Maternal and Child Health Services Title V Block Grant State Narrative for Arizona Application for 2015 Annual Report for 2013 Document Generation Date: Monday, September 15, 2014 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 ......................................................................................................................... 10 A. Overview ................................................................................................................................ 10 B. Agency Capacity .................................................................................................................... 24 C. Organizational Structure ........................................................................................................ 35 D. Other MCH Capacity ............................................................................................................. 38 E. State Agency Coordination .................................................................................................... 43 F. Health Systems Capacity Indicators ...................................................................................... 48 Health Systems Capacity Indicator 03: .................................................................................. 48 Health Systems Capacity Indicator 07B: ................................................................................ 50 IV. Priorities, Performance and Program Activities ....................................................................... 51 A. Background and Overview .................................................................................................... 51 B. State Priorities ....................................................................................................................... 52 C. National Performance Measures ........................................................................................... 57 Performance Measure 01: ...................................................................................................... 57 Form 6, Number and Percentage of Newborns and Others Screened, Cases Confirmed, and Treated ................................................................................................................................... 61 Performance Measure 02: ...................................................................................................... 62 Performance Measure 03: ...................................................................................................... 66 Performance Measure 04: ...................................................................................................... 70 Performance Measure 05: ...................................................................................................... 74 Performance Measure 06: ...................................................................................................... 78 Performance Measure 07: ...................................................................................................... 82 Performance Measure 08: ...................................................................................................... 86 Performance Measure 09: ...................................................................................................... 89 Performance Measure 10: ...................................................................................................... 92 Performance Measure 11: ...................................................................................................... 95 Performance Measure 12: ...................................................................................................... 99 Performance Measure 13: .................................................................................................... 102 Performance Measure 14: .................................................................................................... 105 Performance Measure 15: .................................................................................................... 109 Performance Measure 16: .................................................................................................... 113 Performance Measure 17: .................................................................................................... 116 Performance Measure 18: .................................................................................................... 118 D. State Performance Measures.............................................................................................. 121 State Performance Measure 1: ............................................................................................ 121 State Performance Measure 2: ............................................................................................ 125 State Performance Measure 3: ............................................................................................ 127 State Performance Measure 4: ............................................................................................ 131 State Performance Measure 5: ............................................................................................ 134 State Performance Measure 6: ............................................................................................ 137 State Performance Measure 7: ............................................................................................ 140 State Performance Measure 8: ............................................................................................ 143 E. Health Status Indicators ...................................................................................................... 147 Health Status Indicators 04B: ............................................................................................... 147 F. Other Program Activities ...................................................................................................... 148 2 G. Technical Assistance .......................................................................................................... 150 V. Budget Narrative ..................................................................................................................... 151 Form 3, State MCH Funding Profile ..................................................................................... 151 Form 4, Budget Details By Types of Individuals Served (I) and Sources of Other Federal Funds .................................................................................................................................... 151 Form 5, State Title V Program Budget and Expenditures by Types of Services (II) ............ 152 A. Expenditures ........................................................................................................................ 153 B. Budget ................................................................................................................................. 153 VI. Reporting Forms-General Information ................................................................................... 159 VII. Performance and Outcome Measure Detail Sheets ............................................................. 159 VIII. Glossary ............................................................................................................................... 159 IX. Technical Note ....................................................................................................................... 159 X. Appendices and State Supporting documents ........................................................................ 159 A. Needs Assessment .............................................................................................................. 159 B. All Reporting Forms ............................................................................................................. 159 C. Organizational Charts and All Other State Supporting Documents .................................... 159 D. Annual Report Data ............................................................................................................. 159 3 I. General Requirements A. Letter of Transmittal The Letter of Transmittal is to be provided as an attachment to this section. An attachment is included in this section. IA - Letter of Transmittal B. Face Sheet The Face Sheet (Form SF424) is submitted when it is submitted electronically in HRSA EHB. No hard copy is sent. C. Assurances and Certifications Certifications and assurances will be kept on file at the Arizona Department of Health Services. D. Table of Contents This report follows the outline of the Table of Contents provided in the "GUIDANCE AND FORMS FOR THE TITLE V APPLICATION/ANNUAL REPORT," OMB NO: 0915-0172; published January 2012; expires January 31, 2015. E. Public Input Several avenues were pursued to seek input from stakeholders and the public, both to help identify and understand emerging issues and to help set priorities. Information was posted to the Women's and Children's Health and the Children with Special Health Care Needs websites, and other forms of electronic communications such as emails and newsletters were used to disseminate information about the needs assessment process, issues, and findings, and to seek input. Surveys were also used to solicit input from stakeholders, community partners, and the public. Program managers and staff who directly work with the public, contractors, and community also brought their perspectives to the needs assessment process. Formal public input sessions were held around the state in Tucson, Flagstaff, Phoenix, and Mesa in April 2010. In addition, presentations were made to the Arizona Medical Association Maternal Child Health Committee, the March of Dimes, AHCCCS Health Plan maternal child-health coordinators, and local public health officers. Community partners helped to extend invitations to interested families, and two special sessions were held, one focusing on children with special health care needs, and a tribal consultation session focusing on American Indians. Each session was structured to present information on health trends and issues, and gather input on community concerns, priorities, and preferred strategies. During the public input sessions, information was presented on health issues and trends in Arizona before attendees participated in facilitated group discussion about concerns in their communities, priorities, and strategies. In identifying priorities, public-input participants were asked to consider the size and seriousness of problems, as well as the availability and effectiveness of interventions and resources to carry them out. In addition to the facilitated group discussion, comment sheets were made available for later review. The top priorities presented in this document reflect those needs that participants believed were most important in terms of size and seriousness, and which the Title V maternal-child health program has the capacity to influence. Meetings of key stakeholders were held through an Integrated Services Grant, over a four-year period from 2005 through 2009. Stakeholders included all of Arizona's child-serving agencies, the state Medicaid agency, Arizona Early Intervention Program, Indian Health Services, Arizona 4 Medical Association, American Academy of Pediatrics, hospitals and other health care providers, educators, community colleges, universities, families, youth, and self advocates. Committees focused on transportation, healthcare, education, family and youth involvement, youth to adult transition, adolescent health, telemedicine, cultural competence, and screening for special health care needs. The recommendations from the ISG Taskforce were an important source of public input. Key informant interviews were also conducted from September 2008 through March 2009 to facilitate public input. Participants included agency leaders and physicians working with C/YSHCN. Informants provided suggestions for improving the service delivery system and addressing its gaps. In 2010, OCSHCN began to solicit public input for the needs assessment through its website. Families and providers were sent email invitations to visit the website, where they could find links to slide presentations focusing on: • An overview of the needs assessment process, • Arizona data on MCH Bureau Core Indicators for CYSHCN at two points in time, and • Data showing how CSHCN compared to other children in Arizona on key indicators. Website visitors could then respond with questions or comments to an email address, or could call OCSHCN staff directly. In addition, two survey monkey tools were posted to the website, one for providers, and one for families. The surveys were conducted to compare the perceived needs of the families of C/YSHCN with those of the provider community. The Bureau of Women's and Children's Health conducted a web-based survey of lay health workers and community members throughout Arizona in 2010. Participants (n=878) were asked about the health and needs of women and children living in their communities, and about the ability of their communities to meet these needs. An additional survey was conducted of key partner agencies that serve women and children to assess partners' perceptions of priorities, critical health issues, service gaps, and workforce development issues. The 64 organizations responding to the survey included county health departments, community health centers, Indian Health Services and tribal health departments, and non-profit agencies. The surveys were used to gather input on community perception of needs and assets and results were considered during the priority-setting process. /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 5 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// /2015/ The BWCH website maintained a request for comments and feedback on the 2015 Title V application. A survey was crafted using Survey Monkey(r) as a means to collect information from the public about the availability of and needs for resources and information in their communities with a link from the BWCH webpage. Most questions were not open-ended to ensure consistency in responses and limit the potential bias of interpreting responses. The survey also was shared with stakeholders via program managers, who could then further disperse the survey link. Additionally, OCSHCN distributed a flyer with a link to the website and the survey link was posted to Facebook. To better understand the current status and potential needs for different groups, questions were asked for different populations, including: women, children (including children with special health care needs), and youth (including youth with special health care needs). At the end, respondents were asked to indicate areas they felt could be improved to address the health needs of these populations and were also asked to list solutions on how to improve these areas. This last question was included so the respondents could understand that their feedback is valued. Demographics were also captured in order to evaluate the success of reaching specific populations. A total of 107 individuals responded to the survey. Of those who responded, 87.6% were female, 85.7% were white, 34.6% were 45-54 years old, 59.4% live in Maricopa County, the most populous county, and 36.4% indicated their primary role as "School." Depression Screening was indicated as the top (or tied for the top) resource or information for preventive services not available in the community for each target population, including women, children (including CSCHN), and youth (including YSCHN). Based on the answers of 43 respondents, the top three areas that were identified as areas that can be improved to better address the health needs of women, children, and youth (including CYSHCN), in Arizona were: 1) Behavioral health (51.2%); 2) Access to care (37.2%); and 3) Transition to adulthood for CYSCHN (32.6%). In addition, managers and leadership from the Bureau of Women's and Children's Health used public forums to remind attendees of the importance of providing feedback on the Title V application as this document helps determine the direction of maternal child health services in Arizona. Many in Bureau management serve on statewide committees, task forces and boards and continuously ask for input on the application and plan. Program Managers use site visits as an opportunity to listen to local community concerns. //2015// 6 II. Needs Assessment In application year 2015, 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) seeks to continuously assess the needs of Arizona's women and children by monitoring changes to capacity, population and emerging issues. The outcome of this continual assessment can be found in reports including the annual Child Fatality Report, the Injury Report and the Women's Health Status Report as well as course direction change in program activities when warranted. Reports are posted to the Bureau website and links to larger report updates are posted on Facebook and Twitter. The Bureau utilized MCH funds to include preconception health and adverse childhood experiences questions to the BRFSS survey. In 2013, The Arizona Department of Health Services completed the first comprehensive State Health Assessment. This document encompassed input from all 15 counties as well as both private and public partners from across the state. Each county health department conducted their own health assessment with a great deal of public participation. Based on community input and analysis of the data, fifteen statewide leading public health issues were identified. While teen pregnancy was the only one that was called out as a maternal child health issue by name, in reality each of the other fourteen do as well as they speak to wellness and chronic disease prevention; critical to improving birth outcomes. The Bureau is conducting ‘listening sessions' of various populations in preparation for the 2015 Needs Assessment. For the listening sessions data is strategically not offered in order to hear from communities what they believe to be the ‘as is' state for maternal and child health. This is done in the anticipation of identifying concerns not traditionally discussed. We will then seek appropriate data to inform the issue. The additional data will give us a more robust presentation when we do meet with community groups to identify our next five years' priorities. There have been some changes to system capacity this past year. During this legislative session, the Governor signed House Bill 2491 into law. This bill requires ADHS to add critical congenital heart defect (CCHD) to the Newborn Screening Protocol. This year the legislature also passed a new law that requires the use of ‘people first' language meaning laws would refer to "persons with a disability", rather than a "disabled person". As the result of internal monitoring and national coverage of the issue, ADHS has implemented changes to insure more prompt receipt of newborn screening bloodspots to the state lab. The ADHS director has set the expectation that by July 1, 2014, 95% of all newborn screening bloodspots (initial screens) will be received at the Arizona State Laboratory within three days of collection. That goal was met May 2014. A web site has been set up, the Transit Time Project, which allows hospitals and the general public to view individual hospital performances as they compare to birth hospitals with similar level of perinatal care. The system capacity for the Maternal Child Health program has been additionally enhanced this year through continued and in fact enhanced collaborative efforts. The BWCH participated in the AMCHP Improving Birth Outcomes Learning Collaborative and subsequently participated in the National Governors Association Learning Network to Improve Birth Outcomes. Members from Arizona's Medicaid agency, AHCCCS, county health departments, the local ACOG, the March of Dimes and the statewide Arizona Perinatal Trust formed the initial team. These collaborations culminated in a summit to Improve Arizona's Birth Outcomes January 7, 2014 and ongoing efforts 7 to develop a state plan to address birth outcomes. Many of these partners will participate in Arizona's CoIIN project as well. Arizona has maintained our original eight priorities selected during the last Needs Assessment. A brief look at the state priority needs follows including assessment and implementation activities: Reduce Teen Pregnancy: Teen Pregnancy Prevention (TPP) program began implementation of a statewide cross-site program evaluation to collect data on the TPP programs that are being conducted throughout Arizona in order to provide an assessment of the impact of the programs on the youth in the programs. Outcome data will be available in October 2014. In 2013, the Teen Pregnancy Prevention Program began collaborating with the Arizona Department of Economic Security (DES) Teen Pregnancy Prevention Task Force to develop partnerships to reach youth in foster care with pregnancy prevention messaging by connecting group homes with pregnancy prevention providers. After partnering with the Office for Children with Special Health Care Needs to develop a teen pregnancy prevention curricula supplemental guide for youth with intellectual disabilities, TPP sub-awardees received training on how to implement the guide as well as how to work with this population. Improve Healthy Weight: The Office of Children with Special Health Care Needs (OCSHCN) is working with Special Olympics Arizona and Hummingbird Early Intervention Services to promote nutrition, physical activity and injury prevention classes and activities for CSHCN ages 2-21. OCSHCN also supports a part time position in the Bureau of Nutrition and Physical Activity to promote healthy life styles for all children including children with special health care needs. The Office of Oral Health (OOH) is preparing to conduct the 2014-2015 Arizona Healthy Smiles Healthy Bodies Survey. The survey will collect heights and weights on third-grade students in public elementary schools across Arizona. The plan is to survey about 7,500 students in 100 schools. OOH is collaborating with First Things First (FTF) to extend reach to include kindergarten children for collection of data to measure school readiness indicators. The ADHS continues to sponsor EMPOWER, a program addressing obesity in early care and education centers that incorporates physical activity and nutrition standards. Additionally, the Maternal Infant and Early Childhood Home Visiting (MIECHV) grant is funding a position in the Bureau of Nutrition and Physical Activity to develop EMPOWER Home Visiting. MIECHV is funding breastfeeding support education for home visitors and ICBLC education in the rural counties. Improve the Health of Women Prior to Pregnancy: An MPH intern surveyed home visitors and Title V family planning programs to determine their level of preparedness and comfort with providing preconception education to their clients. Programs expressed a need for more training and educational materials. The program is beginning the development of those resources. The Improving Birth Outcomes Summit also identified the health of women and girls prior to pregnancy as a priority area for the state plan. The Preconception Health Alliance is developing objectives and strategies. Reduce the Rate of Injuries: Injuries continue to be the leading cause of death among Arizonans between 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. Arizona has implemented a program of voluntary certification for three levels of pediatric preparedness for EDs. As of May 2014, 18 of Arizona's seventy six hospital ED's have been designated as pediatric prepared. 8 Improve Access to and Quality of Preventive Health Services for Children: The Office for Children with Special Health Care Needs is helping to sponsor a conference to support primary care physicians to feel better prepared to meet the needs of children and youth with special health care needs. The Office of Children's Health continues to fund early childhood home visiting; both through state dollars for our long standing evidence informed programs and through the evidence based Maternal Infant and Early Childhood Home Visiting Program. Improve the Oral Health of Arizonans: The Office of Oral Health (OOH) will conduct an oral health survey during the 2014-2015 school year. The survey will assess the health of third grade public school children throughout Arizona. The findings will be used to describe the burden of diseases related to tooth decay and obesity among Arizona's children, evaluate the State's preventive health programs and assess the need for additional services. Improve the Behavioral Health of Women and Children: The home visiting programs continue to 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 now includes 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 has been able to loan out hearing screening equipment preschools and midwives. 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: In March 2014, ADHS conducted an evaluation of 13 County Departments assessing current supports and services, identifying gaps and the development of resulting Policy, Systems and Environmental Change strategies that included CYSHCN. The majority of the current CYSHCN's initiatives reported in the evaluation remain in the formation phase, defined as engaging stakeholders, raising awareness and advocating for change. Prepare CYSHCN for Transition to Adulthood: OCSHCN partnered with AHCCCS (Arizona's Medicaid), Rehabilitative Services Administration (RSA), ADE and the Governor's Office on Children Youth and Families, in developing a multi-state grant proposal for the Employment Disability Partnership Promise Initiative grant, which was awarded and now called ASPIRE. 9 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's health. The challenges, as well as the assets, in the overall environment served as important considerations in priority-setting and selection of future strategies. Arizona's selection of state Title V priorities for 2011-2016 was grounded in review of quantitative and qualitative data, as well as careful consideration of public input and capacity. Arizona's priority areas for the maternal and child health population are: teen pregnancy, obesity/overweight, preconception health, injuries, oral health, preventative health services for children, behavioral health, hearing services, transition of children with special health care needs to adulthood, and inclusion of children with special health care needs in all aspects of life. This information presented in this section was extracted from the 2010 Title V Needs Assessment. For more information and citation of reference information, please see this document attached or online at www.azdhs.gov/phs/owch/. Arizona is the sixth largest state in the nation, with a total area of 114,000 square miles -- about 400 miles long and 310 miles wide. Arizona is also one of the youngest states. The end of the Mexican-American War in 1848 resulted in Mexico ceding 55 percent of its territory, including parts of present-day Arizona to the United States. It was not until 1863 that a separate territory was carved out for Arizona. On February 14, 1912, President Taft signed the bill making Arizona the 48th state. POPULATION TRENDS Arizona has 59 people per square mile; however, 75 percent of the population lives in urban areas, where the population density is 673 people per square mile. Twenty-three percent of Arizona residents live in rural areas, where the density is 44 people per square mile, and 2 percent lives in areas that are considered to be frontier, in which there are only 3 people per square mile. From 1999 to 2009, the population of Arizona grew from 5 million to 7 /2012/ 6,595,778 //2012//million people. During that time, Arizona had the second highest growth rate (32 percent) in the nation and came in fifth in terms of the number of new residents. /2012/ According to the 2010 Census, the population of Arizona declined to an estimated 6,392,017, or 3.1% lower than the previous year estimate. The decline is likely due to reduced immigration from other states and Latin America as a result of the economic recession in Arizona. //2012// /2013/ The decline of population seen since 2009 and 2010 in Arizona has leveled off. In 2011, the estimated population of Arizona is 6,438,178. This is a slight increase from 2010 (less than a 1% increase). There were no significant changes in the composition of the population by age group and county since the previous year. //2013// /2014/ There was no significant change to the population by percentage, age group or county in 10 2012.//2014// /2015/ The 2013 population of Arizona grew slightly to 6,581,054, a non-significant change from the 2012 population of 6,498,570. Additionally, there were no significant changes to the population by percentage, age group or county in 2013. //2015// 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// /2015/ There were 84,963 births to Arizona residents in 2013, a less than a 1% decrease from 2012. //2015// There was a similar pattern during this same time period in the proportion of Hispanic births, which increased for most of the decade and declined in recent years. In 2003, Hispanic births (n=39,101) exceeded the number of non-Hispanic, White births (n=38,842). Hispanic births continued to outnumber non-Hispanic, White births until 2009 when there were 38,362 Hispanic births compared to 39,781 births to non-Hispanic, Whites. /2012/ This pattern continued in 2010 as White non-Hispanic births were 38,777 and Hispanic or Latino births totaled 34,333. The decline ton total births in Arizona is being driven by the reduction in Hispanic or Latino deliveries. //2012// /2013/ The pattern of declining Hispanic births has continued. In 2011 White non-Hispanic births were 38,699 and Hispanic or Latino births totaled 32,399. The decline in total births in Arizona continues to be driven by the reduction in Hispanic or Latino deliveries. //2013// /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) NonHispanic and 38 percent (32,399) Hispanic births in 2011. //2014// /2015/ The composition of births remained unchanged from 2012 to 2013, with White nonHispanic births making up 45% (38,220) of births and Hispanic births making up 39% (33,075).//2015// 11 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 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// /2015/ The total number of women of childbearing age in 2013 was 1,286,456, a 4% decrease from 1,340,296 in 2012.//2015// 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// 12 /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 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. 