth and other high risk youth. 2. The Teen Pregnancy Prevention Program provides parent education on how to talk to teens about responsible sexual behavior. 3. The Teen Pregnancy Prevention Program provides technical assistance to providers of teen pregnancy prevention services. 4. The Teen Pregnancy Prevention Program provides abstinence and abstinence plus education programming. 5. Home Visitors educate teens about the importance of a reproductive life plan. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X X X b. Current Activities The Program continues to use lottery dollars to fund 13 county health department projects, six tribal projects and seven abstinence programs. The TPP program also continues to fund 11 community-based projects with federal PREP and Title V funding. The TPP program continues to coordinate efforts with the Office of HIV, STD, and Hepatitis Services to integrate STD prevention in programming and the Arizona Department of Education for coordination of teen pregnancy prevention curricula trainings. The TPP worked 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 curricula supplement has been developed. Grantees received training on how to work with this population as well as how to utilize the guide. In June 2013, the Teen Pregnancy Prevention program presented at the annual Arizona-Mexico Commission, Health Services Committee to report on the collaborating efforts that would take place between Arizona and Sonoran teen pregnancy prevention programs. It was concluded that it would be best to replicate the Teen Facilitator Public Health Certification program in Sonora in 2014. Overall, this was the most practical option for youth living on the border to benefit from the certification program experience. 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 the Affordable Care Act 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 97 curricula as needed. In 2012, the Teen Pregnancy Prevention Program made the transition to offering evidence-based and/or promising practices. The Teen Pregnancy Prevention programs will continue to implement medically accurate, culturally diverse, evidence-based and/or promising practices, abstinenceplus and abstinence-based curricula. The Teen Pregnancy Prevention program will continue to dedicate resources to train contractors in approved curricula to ensure curriculum is delivered with fidelity as outlined by developer. Close contract monitoring and technical assistance will continue to be provided by program managers. ADHS will continue to coordinate with all federally funded "Tier I" and Tier II" agencies to best maximize our funding. "Tier 1" grants to replicate teen pregnancy prevention programs that have shown to be effective through rigorous evaluation and "Tier 2" grants to develop, replicate, refine and test additional models and innovative strategies to reduce teen pregnancy. ADHS will continue to work with the Arizona-Mexico Commission, Health Services Committee to facilitate the Teen Facilitator Public Health Certification program in Sonora in 2014. ADHS home visiting programs; Health Start, the High Risk Perinatal Program and the alliance of Arizona's home visitors StrongFamiliesAZ will continue to address birth spacing with clients. 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 2008 2009 2010 2011 2012 36.5 36.2 36.5 47.1 47.1 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 AZ Office of Oral Health 2013 47.1 2014 47.1 2015 47.1 Final 2016 47.1 Final 2017 47.1 Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective Notes - 2012 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 98 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 - 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. a. Last Year's Accomplishments During the 2011-2012 school year, the Arizona School-based Sealant Program provided dental screenings and referrals to 11,411,children attending eligible public schools. In addition, 6,412 children received 22,664 dental sealants. Two rural counties had difficulties locating dentists to participate in program activities due to lack of dental providers. Lack of dental providers in communities 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 to assist in increasing participation in program implementation. Attempting 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 change 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 in 2012 began 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 Surveillance System: http://www.cdc.gov/nohss/. The OOH conducted 96 professional development Workshops and continuing Education events which offered 188.5 instructional hours on oral health disease prevention programs. A total of 1,102 participants were trained (including dentists, dental hygienists, dental/dental hygiene 99 students, physicians, nurses, and administrators). Training focused on five main topics: Teledentistry & Affiliated Practices -- Concepts and Practice Model Development; Teledentistry Equipment Training -- Hardware & Software; Oral Health Workforce Models -- Affiliated Practice and Other Dental Hygiene Models; Building Infrastructure for Oral Health and Enhanced Dental Teams; and Oral Health -- Early Childhood Tooth Decay, Oral Observations and Prevention. The training events included an evaluation component that identified participants had gained knowledge of the issue surrounding oral health and disease prevention programs for children. The OOH collaborated with the Arizona School of Dentistry and Oral Health and Oral Health America to implement a school-based sealant program in Pinal County. OOH supplied the technical assistance for program implementation, data gathering and program reporting. Table 4a, National Performance Measures Summary Sheet Activities 1. Office of Oral Health provides dental sealants to high-risk children. 2. Office of Oral Health evaluates the dental sealant program. 3. Office of Oral Health collaborates with key stakeholders to expand services 4. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X b. Current Activities The Office of Oral Health continues to provide a school-based sealant program in five Arizona counties. 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. This program has expanded to include four schools located in Pinal County. OOH is partnering with the Arizona Alliance for Community Health Centers and the Inter-tribal Council of Arizona to provide professional development opportunities for dental providers and program administrators on dental public health issues. The OOH is partnering with First Things First, the Early Childhood Development and Health Board to implement a fluoride varnish program in an underserved area Phoenix. The Medical Services Project actively recruits dentists to provide oral health services for free or a nominal rate to children not covered by Medicaid and unable to pay for services and continues to provide oral health services, as dentists are available. 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 100 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. In an ongoing 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 2013-2014 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. OOH will continue to expand and develop workshops and provide continuing education opportunities for dental providers and program administrators. The OOH will convene oral health partners from around the state to address the decreasing participation in this program. The topics to be covered include provider participation, decreasing reimbursement from Medicaid and the confusion between public oral health and for profit mobile oral health services. The Medical Services Project will continue recruiting dentists to provide oral health services and continue to provide oral health services, as dentists are available. 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 2008 2009 2010 2011 2012 4 3.8 3.5 2.5 2.4 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 2.0 27 1358070 AZ Death Certificate 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 101 therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2013 1.9 2014 1.9 2015 1.9 Final Final 2016 1.8 2017 1.8 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. a. Last Year's Accomplishments Arizona has been working on many fronts to reduce the deaths of children due to motor vehicle crashes. The rate of motor vehicle fatalities declined from 9.9 deaths per 100,000 children in 2006 to 3.7 deaths per 100,000 children in 2011. Motor vehicle crashes were the cause of 70 deaths among Arizona's children in 2011. There were only two child deaths related to off-highway vehicle (OHV/ATV) crashes. Ninety-one percent of motor vehicle-related deaths were determined to have been preventable (n=64). Lack of vehicle restraints was identified as a preventable factor for 46 percent of motor vehicle crash fatalities (n=33). One of the goals of the Title V County Health and Prevention grants, funded by Title V is to reduce the rate of injuries, both intentional and unintentional. These contracts must look toward system wide changes using the Spectrum of Prevention. For 2012, injury prevention activities included community education, building coalitions, changing organizational practices, and developing policies. Five out of six participating counties provided car seats and education on installation of car seats. They provided car seat technician training and certification, 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. Apache County Health Department developed a new Safe Kids Chapter. 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. In addition, the Office of Injury Prevention participated in the Four Corners meeting, which focused on improving child restraint use, law enforcement education, and parent education on the Navajo Nation. The Injury Prevention Program also collaborated on a Road Safety Audit with Arizona Dept 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. The Arizona Injury Prevention Advisory Council in partnership with the Arizona Game and Fish Department convened two statewide stakeholders' meetings to raise awareness of the various entities promoting safe all terrain/off-highway vehicle use among Arizona residents. 102 The High Risk Perinatal Program/Newborn Intensive Care Program (HRPP/NICP) Community Health Nurses and the Health Start Community Health Workers conducted environmental risk assessments on every home visit. Car seat checks and information were included in these assessments. Table 4a, National Performance Measures Summary Sheet Activities 1. Child Fatality Review Program reports on motor vehicle crashes among children. 2. Title V County Health Prevention contracts build local infrastructure on injury prevention. 3. Injury Prevention Program provides car seat safety technician training 4. Title V funding enabled programs to buy and distribute car seats 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 Injury Prevention Program continues to build capacity for child passenger safety through providing certified training and continuing education for recertification. Courses will add 40-50 more technicians throughout Arizona. With the recent signage of the booster seat law, the Office of Injury Prevention is focused on ensuring communities have information on and access to booster seats. Apache and Navajo Counties are partnering to provide NHTSA child passenger certification and recertification classes. Apache and Navajo County are also partnering with Arizona Game and Fish to educate people about helmet use while operating an ATV. Apache and Navajo Counties are developing a Safe Kids chapter. Coconino County is sponsoring NHTSA Child Passenger Safety training courses. Coconino County is collaborating with various agencies to conduct presentations on the dangers of drinking and driving and distracted driving. This year the Counties will focus on Battle of the Belt. 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 Maternal Infant Early Childhood Home Visiting Grant (MIECHV) is providing support to the Office of Injury Prevention for a half-time person to provide training on injury prevention for Arizona's home visiting programs. All Arizona's home visitors continue to monitor and educate families about car seat usage. 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 103 surrounding these deaths. The 20th annual report will be produced in November, 2013 and will include information on the deaths that occurred in Arizona during 2012. 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 went into effect August 2, 2012. Health Start will continue to fund Car Seat Safety Technician and recertification training for Community Health Workers. Health Start will continue to purchase car seats and infant seats for its enrolled families. HRPP Community Health Nurses and Health Start Community Health Workers will continue to monitor car seat usage with every home visit and continue to educate the families on the importance of car seat usage. The Maternal Infant Early Childhood Home Visiting Grant (MIECHV) will continue to provide support for a half-time person to provide training on injury prevention for home visiting programs throughout the state. The Injury Prevention Program will continue to build capacity in the state by training new car seat safety technicians. The Title V County Health Prevention contracts will continue to grow through the levels of the Spectrum of Prevention. These contracts will increase activities around building coalitions, changing organizational practices, and developing policies. The Injury Prevention Program will provide technical assistance to county injury prevention staff, and provide collaborative learning opportunities. As an outcome of a meeting of the Health Services Committee of the Arizona Mexico Commission, the Injury Prevention Program will work with Sonora, Mexico to foster education about car safety seats on both sides of the Border. Performance Measure 11: The percent of mothers who breastfeed their infants at 6 months of age. Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source 2008 2009 2010 2011 2012 50 50 53 51 53 48.2 45.3 49.6 52 43.3 CDC National Immunization Survey CDC National Immunization Program CDC National Immunization Program CDC National Immunization Program CDC National Immunization Program Check this box if you cannot report the numerator because 104 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 2013 49 2014 53 2015 57 Final Provisional 2016 59 2017 61 Notes - 2012 Source: Centers for Disease Control and Prevention National Immunization Survey, Provisional Data, 2009 births. http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm Notes - 2011 The CDC National Immunization Survey data for 2011 (2008 birth cohort). 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%. a. Last Year's Accomplishments During Federal Fiscal Year (FFY) 2012, the Arizona Department of Health Services achieved a number of significant accomplishments. The Arizona WIC Program had a rate of 76.8% for ‘ever breastfed' (CDC NIS 2012) with a target rate of 81.9%. The areas of outreach activities, training, and expanded access to services improved in FFY2012. Results of the 2011 Maternity Care Practices in Infant Nutrition and Care (mPINC) survey ranked Arizona as 16th in the country compared to 24th as indicated in the 2009 survey. The greatest improvements were those targeted in the Arizona Baby Steps to Breastfeeding Success program including timing of first feeding, rooming in, supplementation, pacifier use, and support after discharge. The WIC Baby Behavior training by UC Davis Center for Human Lactation was converted to a four-hour learning management system (LMS) course for WIC staff to use, using a blended learning approach. The course was also made available to all Bureau of Women's and Children's Health (BWCH) contract service providers. There were 131 WIC staff who successfully completed the "Introduction to Breastfeeding" LMS class. This required course covers the basics of breastfeeding for new staff to serve as an 105 introduction to WIC's breastfeeding support programs. 