13 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// /2015/ According the Arizona Department of Education, the dropout rate was 3.5% for students in 7th to 12th grade, for school year 2012-2013. Please note that in previous years the rate was calculated based on grades 9-12. //2015// /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 food stamp participation (34th). It is important to note that the actual unemployment rate in Arizona (9.3 percent, April 14 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// /2015/ According to Kaiser State Health Facts, Arizona ranked 31st in the nation in state economic distress. Arizona also ranked 7th in the nation for foreclosures. There was no change in monthly food stamp participation from October 2011 to October 2012. Arizona ranked 38th (tied with three other states) in percent change in unemployment. Arizona's unemployment rate, as of March 2014 it was 7.3%. //2015// During the course of the last decade, unemployment in Arizona ranged from a historic low of 4 percent in July of 2007 to a recent high of 10 percent in February 2010. The Flagstaff Metropolitan Statistical Area (MSA) had the lowest unemployment rate at 9 percent, while the Yuma MSA represented the highest rate, at 30 percent in February 2010. There is also wide variation in the proportion of households on food stamps in Arizona. The most recent American Community Survey data shows that on average, 7 percent of households in Arizona receive food stamps. Maricopa County (6 percent), Yavapai (6 percent), and Coconino County (7 percent) had fewer households receiving food stamps than the state average and two counties (Navajo, 16 percent and Apache 18 percent) had twice the state average. Arizona also has a higher percentage of residents living in poverty compared to the nation. In 2008, 13 percent of the nation lived in poverty compared to 15 percent of those living in Arizona (ranked 39th). /2012/ The 2009 American Community Survey showed 16.5 percent of Arizonans living in poverty. //2012// The American Community Survey published average poverty rates for Arizona residents for 2006 through 2008 by county and other demographic characteristics. During that time period, the average poverty rate for Arizona residents was 14 percent; however, the rate varied greatly by race, educational attainment level, gender, and geographic location. Women (16 percent), children (20 percent), African Americans (20 percent), Indian and Alaska Natives (32 percent), and Hispanics (23 percent) have higher poverty rates than the general population in Arizona. Apache County has the highest poverty rate in the state (34 percent), which is more than twice the state poverty rate. At 13%, Maricopa and Yavapai counties had the lowest poverty rates. /2012/ The 2009 American Community Survey showed increases in the rates of poverty among women (17 percent), children under 18 years (23 percent), Black or African Americans (22 percent), American Indian and Alaskan Natives (37 percent), and Hispanic or Latinos (26 percent). //2012// /2013/ The 2010 American Community Survey (ACS) showed 17.4 percent of Arizonans living in poverty. This is an increase from previous years. In 2010 ACS showed increases in the rates of poverty among women (18.2 percent), children under 18 years (24.4 percent), Black or African Americans (25.1 percent), American Indian and Alaskan Natives (36.9 percent), and Hispanic or 15 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// /2015/ The 2012 American Community Survey (ACS) showed that 18.7% of Arizonans live in poverty, a slight decrease from 19% in 2011. The percent of women in poverty remained stable at 19.7%. From 2011 to 2012, slight decreases in poverty were observed in children under 18 (27%), American Indian and Alaskan Natives (38.5%), and Hispanic or Latinos (29%). In 2012, 26.2% of Black or African Americans were living in poverty. //2015// THE ARIZONA STATE BUDGET The majority of the Arizona state general fund is spent on education. Forty-two percent of the general fund goes to elementary and secondary education and another 13 percent is used for higher education. The next largest expenditures are Medicaid (16 percent) and corrections (11 percent). Rankings of Arizona spending relative to other states prior to the recent recession showed that Arizona spent more per capita on police and fire protection (rank = 11) and corrections (rank = 13), and less on highways (rank = 35), health and hospitals (rank = 37), public welfare (rank = 38), and local public schools (rank = 48). Figure 3.14 shows Arizona's state and local government expenditures as a percent of the national average for state fiscal year 2006-2007. Arizona's tax base depends heavily on income and sales taxes, which have been affected by the recession. A reduction in revenues generated by income and sales taxes, together with numerous tax cuts over the last 15 years, has resulted in a decline in state general fund revenues. State tax revenues have declined 34 percent in the past three years. Since the recession began in state fiscal year 2007, sales tax revenues have decreased 22 percent, personal income tax revenues have decreased 38 percent, and corporate income tax revenues have decreased 57 percent. In state fiscal year 2009, Arizona had the largest decrease (42.5 percent) in income tax in the nation. While the general fund used to receive $50 in revenue per $1,000 of personal income in the mid 1990's, it currently receives less than $30. A structural deficit was created as taxes were permanently reduced during years of high revenues without corresponding decreases in the budget. Even when the economy recovers and begins to expand, revenues are projected to only rise to $36 per $1,000 income, which is 28 percent lower than the historical norm. The result of these economic forces is a budget deficit projection in Arizona for 2010 of $5 billion dollars, representing 52 percent of the total general fund budget. This is the second largest proportional state budget deficit in the nation, exceeded by California, where a $52 billion deficit represents 57 percent of their budget. The average budget deficit nationally is 29 percent. To balance the fiscal year 2009 budget, every state agency was given a lump sum reduction with discretion of where to cut. Agencies used a combination of program cuts, unpaid furlough days, and reductions in force, among other methods, to reduce their budgets. To help balance the 2011 budget, employees of each state agency will take a combination of pay reductions and furlough days for each of the next two fiscal years, which will result in an overall annual compensation reduction of five percent. All state employees will take the same furlough days, according to a state-mandated schedule, which will shut down state government on those days. In addition, Arizona state buildings including, the state capitol, the state hospital and state prisons have been put up for sale. 16 Other state agencies serving children experienced significant cuts. The state budgets for both the Arizona Department of Education and Arizona Department of Economic Security were reduced by 20 percent between state fiscal years 2008 and 2011. Examples of program cuts that Arizona has enacted outside of the Department of Health Services that affect the maternal-child population include: • A cap on KidsCare (which is the state's CHIP program). • Elimination of temporary health insurance for people with disabilities who are coping with serious medical problems. • Elimination of general assistance, a program designed to provide time-limited case assistance to adults with physical or mental disabilities. • Elimination of independent living supports for 450 elderly residents and respite-care funding for 130 caregivers. • Eliminated preschool for 4,328 children. • Increased in-state undergraduate tuition between 9 and 20 percent. • Reduction of TANF cash assistance grants for 38,500 low-income families. • Elimination of substance abuse services for 1,400 parents and guardians. • Decreased homeless shelter capacity by 1,100 individuals. • Stopped accepting new families in its child care assistance program in February, 2009 (denying assistance to more than 10,000 children.) 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; 17 • Suspended all retinal and podiatry screenings for diabetics; • Suspended all grants to counties for public health personnel; • Reduced support for both Arizona Poison Control Centers by more than 50 percent; • Eliminated all birth defect call center services. State funding for maternal and child health programs within the Bureau of Women's & Children's Health reached a high of $10 million in state fiscal year 2007 and comprised 44 percent of the bureau's total budget; by state fiscal year 2010, state funding had dropped by 64 percent to a total of $3 million. State appropriated funds now comprise 18 percent of the bureau's budget. State general funding for Health Start, Abstinence Education, County Prenatal Block Grant, and Pregnancy Services was completely eliminated. The budget for the High Risk Perinatal Program has been reduced by nearly 60 percent. State funding for the Children's Rehabilitative Services Program have also been eliminated. A one percent three-year temporary sales tax known as Proposition 100 was passed in a special election on May 18, 2010, with 64 percent of the vote. A projected $1 billion per year will be raised by the tax. If the initiative had failed, a legislative contingency plan would have cut another $900 million from the 2011 state budget. /2012/ State budget reductions in FY11 and FY12 primarily occurred in education, the Medicaid Program (AHCCCS), and Behavioral Health. No further cuts were made to state public health programs. The State implemented mandatory furlough days in FY11 and a pay cut. Furlough days were eliminated for state FY12. //2012// /2013/ During SFY 2012, there were no additional cuts to programs affecting women and children.//2013// /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// /2015/ During the 2014 legislative session there were no additional cuts to programs affecting women and children.//2015// 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 18 one kind of insurance: 60 percent of people have private insurance, either employment-based (52 percent) or direct purchase (8 percent); and 31 percent had some kind of governmentsponsored insurance such as Medicaid (18 percent), Medicare (12 percent), or military health insurance (4 percent). Seventy percent of all business establishments in Arizona are small businesses with less than 50 employees. There are more than 85,000 small businesses in Arizona, and each year, small businesses add more workers to the workforce than large businesses. One of their top challenges is to offer competitive benefits. Only 35 percent of Arizona small businesses offer employer-sponsored health coverage with cost being cited as the primary barrier to offering coverage. For many Arizonans, healthcare remains unaffordable. Recognizing the importance of affordable health care, the Healthcare Group (HCG) was created in 1985 by the Arizona State Legislature with the support of the Robert Wood Johnson Foundation. It is a state-sponsored, guaranteed issue health insurance program for small businesses and public servants. The Arizona Health Care Cost Containment System (AHCCCS), Arizona's Medicaid agency, oversees and administers the program. Since inception, HCG has undergone several substantial changes, the most notable occurring in 2004 when the Arizona State Legislature eliminated the state subsidy that had supported the program since 1999. Beginning in fiscal year 2005, the program has operated entirely from premiums paid by subscribers. Enrollment has continued to grow, more than doubling between 2004 and 2006, with March 2007 enrollment reaching 26,062 medical plan members. HCG also offers a dental and a vision plan, bringing the total enrollment in all plans to 45,521 and making HCG one of the largest state initiatives to provide health insurance for small businesses nationwide. Arizona Health Care Cost Containment System Arizona was the last state in the nation to implement a Title XIX Medicaid program. After much debate, the legislature rejected traditional fee-for-service financing arrangements in favor of an innovative plan for Medicaid managed care. The Arizona Health Care Cost Containment System (AHCCCS -- pronounced "access"), is today the state's Medicaid program, representing the single largest source of health insurance for Arizonans, providing coverage to over 1 million people. Currently there are over 52,000 AHCCCS-registered providers throughout the State, including approximately 80 percent of Arizona's physicians. The acute care program accounts for the greatest percentage (97 percent) of the AHCCCS population, and includes both Title XIX and Title XXI. The vast majority of Acute Care recipients include children and pregnant women who qualify for the federal Medicaid program (Title XIX). American Indians and Alaska Natives may choose to receive services through either the contracted health plans or the American Indian Health Program. The only other population not enrolled in a contracted health plan includes individuals who, because of immigration status, qualify for emergency services only. In 1998, KidsCare became Arizona's Title XXI Children's Health Insurance Program (CHIP). Eligibility for KidsCare includes children under age 19 whose families' incomes are higher than that allowed for Medicaid eligibility under Title XIX, but lower than 200% of the Federal Poverty Level (FPL). With the exception of American Indians, who are exempt in accordance with federal law, parents pay a monthly premium based on income. In November 2000, Arizona voters approved Proposition 204, which increased the income limit for Medicaid to 100% of the Federal Poverty Level (FPL) and permitted childless adults and parents to enroll in the Medicaid program. In 2002, the KidsCare program was expanded to cover the parents of children enrolled in KidsCare. The expansion, called KidsCare Parents, was a low-cost health insurance program for working parents whose income is below 200% of the federal poverty level. Parents paid a monthly premium of up to $100 depending on their income. 