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 satisfying employment probation requirements. Two hundred and fifty WIC staff from Arizona, American Samoa, CNMI (Commonwealth of Northern Mariana Islands), and Guam successfully completed "Breastfeeding Boot Camp", a 35hour WIC-focused breastfeeding class developed by the ADHS Breastfeeding Coordinators. Upon completion, staff achieved the designation of "Local Agency Breastfeeding Authority," which enables them to conduct breastfeeding assessments, issue breast pumps, select food packages for breastfeeding dyads, and other breastfeeding-related tasks. In October 2012, eight Arizona WIC Program staff earned certification as new International Board Certified Lactation Consultants (IBCLCs). These certifications are indicative of the level of training and skill possessed by WIC staff in Arizona. This raises the total number of Arizona WIC IBCLCs to 58. Arizona continued to offer professional education in breastfeeding at LATCH-AZ (LActation support To Collaborate for Health - AZ) meetings. These meetings are open to the public at no charge. They provide an opportunity for WIC staff to network with community partners interested in lactation. Topics presented included "The Mind Body Connection: Using New Neuroscience Research to help Mothers Achieve their Breastfeeding Goals" and "The Anti-Inflammatory Characteristics of Human Milk: Human Milk as an Immunological Support System for the Infant". The Arizona Breastfeeding Hotline continued to provide access to skilled lactation help 24-hours a day, seven days a week. In 2012, during business hours, the Hotline answered 1,227 calls related to breastfeeding issues. 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. The after-hours aspect of the hotline is especially useful for mothers unable to reach their health care providers. The Arizona WIC Program continued to offer Peer Counselor Services in 11 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, 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. Support for the Breastfeeding Mother/Baby Dyad was included as one of the ten evidence-based standards included in the Empower Program. Empower is a voluntary program that provides a discount in child care provider licensure fees in exchange for following ten evidence-based standards supporting healthy eating, active living, and tobacco prevention. Table 4a, National Performance Measures Summary Sheet Activities 1. Health Start Community Health Workers educate pregnant and postpartum women about breastfeeding. 2. Baby Steps for Baby Friendly educates hospital staff on evidence based maternity care practices that support Pyramid Level of Service DHC ES PBS IB X X 106 breastfeeding through LMS. 3. HRPP Community Health Nurses support 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 answer the Pregnancy and Breastfeeding Hot Line after business hours and on weekends and holidays. 6. WIC conducts free lactation education and networking events. 7. MIECHV fund sponsor breastfeeding professional development for home visitors. 8. 9. 10. X X X X X X X b. Current Activities Arizona is continuing to offer the Breastfeeding Boot Camp Training to another 250 -- 300 WIC staff in 2013. A statewide Breastfeeding Coordinator Meeting developed a Strategic Plan for the WIC Breastfeeding Program for FY2014-2019, evaluating different models for the Peer Counselor Program, and conducting effective breastfeeding assessments. In collaboration with the Communities Putting Prevention to Work (CPPW) grant, the Arizona Baby Steps to Breastfeeding Success training was converted to a LMS course for sustainability of the program as the grant came to an end. In an effort to sustain breastfeeding, 500 Arizona and Navajo Nation WIC staff will attend an inservice that focuses on reinforced messaging about baby behaviors, and then learn to bridge the information to their daily tasks during one of 12 in-person regional trainings to be conducted in the summer of 2013. The Maternal, Infant, Early Childhood Home Visiting grant is funding a position in the Bureau of Nutrition and Physical Activity to provide breast feeding training to all home visitors. They are provided a two-day basic training for 30 home visitors from all home visiting program models to provide the skills, tools, and resources to aid them to help mothers make and reach their breastfeeding goal and to provide a more comprehensive "boot camp" for an additional 30 home visitors providing half of the education hours needed to sit for the International Board Certified Lactation Consultant exam. c. Plan for the Coming Year WIC will continue to offer a breast pump loan program through WIC Local Agencies statewide. Peer Counseling Services will continue to be provided statewide. The Bureau of Nutrition and Physical Activity will continue to offer the 5-day Breastfeeding Boot Camp training to WIC agencies. Baby Behaviors training will be made available to Home Visiting Program Staff. The Arizona WIC Program will continue to offer Peer Counselor Services to the Local Agencies. The WIC Baby Behavior training will continue to be offered through the learning management system (LMS) for WIC staff to use. The course will continue to be made available to all Bureau of Women's and Children's Health (BWCH) contract service providers. Arizona will continue to offer professional education in breastfeeding at LATCH-AZ (LActation support To Collaborate for Health - AZ) meetings. Arizona Department of Health Services Health Start Community Health Workers and High Risk Perinatal Program 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 107 support new mothers in their desire to breastfeed. The Maternal, Infant and Early Childhood Home Visiting grant will continue to fund a Breast Feeding Coordinator to continue to provide two-day basic trainings for home visitors from all home visiting program models to provide the skills, tools, and resources to aid them to help mothers make and reach their breastfeeding goal. In addition, the Breast Feeding Coordinator will continue to provide a more comprehensive "boot camp" for additional home visitors providing half of the education hours needed to sit for the International Board Certified Lactation Consultant exam. In addition, breast feeding training will be included in the annual Strong Families Home Visiting conference for over 600 participants. The MCH hotline will continue to be staffed by one bilingual Certified Lactation Consultant and a bilingual certified IBCLC who answer calls regarding breastfeeding. A Registered Nurse and advanced bilingual IBCLC is available to answer all breastfeeding questions after normal business hours and to answer technical questions 24-hours a day, seven days a week. 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 2008 2009 2010 2011 2012 97 98 100 100 100 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 98.2 85666 87274 AZ Early Hearing Detection and Intervention Progra 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 108 moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2013 100 2014 100 2015 100 Final Final 2016 100 2017 100 a. Last Year's Accomplishments Arizona has been working to ensure all Arizona's babies are screened before discharge. A highrisk follow-up coordinator was hired to provide targeted follow-up for those infants who are at highest risk for hearing loss. The role of the high-risk coordinator is to foster communications between hospital discharge managers and the newborn hearing screening program. Last year, the high-risk coordinator has been able to accomplish the following: Worked with GBYS to implement the 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; Developed the pocket guide "Infant Hearing Guide for Healthcare Providers" and Worked with EAR Foundation of Arizona (EFAZ), and GBYS to educate audiologists and encourage parents to schedule follow up appointments. At the 2012 EHDI conference in February, two topics highlighting the paired education message and the pocket guide were developed and presented ADHS. The provider pocket guide won the outstanding poster award for Relevance to Advancing Practice. The data reported via HiTrack indicated that 98.16% of newborns received their newborn hearing screening prior to discharge. 99% were screened by one month of age. Four midwives who completed the training and were provided loaner equipment were given HiTrack training and provided access to HiTrack for entering their patients. ADHS maintained close contact with hospital screening programs to ensure that state follow-up efforts were focused on those infants who are not already in the screening or diagnostic process. On-site technical assistance was provided to screening programs by incorporating strategies to ensure that screeners more accurately record the disposition of infants including transfers, deceased, parental refusals; scheduled rescreens and inpatient versus outpatient screening results. Timing of calls to hospitals is also optimized versus parents or medical home providers. The newborn screening data was linked to Vital Records with a success rate of matched records of >90%. The hearing screening database, HiTrack, has been upgraded to a centralized platform. All birthing hospitals now have direct, real time and secure access to upload screening results and demographic information on their patients, an important component of the hearing screening program, and can view and edit notes from our case management team. Future plans this year include adding access for audiologists and other providers in a two-way role-based secure environment. This expansion, funded under a data integration grant from the Centers for Disease Control and Prevention (CDC), is expected to result in a significant reduction in our lost-todocumentation rate. A survey was developed and administered to families who refused in-patient blood spot, hearing or both screens. The survey results revealed that the majority of hearing refusals was based on financial criteria and blood spot refusals from a decision to have the initial screen performed at 109 their physician office. In an attempt to reduce the number of in-patient hearing refusals, The EAR Foundation of Arizona provided a "voucher" for the baby to receive a screening via the contracted hospital screening vendor; this ensured that a bill would not be generated for the family. Arizona Hands & Voices Guide by Your Side program provided support to parents in the screening process. The program pairs a trained Parent Guide with a hospital screening program. Each hospital customizes at what point they would like to have the guides interact with their screening program. The types of services offered varies by hospital and included at a minimum follow up to families whose infant failed either the initial or follow up screen. E-learning was expanded to include more screeners and updated to a web version. A newsletter was developed which 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 Listserve. Table 4a, National Performance Measures Summary Sheet Activities 1. Newborn Screening Program provided on-site technical assistance and training for hearing screening 2. Newborn Screening Program continues to enhance education for parents and providers. 3. Sensory Program collaborats with the University of Arizona to train hearing screening trainers. 4. OCSHCN continues to support online training of hospital based hearing screeners. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X X X X b. Current Activities The High Risk Coordinator continues to provide targeted follow-up for those infants who are at highest risk for hearing loss. The most successful change in the follow-up program this year is the implementation of the Fax Back Form to primary care physicians (PCP). The form is faxed to the PCP asking for hearing results and/or additional testing information. Requested information is usually returned within one week. Technical assistance to hospitals continues through on-site training, conference calls and distribution of best practice materials. Hospitals who report <1% or >4% refer rates were contacted to determine equipment issues, staff turnover, or systems interruptions and provided guidance for corrective action. An effort to reduce the number of in-patient hearing refusals has been implemented by The EAR Foundation of Arizona. Funding has been secured for a one year period to provide a "voucher" for families with financial hardship. Refusals are monitored each month including refusal vs those who opt for an outpatient screen. The annual Hospital Screeners meeting will be conducted; midwives and other out of hospital screeners attend the meeting and will be invited in future years. This meeting provides an update on how well the state performs on reporting, updated screening practices and equipment. An e- 110 learning module for standardized screening training for those screening newborns is being expanded to allow all screeners to participate. c. Plan for the Coming Year The High Risk Coordinator will continue to provide targeted follow-up for those infants who are at highest risk for hearing loss. The HR coordinator will work to create new linkages with community providers to enhance follow-up. ADHS will maintain close contact with hospital screening programs to ensure that state follow-up efforts are focused on those infants who are not already in the screening or diagnostic process. On-site technical assistance will be provided to screening programs incorporating strategies to ensure that screeners more accurately record the disposition of infants including transfers, deaths, parental refusals; scheduled rescreens and inpatient versus outpatient screening results. As part of the data integration project funded by the CDC, new data systems will be 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 underway 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. Arizona Hands & Voices Guide by Your Side program will continue to provide parent to parent support to parents in the screening process. NBS plans to expand coordination efforts to reach the families of infants 0-3 who are LTFU. This will be accomplished through our data integration efforts and parent outreach efforts and surveys to ensure that families have family-centered and culturally sensitive access to information about where to get screened (including mechanisms to reach those underserved in the current EHDI system). Included in this partnership will be technology enhancements, such as data sharing and infrastructure building, data exchange and training to include broader use of the e-Learning platform. 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)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator 2008 2009 2010 2011 2012 16.3 13.8 16 16 15.8 13.4 13.1 15 14 13.5 111 Denominator Data Source US Census US Census U.S. Census U.S. Census U.S. Census 2013 13 2014 13 2015 13 Final 2016 13 Final 2017 13 Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective Notes - 2012 Estimate from Table HI05 available at http://www.census.gov/hhes/www/cpstables/032012/health/toc.htm 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) a. Last Year's Accomplishments 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 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 2012, the Medical Services Project provided medical appointments to over 362 different children from approximately 140 different referring schools. In 2012, the Medical Services Project developed new collaborative partnerships with Westside Head Start, Care More Health Plan, Tempe Social Services Network, Avondale Social Services at Care One Center, National Latino Children's Institute, Yavapai Healthy Partners, E-Latina Voices, and People of Color Network, among others. By developing collaborative partnerships 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. 112 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 28% of Health Start clients are without insurance. Home Visiting programs funded by MIECHV assess all people who are part of the household they are visiting regarding their health insurance status. This includes the pregnant woman, female caregivers, male caregivers and children. Of the 1,129 people assessed as of 4/29/13, 57% were on Medicaid (AHCCCS), 13% had no insurance, 8% had private or self-pay insurance, 0.2% had military insurance and 21% are unknown or un-reported. The home visitor works with the family to help them gain access to insurance and to support them using insurance for preventive and acute care. Project LAUNCH parent educators assessed the insurance status of their families and facilitated enrollment when possible or helped the family to find other venues for health care like Federally Qualified Health Care Centers. The Pregnancy & Breastfeeding/Children's Information Center Hotline assisted 15,062 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, MIECHV Home Visitors, and LAUNCH parent educators educate the family on the importance of maintaining a medical home and assists families in accessing health insurance. 4. 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 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 141 referring schools. The 113 primary care provider network consists of 146 active primary care providers, 151 active specialty care providers (e.g. cardiology, dermatology, ears nose throat, orthopedics, pulmonology, and dental). All of Arizona's statewide early childhood home visitors including the Bureau of Women's and Children's Health home visiting programs continue to assess the health insurance status of each client. Families are educated about the importance of establishing and maintaining a medical home and assisted in overcoming the barriers to accessing health care. The program works closely with AHCCCS, Arizona's Medicaid agency, to ensure families receive coverage as quickly as possible. At the end of the 2011 Legislative session Kids Care (SCHIP) enrollment was frozen. In May of 2012, AHCCCS opened up enrollment for a limited number of children already on the waiting list for KidsCare. All of BWCH programs who work with young families continue to help inform families of the limited enrollment opportunity. 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 While the percent of children without health insurance has continued to decrease in Arizona, there is much work to be done. 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 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. In an attempt to establish a medical home, when a child is unable to become insured the family will continue to be referred to a local Federally Qualified Health Care Center. 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 2008 2009 2010 2011 2012 34.5 37.3 38670 103755 34.5 30.2 31174 103089 34.5 29.3 31182 106318 34 28.9 30018 103873 28.5 27.8 27583 99071 114 Data Source AZ WIC Program database AZ WIC Program AZ WIC Program AZ WIC Program AZ WIC Program 2013 27 2014 26.5 2015 26 Final 2016 25.5 Final 2017 25.5 Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective Notes - 2012 Numbers reported before 2009 includes duplicates by error, 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 - 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). a. Last Year's Accomplishments The Arizona Department of Health Services (ADHS) has identified the promotion of nutrition and physical activity to reduce obesity as an opportunity to impact Arizona's winnable battles to achieve targeted improvements in health outcomes in the Department's FY2012-1016 Strategic Map. The Bureau of Nutrition and Physical Activity (BNPA) completed the three-year Action Plan for Improving Arizonans Well-Being Through Healthy Eating and Active Living aligning efforts across federal and state funded strategic plans to influence obesity prevention where Arizonans live, learn, work, play, and receive care. Through the plan, BNPA has aligned programs across WIC, Arizona Nutrition Network (AzNN), and Empower to promote consistent core messaging in nutrition education for infants, children and their families. Empower is a statewide initiative offered to licensed child care centers that include implementing a series of activities that promote wellness for children including: (i) provide at least 60 minutes of structured activity and at least 60 minutes and up to several hours of unstructured physical activity each day; (ii) limit screen time to under one hour a day; (iii) avoid more than 60 minutes of sedentary activity at a time, except while the child is sleeping; (iv) serve meals family style by letting the child decide how much to eat and avoid using food to reward behavior or for a clean plate; (v) provide families education and referrals regarding tobacco prevention, cessation and second hand smoke; (vi) serve one percent low fat or fat free milk for all children over two years; (vii) offer water at least four times during the day (water is not to be served during lunch); (viii) limit juice to 100 percent fruit juice (with no added sugars) and to no more than one half cup (4 115 ounces) per day; (ix) enforce 24 hour smoke-free campuses (no smoking 20 feet from any entrance); and (x) if eligible, participate in the USDA Child and Adult Care Food Program. ADHS continued to enhance training and technical assistance for child care centers around the Empower. ADHS Office of Child Care Licensing continued to require childcare centers to offer meals family style, reduce juice consumption, and reduce screen time. First Things First Child Care Health Consultants continued to reinforce the Empower standards and offer TA. The ADHS Division of Public Health Prevention Services collaborated across bureaus to introduce the innovative Health in Arizona Policies Initiative (HAPI). Through this initiative, ADHS worked with 13 county health partners to implement public health strategies impacting healthy eating, active living, and healthy weight across the lifespan. Training was offered to HAPI Policy Managers, WIC, AZNN, and MCH (maternal child health) program partners from Change Lab Solutions around the implementation of the HAPI strategies. The Bureau of Nutrition and Physical Activity promoted healthier eating habits and lifestyles to WIC children and families by ensuring increasing maternity care practices that support breastfeeding with the implementation of Arizona Baby Steps for Breastfeeding Success. In collaboration with the Communities Putting Prevention to Work (CPPW) grant, the Arizona Baby Steps to Breastfeeding Success training was converted to a LMS course for sustainability of the program as the grant came to an end. Table 4a, National Performance Measures Summary Sheet Activities 1. ADHS continues 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 emotion based education materials for obesity prevention for WIC families. 4. WIC continues to expand staff training and education around participant-centered weight counseling with WIC families 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X b. Current Activities The Arizona WIC Program is currently training WIC staff to increase competencies around the identification of overweight/obesity and effectiveness of conversational approaches to weight management. Training has been stratified across three years with a current focus on infants for FFY13, children in FFY14, and focus on women in FFY15. This year's FFY13 WIC trainings for infants introduce Baby Behaviors as a foundation for the prevention of childhood obesity. Training outcomes include the incorporation of Baby Behavior messaging in assessment and counseling 116 for the establishment of healthy feeding relationships. Arizona WIC Program staff is also being trained in the implementation of the new WHO pediatric growth grids aligning with current WIC risk codes and the proper triage of high risk counseling and community referrals. In FFY 13, with the changes in the Supplemental Nutrition Assistance Program -- Education (SNAP-Ed) guidance, the Arizona Nutrition Network has focused all SNAP-Ed activities in four distinct service settings. One of these settings includes Child and Adult Care Food Program (CACFP) participants/sites. Nutrition Education and Obesity Prevention lessons are provided to staff and program participants. Lessons aim to encourage behavior change toward a healthy, active lifestyle. ADHS home visiting programs include education on healthy weight and behaviors. Obesity prevention will be included in this years' professional development conference. c. Plan for the Coming Year AzNN will continue to provide services in the Child and Adult Care Food Program (CACFP) service setting. Additional trainings will be provided to staff and participants, and efforts to improve Public Health approaches will be included. ADHS will continue to enhance department-wide strategies to reduce and prevent obesity by improving education, access, and opportunities for healthy eating and active living while remaining mindful of weight bias and stigmatization in improving metabolic health across all division programs. ADHS will continue to expand and adapt the Empower standards to be implemented in home visiting settings for the Maternal Infant Early Childhood Home Visiting Program and continuing to support the advancement of the HAPI strategies across the state. These standards are inclusive of (but not limited to) nutrition, physical activity, and breastfeeding standards for young children including CSHCN. The Statewide Early Childhood Home Visiting Task force will continue to include nutrition and physical activity into early childhood home visiting curriculum The Arizona Department of Health Services (ADHS) and Nemours have partnered to implement a 5-year, CDC-funded project that will assist Early Care and Education (ECE) providers in improving the healthy eating and active living practices to young children using a learning collaborative quality improvement method. This initiative will complement current ADHS Empower program efforts, but will be branded as Empower PLUS + to build on the momentum of Arizona's current Empower Standards. Empower PLUS + will support 120 ECE programs during the first year, affecting 12,000 young children and their families. The learning collaboratives will consist of five sessions and include up to three staff members from each ECE facility, such as the Director, kitchen staff, and a teacher. 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 the Quality First; Arizona's early care and education quality improvement and rating curriculum. 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. ADHS was recently awarded the basic and enhanced CDC grant titled State Public Health 117 Actions to Prevent and Control Diabetes, Heart Disease, Obesity and Associated Risk Factors, and Promote School Health. Among many things, Arizona's plan includes educational opportunities for WIC clinics and tribal coalitions. . 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 2008 2009 2010 2011 2012 4.5 4.2 4 4 4 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 4.2 3599 85644 AZ Birth Certificates Final Final 2016 3.6 2017 3.5 Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2013 3.9 2014 3.8 2015 3.7 Notes - 2012 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 2012 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 - 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 2011 who smoked at any time during pregnancy. 118 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. The HP 2020 Goal for abstaining from cigarettes during pregnancy is 98.6% (1.4% using tobacco during pregnancy). a. Last Year's Accomplishments For calendar year 2012, 2012, 6,813 women utilized Arizona Smokers' Helpline (ASHLine) services. Of these, 143 (or 2.1% of women using ASHLine) reported being pregnant and using tobacco. According to Campaign for Tobacco-Free Kids, Arizona has the 6th lowest smoking during pregnancy rate in the Nation at 6.3%. Arizona's tobacco prevalence rate of adults is 19.2% and we are ranked 14th in the nation. Due to changes in CDC's methodology, the 2011 state-specific adult smoking rates cannot be compared to data from previous years. This does reflect a more accurate number of smokers in the state. 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. One of the goals of the Title V County Health and Prevention contracts 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. Counties are developing brochures and toolkits on tobacco use and other preconception health topics. Three counties worked to assist other organizations to develop worksite wellness plans including the prevention of smoking onsite. Two counties worked with schools to determine the need for policy change on topics such as tobacco tolerance. One county worked to develop policy against smoking in public housing. All County contractors provided public education for teens and women related to tobacco use. Starting in 2011, the Bureau of Tobacco and Chronic Disease (BTCD) launched Students Taking a New Direction (STAND); a statewide youth coalition effort. The goals of the Arizona Youth Coalition, Students Taking a New Direction (STAND), are to initiate grassroots efforts that engage and empower youth to directly attack the manipulative efforts of tobacco companies, improve policies related to tobacco control, and change social norms that reduce smoking consumption and age of initiation within the State of Arizona. To achieve this grassroots outreach, BTCD has formed a statewide network of youth through each Arizona County. The development of STAND allows tobacco prevention messaging to reach youth both in and out of school, as they work to change the social norms to make tobacco less desirable, acceptable and accessible. More information can be found on www.standaz.com. The Health Start Program continued to provide the Every Woman Arizona Preconception Health Education materials to contractors. These documents 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 119 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. Additionally, the HRPP/NICP provided the Every Woman Arizona Preconception Health Education materials to contractors which are being utilized during family follow-up visits with the postpartum clients. Arizona's federal home visiting program screens women for tobacco use and provides referrals to the Ashline as well. The Title V Family Planning/Reproductive Health Program collaborates with the county level Tobacco Education and Prevention Program to provide brief interventions and referrals for clients who are using tobacco. If a patient identifies herself as someone who uses tobacco during an exam or a pregnancy test, clinic staff provides information on smoking cessation and a referral to the county Tobacco Education and Prevention Program. Table 4a, National Performance Measures Summary Sheet Activities 1. The Midwife Licensing Program provided materials to the midwifery community regarding tobacco prevention programs. 