19 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// /2015/ The temporary extension of SCHIP, called KidsCare II, funded through a cost sharing agreement between three local hospitals and the federal government ended January 1, 2014. Sixty percent of the children enrolled at that time were transitioned to Medicaid as the result of the Medicaid Expansion and the rest are being directed to the ACA Marketplace. Children enrolled on January 1, 2014 can remain in KidsCare until they turn 19 as long as their application stays current and they continue to qualify. //2015// /2012/ Due to continued budget shortfalls, AHCCCS was required to implement changes to the benefit package for people age 21 and older. Annual well exams and most dental care services were eliminated effective October 2010. Certain transplants that had been eliminated were restored in April 2011. Additional pending changes may result in substantial reductions to the amount of respite care available to families of children with special health care needs. //2012// /2012/ The Arizona Legislature passed a Medicaid Reform Package that will eliminate AHCCCS coverage for specific categories of people, including childless adults, people on a Medical SpendDown Program, and parents earning 75% to 100% of federal poverty level. In total, an estimated 130,000 to 160,000 are expected to lose medical coverage during the next 12 months, pending federal approval. //2012// /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 100133% of the federal poverty level, beginning January 1, 2014. Additionally, preventive well exams have been restored. //2014// /2015/ While Medicaid expansion was successfully passed during the 2013 Arizona 20 legislative session, the issue is still being debated in the courts. At this time expansion is going forward while the courts are deciding if the plaintiffs have standing. //2015// Children's Rehabilitative Services Children's Rehabilitative Services (CRS) Program is administered by the Office for Children with Special Health Care Needs at the Arizona Department of Health Services. CRS provides multispecialty interdisciplinary care to children under age 21 with qualifying chronic and disabling health conditions. There are over 350 conditions covered by CRS, including diagnoses such as cerebral palsy, cleft lip/cleft palate and other cranial-facial disorders, tracheal-esophageal fistula, scoliosis, juvenile arthritis, muscular dystrophy, osteogenesis imperfecta, spina bifida, cystic fibrosis, sickle cell anemia, metabolic and endocrine disorders, neurofibromatosis, heart conditions, Hirschsprungs disease, hydrocephalus, glaucoma, neurosensory disorders, broncho pulmonary dysplasia, and many congenital anomalies. Members typically have more than one diagnostic condition, and are involved in multiple systems of care across child-serving programs and agencies. CRS members often require multiple specialists and a high level of care coordination. A team approach allows for interdisciplinary, family-centered, culturally-competent care to address the multiple medical needs of members, as well as transition and family-support. Covered services include surgeries and other inpatient hospital services; pediatric physician specialty care; physical, speech, and occupational therapies, laboratory, radiology and pharmacy services; vision services; durable medical equipment, such as orthotics and wheel chairs; and social services. CRS does not cover basic primary care that is not related to the CRS diagnosis. The ultimate aim of the CRS program is to enhance members' quality of life through the appropriate utilization of services, optimizing their functionality and minimizing their need for emergency care. The relative scarcity of some specialists poses a challenge for delivering timely services, especially to members who live in remote areas of the state. The CRS program offers statewide management of these specialists and innovative strategies to ensure that services are coordinated and delivered timely throughout the state. In addition to members and providers traveling to clinics, members also receive services through the use of telemedicine and in field/outreach clinics. Before March of 2009, CRS covered the cost of medical services for children that did not qualify for AHCCCS, but were below certain family income limits. These members were called StateOnly members. However in March 2009, due to budget cuts, all State-Only members assumed all responsibility for payment for medical services, regardless of income, but were able to cap 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// /2015/ As a result of the new contract awarded on October 2013 to UnitedHealthcare Community Plan to administer the CRS Program, CYSHCN enrolled in the Medicaid program are fully integrated for their care including primary, specialty, and behavioral health. Children have care coordinated at both the special needs clinics and at the health plan that work together as a medical home to coordinate care that meets the needs of the children. //2015// General and Special Hospitals 21 According to the Arizona Department of Health Services Division of Licensing Services, there were 64 general acute care hospitals in the State of Arizona in 2009, with 13,245 beds and 34 specialty hospitals with 2,433 beds. There are two children's hospitals, both of which are located in the Phoenix metropolitan area. In 2007, the state overall had 2 hospital beds per 1,000 population compared to the national average of 3 per 1,000. Arizona ranks 46 in the number of hospital beds per 100,000 population. Neonatal intensive care units and continuing care units are classified by the level of care they are capable of providing. In Arizona, while hospitals are licensed by the ADHS Office of Licensing, perinatal care facilities are certified by the Arizona Perinatal Trust, a nonprofit organization established in 1980 and dedicated to improving the health of Arizona's mothers and babies. The levels of neonatal care are built on the classification system of the American Academy of Pediatrics with some Arizona specific differences. The Level III facilities are the highest level and are capable of caring for all neonates, while Level I provides services for low-risk obstetrical patients and newborns, including cesarean section at 36 weeks gestation and greater, and In Hospital Birthing Centers, only found within Indian Health Service. In Arizona, there are currently nine Level III, six Level II EQ, fourteen Level II, nine Level I hospitals and two In-Hospital Birthing Centers. /2014/ As of June 2013, there are ten Level lll, seven Level llE, fifteen Level ll, eight Level l and two In Hospital Birthing Centers certified by the APT. //2014// /2015/ There are currently ten Level III, seven Level II EQ, fifteen Level II , nine Level I and two In Hospital Birthing Centers certified by the Arizona Perinatal Trust.//2015// /2015/ In 2014, ADHS completed an exhaustive overhaul of the State's regulations for hospitals, behavioral health inpatient facilities, nursing care institutions, recovery care centers, hospices, behavioral health residential facilities, assisted living facilities, outpatient surgical centers, outpatient treatment centers, adult day health care facilities, home health agencies, behavioral health specialized transitional facilities, substance abuse transitional facilities, behavioral health respite homes, adult behavioral health therapeutic homes, child care facilities and the regulatory standards for licensed professional midwives. The new model sets some prescriptive minimum standards- and then requires facility operators to develop an additional set of policies and procedures to ensure patient and resident health and safety. Facilities are also required to measure patient and resident outcomes. //2015// 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 22 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 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// /2015/ As of May 2014, there are a total of 418 federally designated Health Professional Shortage Areas (HPSAs) consisting of 153 primary care, 171 dental, and 95 mental health designations, as well as 37 Medically Underserved Areas (MUA) and 9 Medically Underserved Population (MUP) designations. According to the Arizona Department of Health Services Bureau of Health Systems Development Arizona has a shortage of 1,087 full-time providers to practice in underserved areas (442 primary care, 441 dentists, and 204 psychiatrists) to eliminate these designations. //2015// 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 23 services, according to the 2009/2010 NS-CSHCN.//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 regardless of their ability to pay. The Arizona Association of Community Health Centers represents health centers statewide and provides advocacy, professional education programs, financial services, and programs designed to improve the health status of the medically underserved and uninsured. The Association reports that their membership included 37 community health centers with more than 150 locations statewide in 2009. Community health centers were affected by Arizona state budget reductions in 2009. Cuts were made to the Primary Care Program which distributed funds to community health centers to assist in supporting the provision of services on a sliding fee scale. Funding for community health centers through the Primary Care Program was reduced from $12 million to $2 million. A onetime appropriation from Arizona's American Recovery and Reinvestment Act funding restored sliding fee scale services in Fiscal Year 2010 for patients between 100 and 200 percent of the federal poverty level. However, the Fiscal Year 2011 state budget will not restore the cuts to community health centers' sliding fee scale program, as the ARRA funds will no longer be available. As a result of the loss of state funds and ARRA funding ending in June 2010, the Arizona Primary Care Program terminated 19 contracts with 138 service sites throughout the state. Some of the sites are expected to close or scale back the availability of services to Arizona's uninsured population. However, significant increases in funding to Federally Qualified Community Health Centers are expected through the passage of the Patient Protection and Affordable Health Care Act. The legislation authorizes a total of $14 billion over a five year period, and is expected to result in 7,000 - 10,000 new and expanded community health center sites nationwide. /2012/ In August 2010, HRSA released the first round of funding from the Affordable Care Act to develop community health centers through new access points. An estimated 20 applications were submitted by Arizona community-based organizations. Awards are expected to be made for 350 new community health centers throughout the country in the fall. In October 2010, HRSA released the first round of funding for expanded services to increase access to care for primary and preventative care. Arizona anticipates benefiting from these grant opportunities. Arizona currently has 16 federally qualified health centers with over 100 sites. These sites are located in every county except for La Paz and Gila counties. //2012// /2013/ Arizona received over $6 million in grants for community health centers.//2013// /2015/ There are currently 17 Federally Qualified Healthcare Centers and two Look-Alikes operating at over 140 sites in Arizona. Arizona received over $89 million in grants to support primary care in health centers.//2015// B. Agency Capacity 24 The Arizona Department of Health Services (ADHS) houses the Title V program. The State Maternal & Child Health (MCH) program resides within the Bureau of Women's & Children's Health, and the Children with Special Health Care Needs program resides within the Office for Children with Special Health Care Needs. This section will highlight statutes relevant to the Title V program; the general capacity of ADHS to promote and protect the health of all mothers and children, including children with special health care needs; and culturally competent approaches. State Statutes Relevant to Title V Program Arizona Revised Statute (A.R.S.SS36-691) formally accepts Title V and designates ADHS as the Title V agency: A. This state accepts the conditions of title V of the social security act, entitled "grants to states for maternal and child welfare", enacted August 14, 1935, and as amended. B. The department of health services is designated as the state agency to cooperate with the department of health, education and welfare for the administration of part 1 and part 4 of title V, of the social security act. Additional state statutes authorize some maternal and child health programs or functions but are not specific to Title V. The statutory list of functions (A.R.S. 36-132) of ADHS includes: encourage and aide in coordinating local programs concerning maternal and child health, including midwifery, antepartum and postpartum care, infant and preschool health and the health of school children, including special fields such as the prevention of blindness and conservation of sight and hearing; encourage, administer and provide dental health care services and aid in coordinating local programs concerning dental public health, in cooperation with the Arizona dental association. Subject to the availability of monies, develop and administer programs in perinatal health care. State statute (A.R.S. 36-697) authorized the Health Start program, administered by Bureau of Women's & Children's Health; the program is required to serve pregnant women, children and their families. The program is required to be statewide, based in identified neighborhoods and delivered by lay health workers through prescheduled home visits or prescheduled group classes that begin before the child's birth or during the postnatal period and that may continue until the child is two years of age. Statute also requires the program to develop and distribute an Arizona Family Resource Directory to enable parents to obtain information that is critical to the development of their young children. State statute (A.R.S. 36-899.01) also requires ADHS to administer a program of hearing evaluation services administered to all children as early as possible, but in no event later than the first year of attendance in any public or private education program, or residential facility for handicapped children, and thereafter as circumstances permit until the child has attained the age of sixteen years or is no longer enrolled in a public or private education program. Bureau of Women's & Children's Health administers this program and provides administrative rules and technical assistance to schools to implement required hearing screening. The Child Fatality Review Program is authorized by state statute (A.R.S. 36-3501). The State Child Fatality Review Team is required to conduct an annual statistical report on the incidence and causes of child fatalities and submit a copy of this report, including its recommendations for action, to the Governor and legislative leadership on or before November 15 of each year. The Team is also required to develop protocols for child fatality investigations including protocols for law enforcement agencies, prosecutors, medical examiners, health care facilities and social service agencies. The team is required to educate the public regarding the incidence and causes of child fatalities as well as the public's role in preventing these deaths. State Statute (A.R.S. 36-2291) established the Unexplained Infant Death Council, which is staffed by the Bureau of Women's & Children's Health. The unexplained infant death advisory council is charged with assisting ADHS in developing unexplained infant death training and educational 25 programs, and periodically review and approving the infant death investigation checklist developed by ADHS. The statute also mandates that ADHS submit an annual report of the incidences of stillborn infants and the reported causes of death for the previous year to the Governor and legislative leadership. In FY07, ADHS was given new statutory responsibility (A.R.S. 36-112) to develop and distribute an umbilical cord blood pamphlet. The pamphlet is available on the Bureau of Women's & Children's Health website. Children's Rehabilitative Services, administered by the Office for Children with Special Health Care Needs, is authorized in state statute (A.R.S. 36-261). Statute mandates that the program shall provide for: (a) Development, extension and improvement of services for locating such children. (b) Furnishing of medical, surgical, corrective and other services and care. (c) Furnishing of facilities for diagnosis, hospitalization and aftercare. (d) Supervision of the administration of services in the program which are not administered directly by the department. (e) The extension and improvement of any services included in the program of services for chronically ill or physically disabled children as required by this section. (f) Cooperation with medical, health, nursing and welfare groups and organizations and with any agency of the state charged with administration of laws providing for vocational rehabilitation of physically handicapped children. ADHS is required to issue a request for proposal at least once every four years to contract for the care and treatment of chronically ill or physically disabled children. The scope of the contracted services shall include inpatient treatment services, physician services and other care and treatment services and outpatient treatment services which shall not be mandated at a single location. Statute also mandates a central statewide information and referral service for chronically ill or physically disabled children. The purposes of the information and referral service for chronically ill or physically disabled children are to: 1 . Establish a roster of agencies providing medical, educational, financial, social and transportation services to chronically ill or physically disabled children. 