2. BWCH bilingual Hotline staff refer pregnant women to ADHS tobacco education and cessation program. 3. Health Start and Family Planning Programs provided training to contractors on tobacco cessation. 4. Breastfeeding program and tobacco prevention/cessation program are implementing methodology for referring new moms to the Arizona Smokers Helpline 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X b. Current Activities Bilingual Pregnancy & Breastfeeding Hotline staff continues 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 and remain a non-smokers. 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 Health and Prevention includes tobacco use and other preconception health topics. Their 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. 120 Health Start and HRPP are piloting a new home safety checklist which incorporates questions about tobacco and facilitate referral to the ASHline as well as a Chronic Disease SelfManagement program. 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 2014. 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 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 (e.g. MIHS) 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. Based on the results of the feedback of contractors, Health Start and HRPP may continue to use Healthy@Home, a new home safety tool for home visitors which incorporates referrals to chronic disease self management programs and the ASHline as necessary or warranted or amend the tool used in the pilot. Performance Measure 16: The rate (per 100,000) of suicide deaths among youths aged 15 through 19. 121 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 2008 2009 2010 2011 2012 13 12 10 8.2 9.8 12.4 56 451910 AZ Health Status and Vital Statistics 10.7 49 456079 AZ Health Status and Vital Statistics 8.4 39 461582 AZ Health Status 10.1 47 464724 AZ Death Certificates 10.3 48 467382 AZ Death Certificates Final Final 2016 9.6 2017 9.4 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 2013 9.8 2014 9.8 2015 9.6 a. Last Year's Accomplishments In 2012, the 19th Annual Child Fatality Report was produced, summarizing reviews of child deaths that occurred in Arizona during 2011. This marks the seventh year that the Child Fatality Review Program has reviewed 100 percent of child deaths that occurred in Arizona. During 2012, Child Fatality Review Teams reviewed the circumstances surrounding the suicides of 39 children that occurred during 2011. Twenty five (64 percent) of the suicides were among children 15 through 17 years, and four teenchildren (36 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 at the ADHS Zero to Five work groupregarding behavioral health resources for women and children. That information was shared with our other colleagues and contractors. In June 2012, the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) in collaboration with the Governor's Office for Children, Youth, and Families (GOCYF) and the Northern Arizona Regional Behavioral Health Authority (NARBHA) rolled out the Screening, Brief Intervention and Referral to Treatment (SBIRT) Program in five (5) northern Arizona counties: Apache, Coconino, Mohave, Navajo, and Yavapai. These counties were selected as focal points for implementation because data indicates that the rates of alcohol and drug related injuries and deaths are the highest in these regions of the state. The early childhood home visiting programs screened women for postpartum depression and made referrals when appropriate. 122 The Title V County Health and Prevention contracts work towards reducing 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. In 2012, these contractors were encouraged to focus on suicide prevention. Navajo County Health Department provided information on suicide prevention in High Schools. Table 4a, National Performance Measures Summary Sheet Activities 1. Child Fatality Review Program produces an annual report on the causes of child suicide. 2. Division of Behavioral Health Services works closely with Injury Prevention, Child Fatality Review, and other maternal and child health programs. 3. Title V County Health Prevention projects address injury prevention. 4. Prescription drop off event details and how-to develop a Prescription drop off community event is available on the ADHS web page. 5. The Injury Prevention Program continues to work with ED to address opiod prescription abuse. 6. Prescription Guidelines have been established for EDs. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X X b. Current Activities Recommendations made based on the findings of the 2011 Child Fatality Review included: examining methods to strengthen the investigation of the circumstances surrounding child suicides in order to enhance statewide suicide prevention strategies; developing a Suicide Investigation Checklist for use by law enforcement when investigating child suicides; for parents to become informed of the risk factors for suicide of their children and friends. Parents should treat all suicidal talk and threats as if they are real. Parents were advised to program the National Suicide Prevention Lifeline phone number, 800-273-8255, into mobile devices and call for help if there was a question about suicidal ideation. It was also recommended that schools educate students on the signs of suicidal ideation, including information where students may go for help both for themselves or a friend thought to have displayed these signs and on bullying, cyber-bullying, and other circumstances at school that may be risk factors for suicide. 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. 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 123 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 on injury prevention. 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. 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 2008 2009 2010 2011 2012 82.5 83 91 91.5 92 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 92.0 913 992 AZ Birth Certificates Final Final 124 or Final? Annual Performance Objective 2013 92.5 2014 93 2015 93.5 2016 94 2017 94 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. a. Last Year's Accomplishments Arizona has a long and rich history of regionalized system of perinatal care. Perinatal centers are certified by the Arizona Perinatal Trust (APT), a 501 ( c) (3) in existence since the early 1970s. Based on the designation by the APT, pregnant women in need of a higher level of care are transported to the appropriate facility. 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 in distress. Local providers made one telephone call to be connected with this service. If a transport was deemed necessary, the board certified Maternal Fetal Specialists determined the availability of the appropriate level of perinatal bed and authorized and provided medical direction for the transport regardless of the woman's ability to pay. The MFM was able to utilize the perinatal screen of the EMSystem, a web-based program with real time information of perinatal bed availability in Arizona, including high-risk labor and delivery and Newborn Intensive Care Unit (NICU) beds. The program continued to fund all uncompensated care associated with the transport itself of pregnant women to Level II Enhanced Qualification or Level III perinatal centers. During CY 2012, 780 women received maternal transport to the appropriate level of perinatal care. The HRPP Manager continued to visit hospitals and providers to educate them about the availability of the transport system. During APT site visits to birthing hospitals, maternal transports were reviewed for appropriateness and technical assistance was provided to the hospital. The Licensed Midwife Program reviewed quarterly reports from licensed midwives for any infants that were below 3000 grams. If the infant was below that weight the Program contacted the midwife who delivered the infant to determine if there were problems with either the delivery or the pregnancy Table 4a, National Performance Measures Summary Sheet Activities 1. High Risk Perinatal Program transported high risk pregnant Pyramid Level of Service DHC ES PBS IB X X 125 women to appropriate level of care regardless of ability to pay. 2. High Risk Perinatal Program promoted public awareness of availability of transport. 3. The BWCH continues to partner with the Arizona Perinatal Trust on the review of maternal transports during site visits to hospitals. 4. The HRPP requires contracted hospitals to use contracted transport providers ensuring the highest quality care. 5. 6. 7. 8. 9. 10. X X X b. Current Activities The maternal transport component of the High Risk Perinatal Program (HRPP) continues funding for a centralized Information and Referral Service. This 1-800 telephone line offers toll free 24/7 consultation services by board certified Maternal Fetal Medicine (MFM) specialists throughout Arizona to providers caring for pregnant women who presented with high risk factors. If a transport is deemed necessary, the board certified Maternal Fetal Specialists determines the availability of the appropriate level of perinatal bed and authorizes and provides medical direction for the transport regardless of the woman's ability to pay. The MFM is able to utilize the perinatal screen of the EMSystem, a web based program with real time information of perinatal bed availability in Arizona, including high risk labor and delivery and NICU beds. The program continues to fund all uncompensated care associated with the transport itself of pregnant women to Level II Enhanced Qualification or Level III perinatal centers. Home visitors are providing pregnant women with education about the signs and symptoms of preterm labor 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. Providers will be able to continue to make one telephone call to be connected with this service. If a maternal 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 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 will continue to monitor maternal and neonatal transport logs during site visits and review transports for timeliness and appropriateness. Home visitors will continue to educate pregnant women of the signs and symptoms of preterm labor. 126 Performance Measure 18: Percent of infants born to pregnant women receiving prenatal care beginning in the first trimester. Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source 2008 2009 2010 2011 2012 79 80 81 83 84 79.4 78738 99215 AZ Birth Certificates 80.3 74331 92616 AZ Birth Certificates 81.9 71331 87053 AZ Birth Certificates 83.3 70953 85190 AZ Birth Certificates 83.9 71882 85725 AZ Birth Certificates Final Final 2016 88 2017 88 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 2013 85 2014 86 2015 87 Notes - 2012 The HP 2020 Goal is 77.9%. Notes - 2010 The HP 2020 Goal is 77.9%. a. Last Year's Accomplishments The Health Start Program is a legislatively mandated 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 2012, Health Start provided educational services to 2,251 clients. The program provided a total of 12,510 home and/or office visits. Additionally, 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 127 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 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 entry into 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 received 1,378 calls about eligibility for Baby Arizona in 2012. The Arizona WIC program continued to screen pregnant women and refer them to prenatal services. Table 4a, National Performance Measures Summary Sheet Activities 1. Health Start Community Health Workers educated pregnant and postpartum women. 2. Health Start Community Health Workers ensured clients and children attended medical appointments. 3. Bilingual Hotline staff prescreened callers for Baby Arizona. 4. Bilingual Hotline staff referred to providers offering sliding scale rates for prenatal care for pregnant women who would not qualify for Medicaid. 5. Arizona's home visitors who see pregnant women encourage early and consistent prenatal care and support the women during the pregnancy. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X b. Current Activities The Health Start Program educates pregnant and postpartum women about prenatal care, nutrition, the benefits of breastfeeding, danger signs of pregnancy, and home safety. The program utilizes Community Health Workers to identify pregnant and/or parenting women within their community and facilitate early entry into prenatal care. Health Start and many of the other 128 home visiting programs continue to outreach to higher risk populations. The BWCH Pregnancy and Breastfeeding Hotlines continue to screen pregnant women for eligibility into Baby Arizona, and to refer women not eligible for Medicaid to prenatal care providers that serve the uninsured. Bureau of Nutrition & Physical Activity promotes the benefits of early entry into prenatal care. WIC participants are referred and tracked, and WIC staff are trained to refer pregnant women for early prenatal care. The MIECHV home visitors assist pregnant women into prenatal care and provide education and support during the pregnancy. OOH continues to provide education and technical assistance to dentists on treatment protocols during pregnancy. OOH provides information to health care workers and pregnant women through internal programs such as Health Start and Baby Arizona as well as external partners, on the importance of oral health during pregnancy. Preconception health materials and education offered by various BWCH contractors include the importance of early entry into prenatal care when a woman is contemplating pregnancy. c. Plan for the Coming Year 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 and maternal depression treatment programs in their community. They will continue to distribute the Arizona Resource Guides in English and Spanish to enrolled clients. The BWCH Pregnancy and Breastfeeding Hotlines will continue to screen pregnant women for eligibility into Baby Arizona. The Hotline will continue to maintain and update a database of participating providers and providers offering reduced rates and sliding scale rates. BWCH staff will continue to disseminate hotline information to the public. Arizona WIC participants will continue to be referred and tracked for access to prenatal services, and new WIC staff will be trained to refer pregnant women for early prenatal care. WIC staff will continue to regularly meet with AHCCCS coordinators. 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. All BWCH programs will include information about the importance of early entry into prenatal care as a part of preconception and/or interconception education offered to their clients 129 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 Annual Indicator Numerator Denominator Data Source 2008 2009 2010 2011 2012 10.6 10.6 11.8 302 2557 Youth Risk Behavior Survey 11.4 326 2856 Youth Risk Behavior Survey Final 11.4 326 2856 Youth Risk Behavior Survey Final 2015 10.6 2016 10.6 2017 10.6 Is the Data Provisional or Final? Annual Performance Objective 2013 10.6 2014 10.6 Notes - 2012 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%). The Survey conducted biennially, therefore reporting 2011 estimates. 