2. Develop or use an existing statewide, computerized information and referral service that provides information on services for chronically ill or physically disabled children. /2012/ In 2011, the Arizona Legislature revised the state child fatality statute to add authority to review maternal deaths. Maternal mortality review will be implemented through a sub-committee of the State Child Fatality Review Team. //2012// /2015/ New rules, R9-101-117, were adopted for the licensing of lay midwives in Arizona. The new rules include a change to the scope of practice to include frank breech and vaginal delivery after caesarean section under certain prescribed circumstances. The rule changes also add clear requirements for reporting, transfer of care and emergency action plans. These rules go into effect July 1, 2014. During the 2014 legislative session, the Critical Congenital Heart Defects (CCHD) screen was added to the core NBS panel with screening scheduled to begin in 2015 after rules are developed. Statute also called for the creation of an advisory panel of community partners and stakeholders to consider adding severe combined immunodeficiency disorder (SCID) and Krabbe disease. If the group agrees to add these two disorders, it is anticipated that they will be added to the core panel of disorders screened for in 2015. //2015// Capacity of Arizona's Title V Program to Provide Preventive and Primary Care Services for Pregnant Women, Mothers and Infants 26 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 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 27 Agency Coordination Team, to address common issues and ensure services are coordinated throughout the state. The BWCH administers the federal Family Violence Prevention and Services Act Grant. These funds are used primarily to support shelter and services in rural Arizona, known as the Rural Safe Home Network. Funds also support infrastructure-building activities of the Arizona Coalition Against Domestic Violence. Between October 1, 2008 and September 30, 2009 the Rural Safe Home Network programs provided 14,567 shelter nights to 466 women, 515 children and three men. Programs provided 1,825 hours of batterers' intervention services to 572 people, as well as 766 domestic violence training and prevention services to 24,741 participants. BWCH also administers the only funding source dedicated solely to primary prevention of sexual violence. The Arizona's federally funded Sexual Violence Prevention and Education Program reached 25,719 Arizonans with primary prevention education in the last fiscal year. The program worked with multiple stakeholders to develop the first state plan specific to the prevention of sexual violence. In 2009, BWCH accepted its first federal funding for direct services for victims of sexual assault. Capacity of Arizona's Title V Program to Provide Preventive and Primary Care Services for Children Medical Services Project To help improve access to care for children, BWCH provides Title V funding to the Medical Services Project. Administered through the Arizona chapter of the American Academy of Pediatrics, the Medical Services Project increases access to and utilization of primary care services for Arizona's uninsured children from low-income families. The Medical Services Project provides delivery of medical services in participating physicians' offices to children without health insurance and to those who do not qualify (or are in the process of qualifying) for public assistance. School nurses identify children who are eligible to participate in the Medical Services Project and facilitate their enrollment. To be eligible for the Medical Services Project a child must have no health insurance, must not be eligible for AHCCCS, KidsCare, or Indian Health Services; and must have a household income less than 185 percent of the federal poverty level. A network of physicians (pediatricians, family practice physicians, and specialists) provides care to children qualifying for the Medical Services Project for a fee of either $5 or $10 as payment-infull for an office visit. The health care providers agree to provide a certain number of appointment slots to Medical Services Project children each month. In addition, prescription medications, diagnostic laboratory services and eyeglasses are provided as necessary to qualifying children. In 2009, the Medical Services Project served 242 individual children. /2013/ The Medical Services Project has been successful in recruiting dentists to participate in the program.//2013// Hearing and Vision Screening While the requirement to providing hearing screening is an unfunded state mandate for the schools and ADHS, the Bureau of Women's and Children's Health uses Title V dollars at the state level to support the infrastructure necessary to carry out the statutory duties of ADHS. The Bureau of Women's and Children's Health contracts with the University of Arizona to develop hearing screening curriculum and to train hearing screening trainers. Arizona currently has 128 hearing screening trainers throughout the state that provide the infrastructure to train enough hearing screeners to screen Arizona's school age children. In the school year 2008-2009, 535,001 students were screened and 1,259 were identified for the first time with a hearing disorder. To help support the schools, ADHS makes hearing screening equipment available by loan to Arizona's schools. /2013/ To address the gap between Newborn Hearing Screening and school, the Sensory 28 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 school-based dental sealants and screenings to over 10,000 children per year. OOH manages the Arizona Fluoride Mouthrinse program, providing approximately 20,000 children in participating schools with fluoride mouthrinse annually. OOH supports the efforts of communities to fluoridate their water systems through providing technical assistance, training, and workshops for community fluoridation campaigns. Office of Oral Health was awarded a HRSA Grant to States to Support Oral Health Workforce Activities in 2006 and a subsequent grant which continues through 2012. These grants funded a program to promote and develop enhanced dental teams utilizing teledentistry practice to improve workforce capacity, diversity and flexibility for providing oral health services to underserved populations. As of June 2010, five dental service delivery sites in Arizona are using teledentistry technology. /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 school-based sealant programs. /2012/ Funds have not been appropriated yet for any of the oral health initiatives included in the health care reform legislation. //2012// /2015/ Julia Wacloff, the Chief of the Office of Oral Health was appointed to the Board of Directors for the Association of State and Territorial Dental Directors. //2015// 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// 29 /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// /2015/ There are now 18 Emergency Departments (ED) verified as pediatric prepared. Enhancing the service of care to over 60% of children seen in ED's for 2013.//2015// Teen Pregnancy Prevention Services Arizona currently receives more than $3 million per year in lottery funds to address teen pregnancy prevention. Arizona funds multiple approaches, including abstinence education and comprehensive teen pregnancy prevention. County health departments, tribal agencies, and non-profit organizations implement these approaches across the state. Strategies focus on youth development and parent education. Growing capacity is expected in this area as federal funding becomes available through the Affordable Care Act. /2012/ Bureau of Women's & Children's Health received $1.2 million in federal Abstinence Education funding that was reauthorized through the Affordable Care Act, as well as $1 million for the new Personal Responsibility and Education Program. Competitive grants will be awarded to community based projects to begin implementing these programs in 2011. //2012// /2013/Four abstinence and eight PREP grants were awarded to community based organizations throughout Arizona.//2013// /2012/ Home Visiting Arizona submitted applications and began receiving new federal funding to implement the Maternal, Infant, and Early Childhood Home Visiting Program. ADHS Bureau of Women's & Children's Health worked collaboratively with Department of Economic Security, Department of Education Head Start Office, Behavioral Health, and First Things First to shape the program. Communities with the high risk ranking on several indicators will be targeted for implementation of evidence-based home visiting programs. ADHS will continue to work with partners on development of infrastructure for home visiting in Arizona. //2012// /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. 30 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// /2015/ Arizona's MIECHV currently supports home visiting in 35 communities and has served approximately two thousand families through over 30,000 home visits. An extensive professional development program serves home visitors throughout the state. Topics addressed this year include breastfeeding, domestic violence, maternal depression and infant mental health, nutrition, car seat safety, preconception health, cultural competency, and an oral health training video for home visitors to use with families is expected to be completed by September 2014. Additionally, 11 online trainings became available through the Strong Families AZ Home Visitor portal on the Strong Families AZ website. The 3rd Annual Strong Families Arizona Home Visiting Conference will be held in September 2014 with 700 home visitors and supervisors expected to attend. //2015// /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 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, 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. 31 /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// /2015/The role of the Office of Children with Special Health Care Needs has evolved since CRS transitioned to Arizona's Medicaid agency, AHCCCS. OCSHCN meets monthly with UnitedHealthcare (UHC) staff for updates on CRS, to discuss trends in family concern contacts received by OCSHCN; to explore opportunities for professional development among UHC providers and support staff on best practice including Medical Home, Family Centered Culturally Competent Care and Transition to Adult Healthcare. OCSHCN collaboration with CRS also reaches UHC providers who serve children and young adults with SHCN in the Arizona Long Term Care Systems; UHC serves over 70% of Arizona's children and adults with special health care needs, who are Medicaid eligible. With less of a clinical role, OCSHCN now focuses on developing and supporting the community and families to be able to better support children and youth with special health care needs to live a more inclusive life connected to the community. The Office of Children with Special Health Care Needs is responsible for coordinating Title V activities to develop and implement innovative models of community based care and resources for children and youth with special health care needs and their families. The Office is responsible for short and long range planning activities for tele-health, e-learning, education and advocacy, training, family and youth leadership, web page, cultural competence, medical home, and transition to adulthood. Additionally, the Office is responsible to assess and implement education for staff, providers, families, and family/youth advisors (leaders); and activities that promote improvement of quality of life.//2015// /2015/As a result of the new contract awarded on October 2013 to UnitedHealthcare Community Plan to administer the CRS Program, CYSHCN enrolled in the Medicaid program are fully integrated for their care including primary, specialty, and behavioral health. Children have care coordinated at both the special needs clinics and at the health plan that work together as a medical home to coordinate care that meets the needs of the children.//2015// Members typically have more than one diagnostic condition, and are involved in multiple systems of care across child-serving programs and agencies. CRS members often require multiple specialists and a high level of care coordination. A team approach allows for interdisciplinary, family-centered, culturally-competent care to address the multiple medical needs of members, as well as transition and family-support. Covered services include surgeries and other inpatient hospital services; pediatric physician specialty care; physical, speech, and occupational therapies, laboratory, radiology and pharmacy services; vision services; durable medical equipment, such as orthotics and wheel chairs; and social services. CRS does not cover basic primary care that is not related to the CRS diagnosis. The ultimate aim of the CRS program is to enhance members' quality of life through the appropriate utilization of services, optimizing their functionality and minimizing their need for emergency care. The relative scarcity of some specialists poses a challenge for delivering timely services, especially to members who live in remote areas of the state. The CRS program offers statewide management of these specialists and innovative strategies to ensure that services are coordinated and delivered timely throughout the state. In addition to members and providers traveling to clinics, members also receive services through the use of telemedicine and in field/outreach clinics. 32 Before March of 2009, CRS covered the cost of medical services for children that did not qualify for AHCCCS, but were below certain family income limits. These members were called StateOnly members. However in March 2009, due to budget cuts, all State-Only members assumed all responsibility for payment for medical services, regardless of income, but were able to cap their fees at rates no higher than AHCCCS provider scheduled rates. In December of 2009, further cuts resulted in the suspension of all State-Only services, and approximately 4,000 members were disenrolled from CRS. Consequently, only members who are enrolled in an AHCCCS Health Plan remain enrolled. Cultural Competent Approaches Culture is defined as a shared, learned, symbolic system of values, beliefs and attitudes that shapes and influences perception and behavior. People typically think of culture as the foods, music, folk costumes, holidays, and religious beliefs associated with different countries and ethnic groups. But culture influences all aspects of everyday life. It is learned and maintained through social interaction. One's own culture seems natural and normal, and is taken for granted. John Culkin (as quoted in Edmund Carpenter's "They Became What They Beheld") said "We don't know who discovered water, but we're certain it wasn't a fish." In fact, people often believe that their own culture is superior to that of others. Other's views can be experienced as wrong, or as a distortion. It can be difficult to realize that what works so well for you, may not work in another's cultural context. OCSHCN has a strong focus on cultural competence. There are many competing definitions of culture. OCSHCN's working definition of culture goes beyond a focus on language and interpretation, and embraces the idea of special health care needs and how it requires a reinterpretation of one's traditional culture. Culture is frequently only observable when there is a clash in expectations. Identifying that a child has a special health care need can represent a challenge to one's cultural expectations. Every family has expectations about what life will be like when their baby is born. Assumptions are made about parents' job participation, daycare, healthcare, school, and the child's integration into everyday family life and ultimately transition to adult life and independence. Different cultures have different ideas about what the special healthcare means and what a family should do or not do. But families also must now renegotiate their every day expectations in ways that their culture did not prepare them. Institutions, such as healthcare, education, and work, are all designed with certain assumptions and rules for what is acceptable and how to participate. These assumptions and rules may present barriers to a person with special healthcare needs, who must constantly find ways to negotiate expectations. Sometimes personal adaptations are needed, but often full participation requires institutional change in terms of policies and practices. In order to ameliorate the harmful effects of failing to appreciate another's everyday reality, OCSHCN promotes cultural relativism. Activities are designed to promote an understanding that your experience of the world is only one of many possibilities, and you cannot judge a culture using the standards of your own culture. Activities are not so much oriented towards trying to 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 33 may be oriented towards a cure or amelioration of disability. The family's priorities could be different, but they are dependent upon the provider to help them to understand risks and possibilities of different treatment options. OCSHCN embeds cultural competence concepts into contract language and training, which go beyond requirements for reading level, interpretation, translation, and alternative formats, and include best practices for family-centered care, including people-first language and disability etiquette. Satisfaction surveys are conducted and analyzed to identify areas of strengths and opportunities for improvement. OCSHCN involves families and youth with special health care needs in policy and resource development, and makes translation and interpretation services available to other community partners. OCSHCN's cultural competence committee brings in regular speakers to address the unique perspectives of culturally diverse groups. The following are just a few examples of how services are linguistically and culturally appropriate, and family centered in Arizona. Arizona Department of Health Services houses the Arizona Health Disparities Center within the Bureau of Health Systems Development. The Arizona Health Disparities Center organizes frequent brown bag speakers that highlight the many cultures present in Arizona. The Arizona Health Disparities Center provides regular updates through email and through its website on news, funding opportunities, publications and events related to health disparities. Subscribers receive links/attachments to the latest resources identified by AHDC on their selected topic by email. The Arizona Health Disparities Center worked closely with the Arizona WIC program to produce online courses and CD-ROMs on orientation to Culturally and Linguistically Appropriate Services (CLAS) standards. Additional courses on CLAS standards are in the process of development. ADHS is working on integrating CLAS standards into the orientation process required of all new employees. Health Start is designed on the principle that workers reflecting the neighborhoods in which they serve will be effective in identifying women in their community who need services. Health Start hires and trains lay health workers from targeted neighborhoods to provide outreach and services to pregnant women and new moms in their community. Project LAUNCH, provides evidence-based services for children ages 0-8 years and their families in neighborhoods in South Phoenix, which has a significant minority population. The program has as one of its guiding principles investing in the community to ensure cultural competence and sustainability by encouraging hiring staff and contracting with organizations from within those neighborhoods. The Office of Women's Health has implemented a social marketing campaign targeting African Americans around a message of preconception health. The campaign consists of radio spots, billboards, brochures, mood piece, website and E-blasts, and educational presentations in African American churches and other appropriate venues in Maricopa County and other areas of the state. The Phoenix Chapter of the Black Nurses Association conducts presentations and trains barbers and beauticians on preconception health so they can educate their clients. The graduate 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 34 training, the availability of TA to support cultural competency and the degree to which BWCH staff has been trained in cultural competency. //2014// /2015/ The Teen Pregnancy Prevention program integrates cultural competence through capacity building workshops and culturally appropriate teen pregnancy prevention curriculum that are culturally relevant and inclusive of curricula that is age, ethnicity, gender, and intellectual ability specific. In addition, the teen pregnancy prevention program offers hands-on training to contractors through capacity building workshops. This past year, the teen pregnancy prevention program offered training on how to include youth with intellectual disabilities in teen pregnancy prevention programs. Cultural competency training is also integrated into quarterly meetings. The MIECHV Home Visiting Coordinators facilitate professional development trainings in local communities. One such training is cultural competency; this training is being provided in Cochise, Gila, Graham/Greenlee, Navajo, La Paz/Mohave, Pima, and Pinal Counties. It is expected that 150 home visitors will attend these training in 2014. In addition, two post conference Train the Trainer workshops will be offered in September. The first training; The Coming of the Blessing is a March of Dimes initiative for American Indian and Alaska Native families. It provides prenatal education, training and resources that encourage women to include traditional beliefs and lessons from their ancestors during pregnancy. Fifteen home visitors are expected to attend this training. The second training; Comenzando Bien was designed with topics such as prenatal care, nutrition, stress, labor and birth, postpartum care, and newborn care and is tailored for the Hispanics Culture. Lastly, Fatherhood is Sacred is a Train the Trainer workshop offered by the Native American Fatherhood and Family Association. This is a culturally rich training that inspires and motivates fathers to devote their best efforts in teaching and raising children and to develop their personal potential for successful living. It will be offered by MIECHV in 2015 and it is expected that 25 home visitors will attend this training. The Office of Children with Special Health Care Needs (OCSHCN) identified and supported a Family Advisor to work with Catholic Social Services, Refugee Relocation Program to facilitate several meetings that provided information, resources and linkages within the system of care, for families whose preferred language was Arabic. In partnership with AZ Birth Defects Monitoring Program, OCSHCN identified and supported two Family Advisors to provide insight on their personal perspective of being on the receiving end of "Delivering a Diagnosis" presentation at the Navajo Maternal Child Forum. OCSHCN has also offered several types of training that can be tailored to meet the specific situation or population. Each explores the role of culture in a personal way, assisting the participant to identify their own beliefs, how they came to hold those beliefs and their effect on personal attitudes. //2015// /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 35 Janice K. Brewer became the 22nd person to take the oath of office as Governor of Arizona on January 21, 2009. She is Arizona's fifth Secretary of State to succeed to Governor in mid-term. Jan Brewer has lived in Arizona for 39 years, and she has spent the past 27 of them serving the people and upholding the public trust. There are few, if any, elected officials in Arizona with a broader range of productive experience in public service. Prior to her succession to Governor, she served as Arizona Secretary of State, as Maricopa County Supervisor, and as a highly respected member of both houses of the Arizona Legislature, where she rose to leadership of the State Senate. The Arizona Department of Health Services (ADHS) is one of the executive agencies that report to the Governor. ADHS was established as the state public health agency in 1973 under A.R.S. Title 36 and is designated as Arizona's Title V MCH Block Grant administrator. The agency has four divisions: Public Health Services, Behavioral Health Services, Licensing Services, and Operations. The Office of Director includes a Native American Liaison, Local Health Liaison, Border Health, Public Information Office, and Legislative Services. An ADHS organization chart can be viewed at www.azdhs.gov/diro/documents/w_orgchart.pdf The Division of Public Health Services is organized into two primary service lines; Public Health Preparedness Services and Public Health Prevention Services (PHPS). Public Health Prevention Services includes four bureaus: Women's & Children's Health, Nutrition & Physical Activity (includes WIC), Tobacco & Chronic Disease, and Health Systems Development (includes Center for Health Disparities). Bureau of Health Statistics is also part of the Division of Public Health Services. The Division of Behavioral Health Services includes the Office for Children with Special Health Care Needs, as well as the State Hospital. Arizona Department of Health Services administrative offices are located in the capitol mall area in the city of Phoenix. This location enhances collaboration between ADHS divisions as well as other state agencies. Structure of Bureau of Women's & Children's Health The organizational structure of the Bureau of Women's & Children's Health is comprised of four offices and two sections: Office of Women's Health, Office of Children's Health, Office of Oral Health, Office of Assessment & Evaluation, Injury Prevention & Child Fatality Section, and Business & Finance Section. An organization chart is attached. The Office of Women's Health provides leadership for planning, program development, and program management of initiatives and programs related to women. Programs include: teen pregnancy prevention, reproductive health services, sexual violence prevention and education, sexual assault services, family violence prevention and services/Rural Safe Home Network, Health Start, and First Time Motherhood. The office lead's the bureau's preconception health initiative and the Department's Women's Health Week activities. The Office of Children's Health provides leadership for planning, program development, and management of initiatives and programs related to children. Programs administered by this office include the Title V Community Health Grants, Pregnancy & Breastfeeding/Baby Arizona/WIC Hotline, Children's Information Center, High Risk Perinatal Program, Sensory Program, Medical Services Project for uninsured children, Project LAUNCH, and early childhood initiatives. /2015/ This office also oversees the MIECHV grant //2015// 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 36 Development scholarship and loan forgiveness programs. OOH administers a HRSA Oral Health Workforce grant which is developing teledentristry sites to provide oral health services to underserved populations. Injury Prevention & Child Fatality Review Section leads the Department's assessment of injuries and child fatality, as well as planning and program development for injury prevention. This section includes overseeing the state injury prevention plan, injury prevention advisory council, injury epidemiology, Child Fatality Review Program, Unexplained Infant Death Council, Emergency Medical Services for Children Program, and the Pediatric Advisory Council for Emergency Services. /2013/The Injury Prevention and Child Fatality Review Section became an office, reflecting the evolution that injury prevention has taken as one of our strategic priorities. //2013// The Office of Assessment and Evaluation Section leads the Bureau's research, evaluation, epidemiology, and data management functions. The office provides technical assistance to Bureau programs on evaluation, data analysis, and outcomes measures. The office supports data collection, management, and reporting for BWCH programs. Current Assessment and Evaluation programs/projects include Title V MCH Block Grant Application and Five-Year Maternal-Child Health Needs Assessment, State Systems Development Initiative, home visiting assessment, and program evaluation for Project LAUNCH, Fetal Alcohol Spectrum Disorders grant, and First Time Motherhood grant. /2013/The responsibility of the State Systems Development Initiative was transferred to the Bureau of Health Status and Vital Statistics.