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 agencies in Arizona. This program is supported by federal Family Violence Prevention and Services Act funding. The seven shelters provided 123 healthy relationship presentations and/or workshops to a total of 4,964 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. The shelters also offer advocacy and support/counseling for the children of domestic violence victims seeking services. Eighty three youth aged 12-17 self-reported being a victim of intimate partner violence this past year. The Rural Domestic Violence Services Network provided 327 awareness presentations to 13,007 adults, 123 presentations to 4,964 youth and attended 214 community awareness events in rural Arizona. 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, 2011 until October 31, 2012 the programs reached a total of 19,304 participants in 496 single/multi-session presentations. Subjects in the 130 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 2012, 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. In three locations in Arizona, the ADHS/SVPEP conducted 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. In 2012 the ADHS explored that concept and we were excited to involve several alcohol-serving establishments and community leaders in this project. The program piloted the training in September and October of 2012. 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 2012, 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 nontherapeutic, 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 2012, a total of 365 victims/survivors and 27 collaterally affected received services. 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 provided awareness presentations to adults, presentations to youth and attended community awareness events in rural Arizona. 4. Yavapai County provides education about healthy and abusive dating relationships using a Safe Dates course. 5. The BWCH will continue to work with other programs throughout ADHS and external partners to identify opportunities to further integrate violence prevention into existing programs. 6. The home visiting alliance, StrongFamilesAz provides Pyramid Level of Service DHC ES PBS IB X X X X X X X 131 professional development around domestic violence to Arizona's home visitors. 7. 8. 9. 10. b. Current Activities RDVSN agencies continue to provide presentations, events, and/or workshops to youth around the state. Teen Mazes are being held educating youth in multiple rural communities. These fun interactive events educate teens on topics of health and wellbeing. From November 1, 2012 until March 2013 SVPEP agencies have given 282 single/multi session presentations to a total of 7,861 attendees and 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 has or is doing outreach for the alcohol-serving establishments. Currently three establishments are scheduled for the two 2.5 hour trainings in May, June and July of 2013. The ADHS has partnered up with the Arizona Department of Liquor and Control. All Arizona's home visiting programs screen for domestic violence and if necessary assist a woman with developing a safety plan. Domestic Violence is one of the most requested topics for home visitors. MIECHV has contracted with the Domestic Violence Coalition to present to home visitors regionally and at the statewide conference. Beginning January of 2013, all twelve Title V family planning clinics are contractually obligated to screen for domestic violence and reproductive coercion. 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. The Seven Rural Domestic Violence Service Network agencies plan to continue providing domestic violence prevention programs in their respective communities throughout Arizona. 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 use the final evaluation tools to ensure we are getting the outcomes we desire and project. The program will continue the bystander intervention training for participating alcohol-serving establishments across Arizona. The Sexual Assault Services Program will continue to provide counseling, outreach and accompaniment in three rural counties. Health Start will continue to coordinate with the AzCADV (Arizona Coalition against Domestic Violence) to provide training to Health Start staff on the Project Connect -- Futures Without Violence education. Health Start will continue to collect the surveys and create a database 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. 132 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. Arizona's home visitors will continue to be trained on recognizing signs of domestic violence, how DV impacts others in the home, and ways to address the topic or offer resources if the alleged abuser is in the home at the time of the visit. This will continue to be offered in collaboration with the Arizona Coalition Against Domestic Violence. Additionally, home visitors will continue to refer families to appropriate services. MIECHV will also continue to fund the AzCADV to provide technical assistance to help Home Visitors on an ongoing basis, at the annual professional development conference. The system of home visiting that is being formed, StrongFamiliesAz, hopes to eventually develop policies for all Home Visiting providers to use. Yavapai County will continue to provide education to youth about healthy and abusive dating relationships using a Safe Dates course. 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 2008 2009 2010 2013 26 2012 27 26.5 27.7 652 2354 Youth Risk Behavior Survey (2009) 27.7 652 2354 Youth Risk Behavior Survey (2009) 24.8 666 2687 Youth Risk Behavior Survey (2011) Final 24.8 666 2687 Youth Risk Behavior Survey (2011) Final 2014 25.5 2015 24.9 2016 24 2017 24 Is the Data Provisional or Final? Annual Performance Objective 2011 Notes - 2012 The HP 2020 Goal for adolescent obesity is 16.1%. The Survey conducted biennially, therefore reporting 2011 estimates. 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% 133 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 ADHS has identified the promotion of nutrition and physical activity to reduce obesity as an opportunity to impact Arizona's winnable battles to achieve targeted improvements in health outcomes in the Department's FY2012-1016 Strategic Map. The Bureau of Nutrition and Physical Activity completed the three-year Action Plan for Improving Arizonans Well-Being Through Healthy Eating and Active Living aligning efforts across federal and state funded strategic plans to influence obesity prevention where Arizonans live, learn, work, play, and receive care. The ADHS division of Public Health Prevention Services collaborated across bureaus to introduce the innovative Health in Arizona Policies Initiative (HAPI). Through this initiative, ADHS has worked with 13 county health partners and community based organizations to educate Arizona's state, county and local decision-makers about the health implications of policy and how to build policy processes. Through the operation of this grant, counties have implemented public health strategies with a large emphasis on strategies in K-12 settings including food availability and physical activity. Funding from Title V has allowed counties opportunities for CYSHCN incorporate wellness into everyday life. One of the goals of the Title V County Health and Prevention contracts 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 Department of Public Health has developed a policy unit. They partnered with many organizations to develop a policy related to community gardens within the City of Phoenix. The city adopted this into their General Plan. This unit is a Board Member partnered with Livable Communities Coalition. They worked with the Breastfeeding Friendly Arizona Strategic Planning to increase the number of Baby Friendly Hospitals. They expanded the "Parent Ambassador" Program originally funded by a tribal nation. This program educates parents to advocate for issues such as nutrition and healthy vending within a school setting. The program trains 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 Pyramid Level of Service DHC ES PBS IB X 134 2. Through the Title V Community Grants, counties imbed preconception health, obesity prevention, and chronic disease prevention into their other programs. 3. The ADHS Bureau of Nutrition and Physical Activity continues to work with the Arizona Department of Education to support the federal Coordinate School Health grant. 4. ADHS has chosen ‘Promote Nutrition and Physical Activity to Reduce Obesity’ as a part of the Strategic Plan. 5. Title V funding is assisting to support counties and local communities are learning to develop policies around nutrition and obesity prevention. 6. 7. 8. 9. 10. X X X X b. Current Activities HAPI Policy Managers are currently working with local schools in K-12 settings to support the implementation of school wellness policies reflective of healthy eating and active living. ADHS collaborates with the Arizona Department of Education to offer trainings to school administration around the implementation of local education agency wellness policies. 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. 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 obesity prevention and chronic disease prevention into their other programs c. Plan for the Coming Year In this upcoming year BNPA is hiring a Healthy School Specialist who will provide targeted technical assistance to local county health contractors and local educational agencies on planning, developing, coordinating, and implementing comprehensive policy, systems, and environmental change to prevent obesity in Arizona school settings. This will allow for leadership in the design and implementation of evidence-based school health programs and coordination with internal programs working in school health, such as: Arizona Nutrition Network, Tobacco and Chronic Disease, and the Health in Arizona Policy Initiative. ADHS will also continue to collaborate with the Arizona Department of Education around the implementation of physical activity and nutrition guidelines for K-12 settings and support the utilization of support through School Health Advisory Councils (SHAC's). ADHS will continue to enhance department-wide strategies to reduce and prevent obesity throughout Arizona consistent with the ADHS strategic map and winnable battles. 135 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 obesity prevention and chronic disease prevention into their other programs. The Division of Preventive Health Services will implement the CDC State Public Health Actions to Prevent and Control Diabetes, Obesity and Associated Risk Factors, and Promote School Health. 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 2008 2009 2010 2011 2012 32 31.5 31 31 30.5 29.0 238 821 AZ Vital Records data 31.5 256 813 AZ Vital Records data 32.0 262 818 AZ Vital Records 11.4 127 1112 AZ Vital Records 39.2 372 949 AZ Vital Records Final Final 2016 29 2017 29 Is the Data Provisional or Final? Annual Performance Objective 2013 30 2014 30 2015 29 Notes - 2012 The 2010 birth cohort was used in this analysis. Notes - 2011 The 2009 birth cohort was used in this analysis. This year AZ changed to 2003 version of death certificates that included changes in race/ethnicity categorization. These changes may have effected group used as reference. Further analysis is needed to see why the estimate is much lower than other years. Notes - 2010 The 2008 birth cohort was used in this analysis. a. Last Year's Accomplishments In 2012, ADHS partnered with the Arizona Perinatal Trust and the Arizona Chapter of the March of Dimes to develop strategies for the Association of State and Territorial Health Offices' challenge to reduce prematurity by 8% by 2014. The ADHS strategies included expanding home visiting programs to families and pregnant women in high-risk communities; developing standards for home visiting programs throughout Arizona and professional development of home visitors so 136 that home visits maximize opportunities to reduce risks for premature birth; expanding awareness of importance of preconception health and implementation of the Arizona Preconception Health Strategic Plan; continuing to support the March of Dimes "Healthy Babies are Worth the Wait" 39 Week Toolkit; renew focus on infant safe sleeping practices to reduce post-neonatal infant mortality and use social media and public relations events to promote the overall campaign. The Bureau of Women's and Children's Health was awarded both the formula and expansion Maternal, Infant and Early Childhood Home Visiting grant. Beyond extending evidence based home visiting to additional at risk communities, the home visiting community has united to become an alliance; StrongFamiliesAz. The grant has allowed Arizona the opportunity to create a robust professional development system for all Arizona's home visitors. One Sub Committee of the StrongFamiliesAz Task Force has been working on developing standards for all home visitors. 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 Every Woman Arizona "Are You Ready" reproductive life plan has been developed in English and Spanish 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. The Title V funded County Health and Prevention contractors addressed preconception health. Their preconception health activities included community education, building coalitions, changing organizational practices, and developing policies. Maricopa County Department of Public Health established a policy unit. They partnered with many organizations to develop a policy related to community gardens within the City of Phoenix. The city adopted this into their General Plan. This unit collaborated with Livable Communities Coalition. They worked with the Breastfeeding Friendly Arizona Strategic Planning to increase the number of Baby Friendly Hospitals. They expanded the "Parent Ambassador Program originally funded by a tribal nation. This program educates parents to advocate for issues such as nutrition and healthy vending within a school setting. The ADHS and the Arizona Perinatal Trust worked with the Arizona Chapter of the March of Dimes to distribute the ‘39 week Toolkit' to all APT certified hospitals. During all APT site visits hospitals were asked to explain their process to prevent elective inductions before 39 weeks as well as their safe sleep policies. Additionally, the Child Fatality Review Program issued an annual report in November 2012, 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. Table 4b, State Performance Measures Summary Sheet Activities 1. Child Fatality Review Program promotes use of the Infant Death Investigation checklist. 2. Unexplained Infant Death Council and Bureau of Women’s & Children’s Health produces annual report on stillbirth. 3. Child Fatality Review Program produces annual report on Pyramid Level of Service DHC ES PBS IB X X X 137 infant and child deaths, including recommendations for prevention. 4. ADHS programs promote use of folic acid and multivitamins. 5. Title V County Health projects are implementing preconception health strategies at multiple levels of spectrum of prevention 6. BWCH promotes preconception health materials and strategies. 7. 8. 9. 10. 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. BWCH is participating in the CDC's Preconception Health Show Your Love social marketing campaign by printing posters and health checklists for partner agencies to use in their sites. The Bureau of Nutrition and Physical Activity launched a folic acid campaign Power Me A2Z. The campaign includes a broader preconception health focus and materials are geared for women 1830 years of age. Women are encouraged to visit the Power Me A2Z website to request a 90 day supply of multivitamins. The vitamins are mailed to woman in a knapsack that includes a brochure and other materials that highlight the benefits of folic acid and preconception health. The Emergency Medical Services for Children is working on the pediatric designation system for emergency departments. There are currently 9 hospitals that have sought verification status. This represents 12% of Arizona's EDs. The Title V County Health Prevention preconception health activities 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. c. Plan for the Coming Year 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.Health Start Community Health Workers and Community Health grantees will continue to utilize the Empire State Public Health Training Center free online preconception health training. Arizona's home visiting alliance will continue to encourage preconception health, early entry into prenatal health, elimination of elective inductions before 39 weeks and safe sleep practices. The work of the Title V County Health Prevention contracts will continue to include community education, building coalitions, changing organizational practices, and developing policies. The Office of Child Care Licensing will continue to enforce ‘back to sleep' regulations in early care and education settings. BWCH will continue to work with our county health departments and other partners to facilitate 138 the implementation of the CDC Preconception Health Show Your Love social marketing campaign in Arizona and continue to promote the Power Me A2Z website and consumption of folic acid. 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 Child Fatality Review Program will issue annual report in November 2013, with recommendations for prevention of infant deaths. The Child Fatality Review Program and Arizona Unexplained Infant Death Council will continue to promote use of updated Infant Death Investigation Checklist. Bureau of Women's & Children's Health will focus future activities for prevention of infant deaths based on the results of the data analysis. As a result of the deaths due to unsafe sleep environments, the Office of Injury Prevention has gathered stakeholder to look at safe sleep through the Collective Impact framework. The OIP will work with partners to identify a shared vision, ways to measure data across disciplines, opportunities to collaborate and collectively 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 Offices challenge to reduce prematurity by 8% by 2014. The BWCH has been chosen to participate in a learning collaborative sponsored by AMCHP to improve birth outcomes. The partners in this work will learn through the year the collective impact process and while learning, create an environment in Arizona that will result in improved birth outcomes. State Performance Measure 4: Emergency department visits for unintentional injuries per 100,000 children age 1-14. Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source 2008 2009 2010 2011 2012 7477 7476 7000 7400 7250 6,835.2 90940 1330464 AZ Hospital Discharge data 7,077.9 95037 1342722 AZ Hospital Discharge data 7,558.6 96070 1271006 AZ Hospital Discharge Data 7,436.0 95181 1279995 AZ Hospital Discharge Data Final 7,745.0 98430 1270886 AZ Hospital Discharge Data Final 2013 7100 2014 6950 2015 6800 2016 6650 2017 6650 Is the Data Provisional or Final? Annual Performance Objective 139 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. In 2012, the program conducted a series of pediatric readiness surveys to assess hospitals' capacity to adequately care for emergency department visits among children. The Office of Injury Prevention hosted an emergency department stakeholders meeting to discuss unintentional poisoning and prescription drug abuse. The outcome of this meeting was the creation of consensus-designated prescribing guidelines for utilization in EDs throughout the state. Child Care Licensing continued to monitor 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 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 140 provided 150 encounters in preschools which include assessment, consultation, and recommendations regarding playground safety. The 19th 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 has established and is implementing pediatric designation criteria. 4. Injury Prevention Program provides data analysis and technical assistance on various injury issues 5. State Child Fatality Review Team makes recommendations for prevention of unintentional injuries. 6. County Health projects address injury prevention through education, coalitions, organizational practices, and policy development 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X X b. Current Activities Emergency Medical Services for Children continues to work on the pediatric designation system for emergency departments. There are currently 9 hospitals, or 12% of Arizona's EDs, that have sought verification status. These ED's will see approx. 250,000 children in 2013. The Office of Injury Prevention, along with the Arizona Criminal Justice Commission and other state agencies, continue to pilot the Arizona Rx Drug Reduction Initiative. In 2013, the Office of Injury Prevention published the Injury Prevention Plan, 2012-2016, to guide state and community efforts to reduce the burden of injury throughout Arizona. ADHS was awarded an ASHTO and Robert Wood Johnson Foundation (RWJF) Quality Improvement Integration Project. Health Start and NICP are participating in the project by implementing the Healthy @ Home: Arizona Home Safety and Family Wellness Assessment pilot project in eight sites. The new assessment integrates environmental health and chronic disease components in to the home visiting process. The MIECHV grant is funding .5 FTE in the Office of Injury Prevention to develop trainings for home visitors around safety. ADHS formed an informal Task Force to address safe sleep. The group will use the Collective Impact model as a framework. 141 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 Title V County Health Prevention contracts will continue increasing activities around community education, building coalitions, changing organizational practices, and developing policies. The High Risk Perinatal Program CHNs and Health Start Community Health Workers will continue to conduct environmental risk assessments during home visit. The home visitors will continue to work with families to correct identified concerns. BWCH will continue to implement the federal Maternal, Infant, Early Childhood Home Visiting Program and ensure these programs conduct environmental assessments of the families' homes to identify injury risk. Additionally, safety will be a topic area for the yearly professional development conference held for Arizona's home visitors. Over 500 home visitors and managers attended the inaugural conference last year. The Injury Prevention .5 FTE working on home visiting will assist. BWCH will continue to utilize a standardized home visiting safety assessment tool developed through the Robert Wood Johnson CQI grant. Based on results of the pilot, changes will be made to the tool. 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. The Office of Injury Prevention will continue to work with the Arizona Criminal Justice Commission and other state agencies to pilot the Arizona Rx Drug Reduction Initiative. This effort, to be rolled out statewide over the next few years, is a multi-agency, multi-pronged approach to reducing the burden of prescription drug related overdose, injury, and death in Arizona. This includes adoption of ED Prescribing Guidelines in participating hospitals, improving utilization of the Prescription Drug Monitoring Program (PDMP), identifying "above average" prescribers, and improving accessibility of drug drop boxes in participating counties. BWCH will continue to work on safe sleep by utilizing the Task Force and developing a plan of action. The intent is to create a united message, determine data we can all measure and agree on, assess what is happening now and make sure there is coordination of efforts and ensure continuous communication. State Performance Measure 5: The percent of women having a subsequent pregnancy during the inter-pregnancy interval of 18-59 months. 142 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 2008 2009 41.7 24748 59309 AZ Birth and Fetal Death Certificates 2010 43.8 24330 55589 AZ Birth and Fetal Death Certificates Is the Data Provisional or Final? Annual Performance Objective 2013 46 2014 46.5 2015 48 2011 2012 45 45.5 44.2 24449 55265 AZ Birth Certificates 44.2 24797 56160 AZ Birth Certificates Final Final 2016 48 2017 48 a. Last Year's Accomplishments BWCH staff chose to use a measure of inter-pregnancy intervals as an indicator of progress on the new Title V preconception health priority of improving women's health prior to pregnancy. Stakeholders and staff recognized how critical planned pregnancies and birth spacing is to preconception health and improving birth outcomes. 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 (County) 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 6,255 women who received an initial or annual exam in 2012, 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 2012, 50.1% 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 Newborn Intensive Care Unit. Even though the Project Connect grant ended last year, BWCH will continue to require all funded family planning clinics to continue screening clients for domestic violence. The BWCH will continue to participate on the CDC's Preconception Health Consumer Workgroup and this will allow Arizona to be an active partner in national efforts to promote preconception health and health care. In addition, Arizona will continue be able to disseminate and utilize current marketing strategies for increasing public awareness of preconception health. 143 Table 4b, State Performance Measures Summary Sheet Activities 1. The Reproductive Health/Family Planning Program (RHFP) funds IGA's to sustain and increase the number of low income women receiving reproductive health services. 2. The RHFP program works with other agencies to integrate various women’s health issues such as domestic violence, preconception health, tobacco cessation and prevention, and STDs . 3. Office of Women’s Health is leading preconception health initiatives. 4. Title V County Health projects are implementing preconception health strategies at multiple levels of spectrum of prevention. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X b. Current Activities The Reproductive Health/Family Planning contractors continue to receive level Title V funding to provide 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. Understanding that sexual coercion is a part of intimate partner violence, BWCH continues to assist in the training of family planning providers to screen women for domestic violence in the clinic setting. Health Start Program continues to be trained by the Arizona Coalition Against Domestic Violence to provide screening of women for domestic violence in the home setting as well. 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. 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 the preconception health plan. Office of Women's Health is participating on CDC's Preconception Health Consumer Workgroup. BWCH is using Title V to fund six county health departments to implement preconception health activities across the spectrum of prevention, with emphasis on coalition-building, organizational practices, and policy development. c. Plan for the Coming Year The Reproductive Health/Family Planning Program (RHFP) will continue to provide Title V funding to county health departments and Maricopa Integrated Health Systems to offer services to underserved populations. The program will continue to focus on women at or below 150% of 144 the federal poverty level. The program will continue to seek out locations where underserved clients can be reached. Health Start will continue to provide the Every Woman Arizona "Are You Ready" reproductive life plan booklets and folders to Health Start contractors for use with their clients and any woman with a negative pregnancy test. BWCH will continue to promote the integration of preconception care into family planning services and other appropriate venues. BWCH will continue to work in partnership with the Arizona Family Planning Council and the March of Dimes to identify opportunities to expand preconception care training of clinical care staff across the state. BWCH will explore opportunities to enhance interconception education, particularly regarding appropriate birth spacing, among home visiting programs and WIC program. The Title V County Health Prevention contracts will continue to grow through the levels of the Spectrum of Prevention. Their preconception health activities will include community education, building coalitions, changing organizational practices, and developing policies. BWCH, the Preconception Health Task Force members and other stakeholders will continue to work on identifying and implementing strategies designed to increase awareness about the importance of preconception health and enhance access to preconception health care. State Performance Measure 6: Percent of Medicaid enrollees age 1-14 who received at least one preventive dental service within the last year. Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source 2008 2009 2010 42.9 240529 560823 AZ Medicaid 47.3 281134 594701 AZ Medicaid 2014 51 2015 52 Is the Data Provisional or Final? Annual Performance Objective 2013 50 2011 2012 48 47.9 285371 596114 AZ Medicaid Final 2016 53 49 46.0 274712 596644 AZ Medicaid Final 2017 53 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 145 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 (OOH) maintained Intergovernmental Agreements with counties to provide school-based dental screenings, referrals and sealants to children in low-income schools. The Office of Oral Health collaborated with First Things First to promote and implement prevention programs for children ages 0-5 including support for establishing a dental home by age 1 and providing technical assistance for oral health initiatives. Through a HRSA Workforce grant, the Office of Oral Health 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. The Bureau of Women's & Children's Health provided Title V funding to the Medical Services Project (MSP). Administered through the Arizona chapter of the American Academy of Pediatrics, the MSP was designed to increase access to and utilization of primary care and dental services for Arizona's uninsured children from low-income families. School nurses identify children who are eligible to participate in the Medical Services Project and facilitate their enrollment. The child is provided with a referral form to a participating health care provider and the school nurse makes the appointment. 