//2013// Structure of Office for Children with Special Health Care Needs The Office for Children with Special Health Care Needs has five divisions, plus a medical director and chief financial officer. The medical director is responsible for medical direction of the quality and utilization management functions of the Office, and gives expert opinions on medical necessity determinations. The chief financial officer oversees all financial functions, including encounter submissions, financial statement reporting and reinsurance, and capitation rate development for Children's Rehabilitative Services. The Division of Member and Provider Services, Advocacy and Education assists families in accessing appropriate care and services for children and youth with special health care needs, and provides information and referral services. The Division oversees the telemedicine program, e-learning, social service funds, family involvement, member materials and correspondence, websites and compliance with Americans with Disabilities Act. They also lead the office in the development of best practices for CSHCN among providers, school nurses, community partners 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 ensue compliance with all state and federal requirements related to these processes. The Division of Quality, Utilization, and Medical Management assures appropriate utilization of services through monitoring authorization and denial processes, and overseeing compliance with service plans. Timeliness and quality of services is improved through investigating member complaints, auditing credentialing and medical records, monitoring of performance improvement projects and compliance with clinical practice guidelines. The Compliance and Policy Division's responsibilities include developing contracts and 37 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 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 38 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 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 39 an epidemiologist with the Centers for Disease Control and Prevention. /2015/ Julia Wacloff, the Chief of the Office of Oral Health was appointed to the Board of Directors for the Association of State and Territorial Dental Directors. //2015// Tomi St. Mars serves as the manager of the Injury Prevention & Child Fatality Section, and has lead the Department's injury prevention initiatives since August 2005. Ms. St. Mars is Arizona's representative to the State and Territorial Injury Prevention Directors Association, an active member of the Emergency Nurses Association (ENA) at the national and state level and is a Certified Emergency Nurse. Ms. St. Mars holds a degree in Master of Science in Nursing. Debi Morlan has served as the Bureau's Finance Manager since 2001. Ms. Morlan provides financial and contractual oversight to Title V funded programs, as well as the other federal and state programs with the Bureau. /2013/ Jeanette Shea retired and Sheila Sjolander became the Assistant Director of Public Health Prevention Services. Mary Ellen Cunningham became the Chief of the Bureau of Women's and Children's Health. Dr. Khaleel Hussaini was promoted to become the Chief of the Bureau of Health Status and Vital Statistics. Emma Kibisu has been hired to become the Chief of the Office of Assessment and Evaluation. Ms. Kibisu has many years of combined national and international health experience including evaluation and research. She holds a Master's of Science in International Health Policy and Management from Brandeis University. Dyanne Herrera became the Bureau's MCH epidemiologist in June 2011. Ms. Herrera previously was a CDC/CSTE Epidemiology Fellow and has worked on MCH capacity building in the border region, and has presented various MCH studies at local and national conferences. She holds a Master's in Public Health with a concentration in Epidemiology from the University of Florida.//2013// /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 40 to both public and private organizations related to program evaluation, strategic planning, needs assessment, reimbursement design, and community outreach. In addition to serving as the CSHCN director for title V, she is the administrator of the Children's Rehabilitative Services Program. Michael S. Clement, MD, serves as the medical director for Children's Rehabilitative Services. Dr. Clement received his medical degree from the University of Utah in 1963. He holds a current medical license in Arizona, and is a board certified pediatrician. Dr. Clement has previously served as an assistant director at ADHS, the director of a county health department, the director of Ambulatory Services at Phoenix Children's Hospital, and as a consultant to the Arizona Perinatal Trust. He is a fellow of the American Academy of Pediatrics Cynthia Layne has served as the chief financial officer for OCSHCN since 2002. She is a certified public accountant, and has held positions as a financial consultant at AHCCCS and in the Auditor General's Office and in private industry before coming to ADHS. Jennifer Vehonsky is the division chief for policy and contract compliance. She has extensive experience with Medicaid program administration and policy development, and was formerly the Bureau Chief of Policy at ADHS/BHS and assistant to the legislative liaison at AHCCCS before joining OCSHCN. Stephen Burroughs is the division chief for Medical, Utilization, and Quality Management. Mr. Burroughs is a registered nurse with a Bachelor of Science in Nursing. He formerly held positions as quality director, quality manager, and risk manager for hospitals and managed care organizations. Margery Ault is the division chief of Consumer Rights for both OCSHCN and BHS. Ms. Ault holds a Juris Doctor, and has been the division chief of Consumer Rights since October of 2000. Ms. Ault brings to OCSHCN over 15 years of experience in managed health care operations for persons who have special health care needs. Judith Walker joined OCSHCN in 2002, and leads the Division of Member and Provider Services, Education and Advocacy. She has over 24 years as an educator on best practices regarding including children and youth with special needs in all aspects of life throughout the lifespan, and is a recognized leader in medical home, transition to adulthood, and community development. Ms. Walker led nationwide technical assistance on early intervention to parent training and information centers. She has testified on behalf of CSHCN at state and federal hearings on health care, early intervention, special education, and inclusion. She is also the parent of an adult with special health care needs. Lisa Anne Schamus leads the Division of Assessment and Evaluation. She holds a Master of Public Health with an emphasis in Epidemiology, and a B. A. in Spanish Literature. Ms. Schamus formerly served as the office chief for Assessment and Evaluation for the Bureau of Women's and Children's Health, and as a manager at the Arizona Family Planning Council. Ms. Schamus has over 15 years experience guiding program development and improvement through in research and survey design, data analysis, needs assessment and program evaluation. Jennifer Jung is the Research Manager in OCSHCN. She has worked at ADHS for five years and has a Master of Science degree in Public Health. She has experience in epidemiological and health services research related to Women's and Children's Health as well as Children with Special Health Care Needs. She is skilled in designing reports and conducting data analyses using SAS. She maintains databases, performs data validation to ensure data quality, and establishes methodologies for analysis. Thara Maclaren manages special projects for OCSHCN, including overseeing survey activities. She holds a Bachelor of Science in Mathematics and a Master of Science in Economic Systems 41 and Operations Research. Ms. Maclaren has worked in several industries including defense, utilities, education, and public health. She joined OCSHCN in June 2006, and her expertise in mathematical modeling, decision analysis, and experimental design supports program decisions and operations within OCSHCN. She contributed statistical support for the needs assessment process. Role of parents of CSHCN on staff: OCSHCN has a long history of involving parents of CSHCN and youth with special health care needs in program development and decision making. This is accomplished primarily by using families of CSHCN and YSHCN in paid consultant roles. There are several full time staff who are parents of CSHCN, including two of the division chiefs described above, and a few others, who did not choose to share their family information in this application. However, the following two people who play key professional roles in OCSHCN shared the following information. Marta Urbina serves as the Clinical Programs Executive Coordinator, chairs the cultural competency committee, and is responsible for information and referral. Ms. Urbina first learned the importance of understanding the multiple, complex systems of care when she became a parent in 1982. Her experience began with the neonatal intensive care unit and continued to community based supports and services that included early intervention, transition to preschool, navigating the special education system and transitioning to adult life. She immersed herself in her daughter's medical and educational needs and sought out training, workshops and conferences to learn to better advocate on her daughter's behalf until she could do so for herself. Ms. Urbina has worked at Raising Special Kids and the Division of Developmental Disabilities, with families of CYSHCN, adults living independently in their community, and with professionals that support them. Rita Aitken serves as a Title V outreach coordinator for OCSHCN. Ms. Aitken has two adult children with special health care needs, and has many years experience working with families and providers, including trainings on best practices for healthcare professionals. Rita is a board member of Canine Companions for Independence, an organization that provides service dogs to people with disabilities, and is a member of the Consumer Advisory Workgroup with Mountain States Genetics Regional Collaborative Council and co-founder of Lactic Acidosis Family Resource Group in Denver, CO. /2012/ Marta Urbina was appointed Office Chief for Children with Special Health Care Needs in January 2011. Rita Aitken has served as Education & Advocacy Manager since April 2011. Ralph Figueroa was hired as the Title V Outreach Manager in April 2011. Mr. Figueroa is a parent of a young adult with learning disabilities. He has worked as an administrator for the Division of Developmental Disabilities and for Arizona's Parent to Parent Center, Raising Special Kids. Mr. Figueroa has extensive expertise in the educational system, social services, and community-based organizations. //2012// /2015/ Marta Urbina moved to another position and Rita Aitken assumed the role of Acting Office Chief.//2015// /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// 42 E. State Agency Coordination The Arizona Department of Health Services Maternal and Child Health Program, consisting of Bureau of Women's and Children's Health and Office for Children with Special Health Care Needs (OCSHCN), has many partnerships with a variety of public, private, and government agencies. Partnerships are built and enhanced through multiple formal and informal methods. A summary of key collaborations follow, and is not intended to cover the full spectrum of partnerships occurring. Maternal and Child Health staff and leadership participate on committees or groups of many partner agencies, including March of Dimes, Arizona Family Planning Council, Arizona Coalition Against Domestic Violence, South Phoenix Healthy Start, the Early Childhood Development and Health Board (First Things First), Arizona Perinatal Trust, School Based Health Care Council, and Children's Action Alliance. Staff participates on committees or workgroups and collaborate on projects with many child-serving community organizations including, Raising Special Kids -Arizona's Family to Family Health Information Center, Special Olympics Arizona, United Cerebral Palsy of Central Arizona, Arizona Chapter of Academy of Pediatrics, and Ronald McDonald House among others. Participation in coalitions, networks, and associations has been a critical strategy in partnership development. Staff actively participates in groups such as the Arizona Public Health Association, Arizona Rural Women's Health Network, Arizona Asthma Coalition, Taskforce on Alcohol and Drug-Exposed Infants, Arizona School Nurse Consortium, Rocky Mountain Public Health Education Consortium, the Arizona Association of Community Health Centers, the Arizona Developmental Disabilities Network (consisting of the Institute for Human Development University Center of Excellence for Developmental Disabilities (UCEDD), Sonoran UCEDD, Arizona Developmental Disabilities Planning Council, Arizona Center for Disability Law, local oral health coalitions, and the Arizona chapters of the Dental Association and Dental Hygiene Association. ADHS also leads collaborative efforts to address specific public health issues. For example, ADHS coordinates an Injury Prevention Advisory Council that works on development and implementation of the state injury prevention plan. ADHS also coordinates the Pediatric Advisory Committee for Emergency Services, which helps facilitate accomplishment of performance objectives of the HRSA Emergency Medical Services for Children Program. The Unexplained Infant Death Council and State Child Fatality Review Teams address deaths of children and strategize around areas of preventability. The Office of Oral Health has established regional oral health workgroups to facilitate strategic planning for the state oral health workforce plan. Staff works with University of Arizona to develop services for children with neuro-developmental and related disabilities. In addition, ADHS has multiple partnerships in place with higher institutes of learning that provide education for the health professions. For example, staff participates on advisory boards, provide technical assistance and consultation on public health curricula, and mentor students. Most ADHS maternal child health programs contract with local organizations to carry out the mission of the programs. These organizations are primarily county health departments, non-profit human services agencies, and community health centers. Programs coordinate regular contractor meetings to provide educational opportunities, technical assistance, and opportunities for networking. Collaboration with other state agencies occurs on a regular basis. The Governor's Office for Children, Youth, and Families facilitates monthly meetings of the State Agency Coordination Team, which is comprised of all state agencies providing any kind of services related to domestic violence and sexual violence. The State Interagency Coordinating Council for Infants and Toddlers, which includes Department of Economic Security(DES)/Arizona Early Intervention 43 Program (AzEIP), AHCCCS, Division of Developmental Disabilities (DDD), Arizona Schools for the Deaf and Blind, families of young children and ADHS, meets regularly to advise and assist with the development and implementation of the statewide system of early intervention services. Maternal and child health staff also participate in meetings of Governor's commissions or councils, such as Council on Spinal and Head Injuries, the Arizona Traumatic Brain Injury Project, Council on Aging, and the Commission to Prevent Violence Against Women. /2015/ The ADHS has been working closely with the Arizona Criminal Justice Commission and other state agencies to pilot the Arizona Rx Drug Reduction Initiative. This includes adoption of Emergency Department 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. Additionally, draft voluntary, consensus guidelines that promote best practices for prescribing opioids for acute and chronic pain are being vetted in the community. //2015// /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// /2015/ Seven Home Visiting Coordinators (HVC) have been hired at county health departments to increase home visiting capacity in their communities, build local coalitions, and improve coordination and referrals with other community resources and supports. The Home Visiting Coordinators provide support to 9 counties and 43 Community Health Analysis Areas throughout the state. Arizona's MIECHV supports an active website, www.strongfamiliesaz.com which includes an online referral system for parents and a portal for professionals. Arizona's MIECHV supports locally targeted marketing campaigns to increase awareness of home visiting, inform parents where to find home visiting and enhance its positive perception. This includes shopping cart ads in 117 stores, success stories played in 140 physicians' offices and on 13 radio stations and the Strong Families AZ Facebook page which has almost 900 followers. The Interagency Leadership Team (IALT) includes all state agencies that fund or provide home visiting services and meets 13 times a year to make decisions regarding the MIECHV grant and to prioritize tasks regarding the home visiting system. The Strong Families Arizona Home Visiting Alliance, representing 93 members from 63 different organizations convenes once a quarter. Members participate in workgroups and during this year addressed the feasibility of a Coordinated Data Management System, created a tool kit for local Coordinated Referral system, coordinated the tri-level evaluation through the Evaluation Alignment Team, investigated and acted on Continuous Quality Improvement measures, and guided professional development activities.