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. The Arizona Preschool Fluoride Varnish Program began in 2012 as a result of a successful grant proposal submitted by the Office of Oral Health to the South Phoenix Regional Partnership Council of First Things First. The program addresses the problem of excessive dental disease among children who live in communities with a high proportion of persons living below 185% of the federal poverty level. Partnering with the Maricopa County Department of Public Health (MCDPH), the application of fluoride varnish, an extremely effective cavity-prevention agent, in combination with dental screenings, referral and other educational services, are the core of the primary prevention program. Services began at the first South Phoenix site in November of 2012. Between November and December of 2012, 349 children received dental screening and oral health education at the South Phoenix WIC site. Of those screened, 348 children received fluoride varnish application and 12 children with urgent dental needs were identified and referred for treatment. 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 provides training to childcare providers and early childhood teachers. 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. Pyramid Level of Service DHC ES PBS IB X X X X 146 4. The Office of Oral Health administers a state-wide Schoolbased Fluoride Mouthrinse Program (FMR) for children attending eligible schools. 5. 6. 7. 8. 9. 10. X b. Current Activities The OOH is working the Southwest Telehealth Resource Center to identify linkages with telehealth resources that may be applied to teledentistry activities. Teledentistry grant activities have established four Regional Oral Health Coordinators to serve 10 of Arizona's 15 counties; developed 4 new or expanded Regional Oral Health Coalitions; completed 4 regional needs assessments and 4 regional oral health improvement plans. Partnerships have been built that implement 5 enhanced dental team practice models. The Grant has integrated enhanced dental team strategies into 3 health initiatives for increasing access to care and establishing dental homes for children ages 0-5, Head Start children, and tribal populations. The Office of Oral Health is developing contractual relations with Inter-Tribal Council of Arizona (ITCA) and the Sells Area Dental Service Unit to provide TA and equipment for a teledentistry demonstration practice model and Train the Trainer materials on oral health. Continued partnership with the MCDPH enables the Office of Oral health to facilitate the application of fluoride varnish, dental screenings, referral and educational services for children ages 0 to 5 living in the South Phoenix First Things First Region. During 2012-13, a second program service delivery site was opened. Of those screened, 2,256 children have received fluoride varnish application and 29 children with urgent dental needs were identified and referred for treatment. c. Plan for the Coming Year The OOH will continue to 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 (Arizona's Medicaid) utilization of care will continue, as will collaboration with internal state agencies, external partners and organizations to promote oral health education, early intervention by dental professionals and early dental referrals by medical professionals. The OOH 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 OOH 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. Based on the results of findings in the 2012-13 school year, OOH has made significant adjustments to the implementation of the program and expects to increase the number of children 147 served next year. The OOH will continue to provide TA for active teledentristy sites currently funded through First Things First. 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 Health to enhance integration of oral health strategies into existing programs, such as Health Start and WIC. The Title V funded Medical Services Project will continue to provide access to and utilization of dental care, for Arizona's uninsured children from low-income families. The BWCH Office of Children's Health will educate home visitors of the importance of maintaining good oral health. The Office of Oral Health will continue to partner with Maricopa County and First Things First in order to provide oral health preschool prevention services through the Arizona Preschool Fluoride Varnish Program. The Office of Oral Health will continue to work with Office for Children with Special Health Care Needs (OCSHCN) to identify opportunities to provide dental sealants to children with special health care needs. OCSHCN will continue to incorporate brochures on oral health during pregnancy and for children ages birth-3 within OCSHCN's health care organizer in English and Spanish. Additionally, the OOH will continue to partner with OCSHCN to provide funding to train dental students to provide treatment to CYSHCN. Using Title V funds, the OOH will partner with BHSD to complete an update to the Dental Professional Shortage Area designation. 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 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 2015 9 Is the Data Provisional or Final? Annual Performance Objective 2011 2012 11 11.7 404 3451 AZ BRFSS Final 2016 8.5 10.5 10.1 240018 2370973 AZ BRFSS 2011 Final 2017 8.5 Notes - 2012 Estimate is weighted. 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?" In 2011 New weighting methodology—raking, or iterative proportional fitting—replaced the post stratification weighting method that had been used with previous BRFSS data sets. Also, BRFSS incorporated cell phones into their sample. Therefore, estimates from the 2011 BRFSS and forward may not be comparable to estimates created in previous years. Notes - 2011 148 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 BWCH selected this as a new state performance measure for the Title V priority of improving the behavioral health of women and children. While Arizona did not select a measure specific to substance abuse, MCH programs also promote substance abuse prevention. The Health Start Program, for example, has institutionalized fetal alcohol spectrum disorders screening, brief intervention, and referral protocol into the program. The Health Start Program 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. In June 2012, the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) in collaboration with the Governor's Office for Children, Youth, and Families (GOCYF) and the Northern Arizona Regional Behavioral Health Authority (NARBHA) rolled out the SBIRT Program in five (5) northern Arizona counties: Apache, Coconino, Mohave, Navajo, and Yavapai. These counties were selected as focal points for implementation because data indicates that the rates of alcohol and drug related injuries and deaths are the highest in these regions of the state. This $7.5 million federal grant allowed Arizona to identify substance abuse problems and begin intervention in primary care offices and the emergency room. The Screening, Brief Intervention and Referral to Treatment (SBIRT) grant helped primary care providers identify patients who are at risk for or who have underlying substance abuse problems that might otherwise go unnoticed and untreated. Begun in 2011 after the tragedies in Tucson, Mental Health First Aid continues to be implemented. Mental Health First Aid is an evidence-based interactive 12-hour course designed to teach people a five-step process to assess a situation, select and implement apprpriate interventions and help a person in crisis or who may be developing the signs and symptoms of mental illness. The training equips people to provide initial help until appropriate professional, peer or family support can be engaged. Participants also learn about risk factors and warning signs of specific illnesses such as anxiety, depression, 149 psychosis and addiction. 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. Mental Health First Aid training available. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X b. Current Activities The Health Start Program and HRPP/NICP Community Health Nurses (CHN) continue to provide the Edinburgh Postnatal Depression Scale (EPDS) screening as part of the family follow-up visits for all postpartum clients. Community Health Workers were provided continuing education on the EPDS screening tool. Referral resources were updated and lists of service providers were distributed. Community Health Workers educated all clients on the postpartum warning signs of depression and perinatal mood and anxiety disorders. CHNs provide 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 as well. BWCH promotes mental wellness among women through preconception health materials and women's health week activities. During the 2012 Women's Health Week events 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. Arizona DBHS continues to implement the SBIRT grant. In addition, this legislative session appropriated $250,000 to support Mental Health First Aid training. c. Plan for the Coming Year ADHS will continue to support department-wide effort to better integrate behavioral health and physical health. The Division of Behavioral Health will continue to implement mental health first aide training statewide. The Health Start Program Manager will continue to attend a Division of Behavioral Health Women's Treatment Workgroup to discuss Health Start services and fetal alcohol screening. The workgroup consists of behavioral health providers. There will continue to be ongoing discussions regarding making cross referrals; linking pregnant behavioral health clients with home visitation 150 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 continue to 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. HRPP/NICP Community Health Nurses will continue to provide the Edinburgh Postnatal Depression Scale (EPDS) screening as part of the home visit made to infants, children and their families after discharge from the Neonatal ICU or Pediatric ICU. Each Community Health Nursing 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 provide education regarding mental wellness and depression as part of women's health week activities. BWCH will continue to work with Division of Behavioral Health Services to identify appropriate mental wellness messaging as well as identify opportunities for integration of mental wellness into existing programs. BWCH will participate in ADHS initiatives to further integrate behavioral health and public health interventions. BWCH will monitor the impact of the Affordable Care Act as it relates to access and availability of behavioral health services for adult women in urban and rural areas of the state and work with ADHS Health Systems Development and DBHS on coordination of services for the maternal and child health population. Information will be shared with BWCH partners as it becomes available and technical assistance will be provided as needed. State Performance Measure 8: Percent of newborns who fail their initial hearing screening who receive appropriate follow up services. Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source 2008 2009 2010 2012 79 81 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 86.3 2292 2655 AZ Early Hearing and Detection Final 86.3 2013 83 2014 85 2015 86 2016 86 2017 87 Is the Data Provisional or Final? Annual Performance 2011 AZ Early Hearing and Detection Provisional 151 Objective Notes - 2012 2012 Number not ready by deadline of application. a. Last Year's Accomplishments Community Hearing Screening efforts have been very successful in the past year. More than 20 programs serving families with newborns from 6 months to 2 years of age reported screening results with greater than 5,000 babies screened in 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. Community screening programs included home visiting programs such as Parents as Teachers, Early Head Start and Head Start, the Arizona Early Intervention Program; BASICS program Community Health Centers and others. Equipment has been purchased through OCSHCN for the Sensory program to do short term loans to community providers including early care and education centers. Long term equipment loans have been arranged through the Ear Foundation of Arizona. (EFAZ) In order to assess the success of the program it is critical to look at actual individual child outcomes for language. Language is the foundation for speech, sign, reading readiness and school readiness. The approach for this strategy is to partner with the University of Colorado's (UC) National Early Childhood Assessment Project. In 2012, the UC experts provided onsite training to the Arizona State Schools for the Deaf and the Blind staff who provide Part C Early Intervention services to children with bilateral permanent hearing loss. This training is in preparation for the implementation of biannual standardized assessments in 2013. The Office for Children with Special Health Care Needs (OCSHCN) partnered with EFAZ and the University of Arizona Cooperative Extension T3 program to develop curriculum to provide standardized training to screeners and screening programs providing services to families with children between six months and three years of age. Efforts were focused on training master trainers on the Birth to Three curriculums. Trainers must be experienced and submit an application. Two-day training was completed with a hands-on component. Ten have completed part of the training and four trainers have completed the process as master level trained trainers. In conjunction with Arizona's Interagency Coordinating Council (AzEIP ICC), OCSHCN developed and disseminated a survey for providers of hearing screening, to assist in identifying areas of need and gaps in services. A significant effort was made to ensure that health care providers are informed about screening results and are aware of the requirement that they report to the Arizona Department of Health Services (ADHS) any hearing screening or testing completed on a baby up to two years of age. ADHS early childhood home visiting programs have been educated about the need to check both blood spot and hearing screening status when doing home visiting and helping to educate families about the importance of follow up and refer them to community resources. The ADHS High Risk Perinatal Program partnered with the Office of Newborn Screening to enhance education for parents on Newborn Screening through the HRPP/NICP Parent Handbook. The HRPP/NICP Parent Handbook provides information on the program components and resources in English and Spanish. In 2012, the HRPP/NICP Parent Handbook was revised to include expanded information on Newborn Hearing Screening follow-up for NICU infants as well as resources from other BWCH, state and national programs. Community Partnerships continued to be coordinated through Quarterly AzEHDI Stakeholders meetings. Regular attendance includes ADHS ONBS, BWCH, OCSHCN, ASDB, Desert Voices, AzEIP, AAP EHDI Chapter Champion, EFAZ, Head Start, Deaf and Hard of Hearing Consumers, Hands & Voices and others. EHDI PALS is an online national database that will allow providers and parents to enter data 152 specific to their child and receive a list of sites that have self-reported both the staffing and equipment to provide appropriate services. Targeted for 2013, audiologists were educated about the project and, starting November 2012, were encouraged to register and submit their site-specific data. First Things First Child Care Health Consultants continued to advise child care centers about the importance of encouraging parents to follow up on hearing screens. Table 4b, State Performance Measures Summary Sheet Activities 1. OCSHCN partners with UA to develop curriculum to provide standardized training to screeners and a screening program providing service 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. All BWCH home visitors 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 Programs serving children 0-5 are providing hearing screening to allow for the 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. The approach for this strategy is to partner with the University of Colorado, National Early Childhood Assessment Project and the Arizona State Schools for the Deaf and the Blind who provide Part C Early Intervention services to children with bilateral permanent hearing loss. Training was provided in 2012 which resulted in a decision to provide the standardized assessments twice a year in April and September. Data collection is currently occurring and it is anticipated that standardized reports will be available later in 2013. The National Center for Hearing Assessment and Management partnered with ADHS and ASDB to provide a six week online and three day onsite training for pediatric audiologists. Seventeen audiologists have completed all but the practicum portion of the training, which covered diagnostic testing and hearing aid fitting. EHDI PALS is in the process of being implemented statewide for the follow up program and providers. Audiologists have been registered and the system is operation. Current activities involve educating parents and providers; changing forms to include information about EHDI PALS and transitioning follow up to drop the provider list and refer to EHDI PALS. 153 c. Plan for the Coming Year OCSHCN's contract with EFAZ will continue to build infrastructure to support follow-up of children with hearing loss outside the newborn period by ensuring T3 training updates, providing training for Head Start and Early Head Start and other early childhood programs staff, providing training on reporting requirements and use of updated forms. Through EFAZ, OCSHCN will collaborate with Arizona Academy of Pediatrics (AAP) to reach providers through Grand Rounds, at AAP annual conference, through Medical Home Curriculum and at private practices, through materials distribution and training opportunities. Education will continue to be provided to screeners, audiologists, early interventionists and others to ensure quality of the program and will include reporting requirements and appropriate treatments. Efforts will be continued to assure that health care providers are informed about screening results and are aware of the requirement that they report to ADHS any hearing screening or testing completed on a baby up to two years of age. ADHS will continue to work with ASDB and UC NECAP project to collect and analyze outcome data. 2014 should have data from three to four six-month evaluations which will allow the program to begin presenting trend data. Community Partnerships will continue to be coordinated through Quarterly AzEHDI Stakeholders meetings. Regular attendance will include ADHS ONBS, BWCH, OCSHCN, ASDB, Desert Voices, AzEIP, AAP EHDI Chapter Champion, EFAZ, Head Start, Deaf and Hard of Hearing Consumers, Hands & Voices and others. OCSHCN will continue to partner with the EAR Foundation of Arizona and NBS to support ADHS' follow up efforts. OCSHCN will work with the EAR Foundation of Arizona and other EHDI 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. 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 will continue to work with home visiting programs statewide to determine how programs can enhance their review of hearing screening. HRPP/NICP contracted hospitals will continue to provide a handbook to every parent/guardian of infants enrolled in the program at Neonatal Intensive Care Units (NICU) or Special Care Nurseries (SCN). 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 Equipment loans for community providers will continue. Long Term Equipment loans will continue to be arranged through the EFAZ. EFAZ is also pursuing funding to provide short term equipment loans in the Phoenix region to allow providers of home visiting programs greater access to specific equipment for both hearing and vision screening in early childhood. E. Health Status Indicators Health Status Indicators 01A: The percent of live births weighing less than 2,500 grams. 154 Health Status Indicators Forms for HSI 01A - Multi-Year Data Annual Objective and Performance Data 2008 Annual Indicator 7.1 Numerator 7026 Denominator 99215 Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? 2009 7.1 6573 92616 2010 7.1 6155 87053 2011 7.0 5949 85190 2012 6.9 5946 85725 Final Final Narrative: By examining the data for Health Status Indicators, Arizona is able to monitor our health outcomes. Indicator #01A looks at the percent of live births weighing less than 2,500 grams. This percentage has remained stagnant the last few years. A review of infant mortality, disparities continue based on race and ethnicity. Infant mortality remains higher for Black or African American children and American Indian or Native Alaskans. Arizona has initiated many programs to address improving birth outcomes. Like many states, Arizona has accepted the ASTHO Challenge to reduce prematurity by 8% by 2014. The ADHS partnered with the Arizona Chapter of the March of Dimes and the Arizona Perinatal Trust (APT) to eliminate elective inductions before 39 weeks. The hospitals certified by the APT have in place policies that effectively ensure a ‘hard stop' for these elective deliveries. Additionally, ADHS is working with the Arizona Perinatal Trust and our local AZ March of Dimes to implement evidence-based strategies to reduce prematurity including: expanding home visiting programs to families and pregnant women in high-risk communities; developing standards for home visiting programs throughout Arizona and professional development of home visitors so that home visits maximize opportunities to reduce risks for premature birth; expanding awareness of importance of preconception health and implementation of the Arizona Preconception Health Strategic Plan; continuing to support the March of Dimes "Healthy Babies are Worth the Wait" 39 Week Toolkit; renewing focus on infant safe sleeping practices to reduce post-neonatal infant mortality; and using social media and public relations events to promote the overall campaign. The BWCH is currently participating with our partners in the AMCHP Improving Birth Outcomes Learning Collaborative. 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 155 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 multisession workshops of primary prevention of sexual violence and education. In 2009 BWCH expanded its scope beyond primary prevention of sexual violence and was awarded a Department of Justice grant for direct services of survivors of sexual assault. These funds are unique with respect to providing services to those collaterally affected by the victimization, including but not limited to, friends, coworkers, and classmates. /2012/ In 2011, in line with the state plan on Primary Prevention of Sexual Violence, BWCH expanded training on Bystander Intervention Skills ("Bar Campaign') to include staff at alcohol serving establishments in three key areas of the state. The outcome is to increase staff's knowledge of sexual violence primary prevention issues, strategies, policies and enhance their skills in being an active bystander in an alcohol-related environment. //2012// /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 toll-free number that provides 156 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, 157 and is scheduled to begin in fall of 2010. /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// /2014/ The Arizona Department of Health Services has strengthened its relationship with the Sonora, Mexico Department of Health as they seek to address public health issues on both sides of the border. The director of ADHS sits on the Health Services Committee of the Arizona Mexico Commission. The states of Sonora, Mexico and Arizona have identified teen pregnancy prevention and injuries from car crashes as maternal child health issues they are interested in working on together. As a result of this collaboration for teen pregnancy prevention, the state of Sonora will send staff to observe the Summer Youth Institute, a youth leadership training to be held in Nogales, Arizona. The staff will then be able to replicate the program in their communities. To address mortality and morbidity in children as a result of car crashes, a declaration between the two countries was signed to address Child Restraint Education and a car seat donation program. As a result of this partnership Sonora, Mexico became the first Mexico Safe Kids coalition for Safe Kids Mexico. Arizona will provide educational and technical assistance to Safe Kids Sonora to establish car seat trainers.//2014// 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. 158 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. 159 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 2012 Budgeted Expended 7065379 6456667 FY 2013 Budgeted Expended 6941708 FY 2014 Budgeted Expended 6468652 1920000 1015975 1420000 985000 7625192 6466495 7693086 7693086 0 0 0 0 7472018 5899341 7472018 7472018 0 0 0 0 24082589 19838478 23526812 22618756 53932696 44631639 61382212 55357356 78015285 64470117 84909024 77976112 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 2012 Budgeted Expended FY 2013 Budgeted Expended FY 2014 Budgeted Expended 3713835 2887931 3632356 3619625 5608571 4588427 5523094 5512859 9393274 8346192 9573184 9304919 3845832 2776627 3306713 2689641 160 Special Healthcare Needs e. Others 1158238 1094175 1163887 1166341 f. Administration 362839 145126 327578 325371 g. SUBTOTAL 24082589 19838478 23526812 22618756 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 100000 100000 100000 c. CISS 0 0 0 d. Abstinence 1260250 1302706 1217627 Education e. Healthy Start 0 0 0 f. EMSC 130000 130000 110000 g. WIC 45136403 42599706 40360259 h. AIDS 0 0 0 i. CDC 0 0 0 j. Education 0 0 0 k. Home Visiting 0 12045184 9430000 k. Other EMSC DEMO 199915 PROJ FAMILY 1766500 1813619 1694140 VIOLENCE PREP 1099600 1103821 1044259 RAPE PREV ED 624000 624000 665799 SEXUAL 198000 198555 298736 ASSAULT SVCS STATE INJURY 180500 180621 180621 SURVEIL SUDDEN UNEXP 56000 INFANT ORAL HEALTH 384000 384000 WORKFORC PROJECT 900000 900000 LAUNCH MI&EC HOME 1893443 VISITING NGIT FASD250000 SAMHSA WOMENS HLTH 10000 CONF Form 5, State Title V Program Budget and Expenditures by Types of Services (II) I. Direct Health Care Services II. Enabling Services III. PopulationBased Services FY 2012 Budgeted Expended 4350018 3798228 FY 2013 Budgeted Expended 4355595 FY 2014 Budgeted Expended 4289355 3583506 3097993 3459392 3312148 10765807 8831371 10657349 10666511 161 IV. Infrastructure Building Services V. Federal-State Title V Block Grant Partnership Total 5383258 4110886 5054476 4350742 24082589 19838478 23526812 22618756 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// /2014/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.//2014// 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 162 Teen Pregnancy Prevention and Prenatal Outreach (Health Start) Programs. The $101,968 in donation funds are for the Children's Rehabilitation Services Program and $250,000 is from fees generated by the Dental Sealant Program. Arizona's FY2010 match and overmatch of $39,703,718 continues to exceed the maintenance of effort amount of FY1989's $12,056,360. Other federal funds administered by the MCH Chief and CSHCN Chief besides the MCH Title V Block Grant Program include matching funds from Title XIX and Title XXI for Children's Rehabilitative Services, Rape Prevention and Education, Sexual Assault Services, Oral Health Workforce Activities, Family Violence Prevention, Core State Injury Surveillance and Program Development, Emergency Medical Service for Children, State Systems Development Initiative, NGIT Fetal Alcohol Spectrum Disorders, 1st Time Motherhood, and Project Launch. Core Public Health Infrastructure - $3,564,141: Bureau of Women's and Children's Health (Part A & B): $1,573,939 will support the Department's birth defect registry, management service, information technology automation, assessment, evaluation and epidemiologic analysis, Child Fatality services, and the Midwife Licensing Program. Strategic planning is currently in progress to finalize how best to utilize Title V funds to support new priorities of preconception health, obesity/overweight, injury prevention, and behavioral health. Infrastructure strategies to address these priorities may include policy initiatives, coalition building, and provider education. Title V funds may be used to support the Empower program, which promotes health standards for child care providers, if alternative resources are not secured to support Empower. 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 163 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 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. Population-Based Services: $859,798 is budgeted for initiatives that include the Sensory Program, Pregnancy and 164 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// /2014/The estimated Title V allocation for Arizona, FFY2014, is $6,468,652. For FFY 201, 32.90% ($2,127,943) of the Title V Block grant will be allocated for preventative and primary care needs for children and adolescents; 31.22% ($2,019,441) will be allocated to children with special health care needs; 30.85% ($1,995,897) will be allocated for women, mothers, and infants and 5.03% ($325,371) will be budgeted for administrative costs. It is projected that there will be $985,000 unobligated funds from our FY2013 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 2014, 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 FY2014 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, Family Violence Prevention, Core State Injury Surveillance and Program Development, Emergency Medical Service for Children, EMSC Demonstration Project, 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 Sudden Unexpected Infant Death Case Registry. Core Public Health Infrastructure - $2,312,227: Bureau of Women's and Children's Health (Part A & B): $1,175,873 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): $1,136,354 will support administrative initiatives, education, training, support services, advocacy and outreach. A Health Advocacy for Children, Youth and Families RFP was issued and in 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. Population-Based Services: $868,960 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. 165 Enabling and Non-Health Support: $1,216,139 will support the Medical Home Project and the Pregnancy, Breastfeeding Hotline and Children with Special Health Care Needs ($683,087), which includes respite and palliative care services. Direct Health Care Service: $1,745,955 will support hospital, physician, transport, community nursing services for high-risk infants, and Reproductive Health services for women. Indirect Administrative Costs: $325,652 //2014// 166 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. 167