//2015// /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// 44 /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// /2015/ The Teen Pregnancy Prevention Program, collaborating with the Arizona Department of Economic Security (DES) Teen Pregnancy Prevention Task Force, has developed a Tool Kit for foster case managers that will serve as a guide for initiating and conducting discussions with youth 12 years and older on sensitive subjects related to physical development and sexual health. The case manager will then give the youth the toolkit for future reference. The Youth Tool Kit provides education on information around sexual/reproductive health, healthy relationships, puberty, risks associated with sex, etc., as well as community resources. The toolkit will also be available to group home staff and foster care parents who want to use it as a tool for having similar discussions with their youth. In addition, communication resources will be compiled for foster care parents that provide information on how to discuss teen pregnancy prevention with y0uth in their care. //2015// BWCH and OCSHCN collaborate with the Division of Behavioral Health Services (BHS) on the Arizona Children's Executive Committee which includes partners from Department of Economic Security, Department of Juvenile Corrections, Department of Education and the Administration of the Courts to ensure that behavioral health services are being provided to children and families. Staff collaborates on the Building Partnerships for Quality Care contract that funds two community organizations to involve family and youth partners in agency decision-making. ADHS works particularly closely with the state's Medicaid agency, AHCCCS, participating in many AHCCCS Health Plan meetings. Health Start, Community Nursing, and Hotline staff all facilitate families enrollment in both Medicaid and SCHIP programs. OCSHCN staff assists families in understanding eligibility requirements and help with application processes for various programs that serve CSHCN. Baby Arizona is a program to help pregnant women begin prenatal care while waiting for AHCCCS eligibility. Baby Arizona providers help women apply for AHCCCS and pre-enroll her into a health plan, and women begin prenatal care at no cost while their eligibility is processed. If a woman is determined to be ineligible for AHCCCS, she and her Baby Arizona doctor work out a reasonable payment plan and continue care. The Bureau of Women's & Children operates the Baby Arizona hotline and assists callers in how to apply for AHCCCS and helps them locate a prenatal care provider. /2015/ While Baby Arizona was formally ended with the advent of Medicaid expansion and the Marketplace, AHCCCS reached out to participating Baby Arizona physicians to gather a list of those willing to informally agree to continue to see pregnant women while Medicaid status is verified. If a woman is not eligible for AHCCCS, the physicians will continue to see them and will agree to a payment plan. AHCCCS has shared this list with the Title V MCH Hot Line. The Administrator of Clinical Quality Management at the state Medicaid agency has participated with ADHS and other partners on the AMCHP and National Governors Association Learning Collaboratives and now on the CoIIN initiative. //2015// 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 45 Nurses, and AzEIP to identify resources to ensure that children and youth receive Early and Periodic Diagnosis and Treatment (EPSDT) services for children and youth. The Arizona Community of Practice on Transition (AzCoPT) offers additional opportunities for cooperation among Department of Education (ADE), Vocational Rehabilitation, Southwest Institute for Families and Children with Special Health Care Needs, DDD, BHS, and young adults. This partnership of stakeholders promotes collaboration and coordination for transition planning, professional development and youth involvement. At the annual ADE Transition conference, partners will co-present "Partnering for Transition," describing the role of each agency in coordinating transition for young adults with disabilities and special health care needs. This presentation will be available online to Vocational Rehabilitation, Behavioral Health, and DDD case managers, as well as special educators, reinforcing collaboration across agencies, inclusive of health care, for successful transition. ADHS also works with DES Family Assistance Administration which provides families with nutrition assistance, cash assistance, emergency food assistance and applications for AHCCCS health insurance. The agencies strategize ways to include the nutritional needs of children with special health care needs in FAA policy and programs allowing for better planning and access to resources to meet the needs of all children and families who require nutrition assistance. ADHS staff participates in a monthly Genetics Services Advisory Committee with the Arizona Schools for the Deaf and Blind, EAR Foundation of Arizona, and pediatric genetics services providers to discuss emerging practice around newborn screening, diagnosis and provision of care to children with heritable disorders. Additionally, ADHS staff takes part in Mountain States Genetics Regional Collaborative Center's (MSRGCC) annual meeting which includes professionals and consumers from Texas, New Mexico, Arizona, Utah, Colorado, Wyoming, Nevada and Montana. Staff participate in the Arizona Telemedicine Council to explore innovative ways to expand the reach of heath care providers to underserved areas of the state. Within ADHS, there is substantial collaboration among program areas. Children with Special Health Care Needs and Women's and Children's Health work in tandem to assess needs of the maternal and child health population, provide a Children's Information Center hotline, and provide community nursing visits to infants through the High Risk Perinatal Program. Both offices work closely with Newborn Screening, participating in the monthly Newborn Screening Partners Meetings that include the Early Hearing Detection Coordinator, Arizona Chapter of the Academy of Pediatrics representative for hearing and pediatric sub-specialists in genetics, endocrinology and pulmonology. BWCH and OCSHCN collaborate with Bureau of Nutrition and Physical 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// /2015/ /2015/OCSHCN administers the metabolic formula program that provides children and adults with certain metabolic conditions with no source of insurance coverage needed 46 metabolic formula through a contract with the UnitedHealthcare Community Plan Pharmacist. //2015// //2015// /2015/ The Bureau of Nutrition and Physical Activity joined with the Arizona Immunization Partnership for Immunization (TAPI) to provide a lunchtime Immunization Webinar developed specifically for WIC staff. //2015// Methods for partnering with tribal and Native American organizations are also in place. ADHS leadership has quarterly meetings with the Indian Health Services directors located in Arizona. Maternal and child health program have agreements in place with Indian Health Services for sharing of injury data as well as delivery of oral health services. ADHS also has in place a tribal consultation policy that was utilized as part of the public input process for this year's Title V needs assessment and application when a special session was held specific to the Native American population. The ADHS teen pregnancy prevention program has an intergovernmental agreement in place with the Navajo Nation and a contract with the Inter-Tribal Council of Arizona. ADHS staff participates in planning the annual Native American Disability Summit. ADHS maternal and child health programs work with primary care providers in multiple ways. Programs make referrals to primary care providers, and assist individuals and families in accessing Medicaid and/or private providers that serve uninsured or underinsured individuals. The MCH program works closely with the Bureau of Health Systems Development, which serves as the ADHS primary care office. Programs share data about medically underserved areas and MCH programs work with HSD when a provider shortage issue arises. The programs also collaborate on workforce development programs. The state MCH role with primary care providers also includes sharing information on new public resources available, such as screening tools or patient education materials. The state MCH program develops materials specifically for use among primary care providers, such as the new preconception health Every Woman Arizona materials and materials on enhancing care for children with special health care needs. The ADHS MCH program has partnerships with community health centers as well as schoolbased health care. Community health centers are often partners in implementation of state administered and or federally funded maternal and child programs. For example, community health centers have been recipients of MCH Community Health Grants for reducing obesity, and currently are partners in implementation of Project Connect integrating domestic violence screening into primary care and family planning sites. With the implementation of health care reform, the state MCH program will look for opportunities to assist primary care providers in implementation of new preventive health requirements, as well as to inform the public and partners about impacts on access to primary care services. /2012/ Additional partnering with tribal and Native American organizations occurred in 2011. The Office of Oral Health assisted with development and implementation of an Arizona Native American Oral Health Summit in April 2011. The Office for Children with Special Health Care Needs will join the planning process for the next oral health summit. BWCH developed a partnership with the White Mountain Apache Tribe to implement a promising practice as part of the federal home visiting program. OCSHCN engaged the Salt River Pima-Maricopa Community around youth leadership for youth with special health care needs. //2012// /2012/ The Association of Community Health Centers is an active participate in the BWCH Preconception Health Taskforce and the Women's & Girls' Health Conference Planning Committee. BWCH also engaged city housing and employment agencies in planning of the 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 47 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/ OCSHCN is an active participant in the 9th Annual American Indian Disability Summit 2013 Planning Committee. //2013// /2013/The Office of Oral Health participates on the Governor's Advisory Council on Aging -- Oral Health subcommittee. The goal of the subcommittee is to improve the oral health of older/vulnerable adults through developing strategies for increasing partnerships and sustainability of programs and resources. OOH has posted resources developed in part by the oral health subcommittee at the following link: http://www.azdhs.gov/cfhs/ooh/adults-seniors.htm. //2013// /2015/ The Office of Oral Health will be participating in a steering committee of the Arizona Board of Dental Examiners to examine the oral health statute (Title 32, Article 4 32-1289) affecting the Scope of Practice for dental hygienists employed by public health agencies. Currently, a dental hygienist employed by a public health agency before an examination by a dentist is limited to providing oral health screenings and topical fluoride. The steering committee will be looking at the feasibility of adding other prevention services to the scope of practice to include dental sealants. Dental hygienists are the primary providers in the Arizona school-based dental sealant program. How many kids are served by the dental sealant program and how cost effective it is depends in part on whether the program must locate dentists who are willing to examine children before sealants can be placed. By expanding the scope of practice to include dental sealants for public health dental hygienists without a prior exam by a dentist there is the potential to increase the prevalence of dental sealants for children who live in rural and underserved communities. //2015// /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// /2015/ Efforts around improving birth outcomes continue. In January, ADHS held a summit with 160 partners to begin the process of developing a state plan to improve birth outcomes. The purpose of this summit was to gather stakeholders and decision makers to identify key strategic areas for improving birth outcomes; to identify how we could build on and support current efforts taking place around Arizona and replicate successful strategies; to develop a framework for ongoing collaboration; to establish reliable and accurate measures to track outcomes and integrate elimination of health disparities into all aspects of the state plan. Four goals were identified: Improve the health status of all women and girls; Promote safe, stable families; Reduce premature births and Reduce health disparities. These efforts will continue as Arizona participates with CoIIN.//2015// F. Health Systems Capacity Indicators 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 48 Annual Objective and Performance Data 2009 2010 2011 2012 2013 Annual Indicator 82.1 100.0 100.0 100.0 78.9 Numerator 320 21 11 10 228 Denominator 390 21 11 10 289 Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Final Final Notes - 2013 KidsCare II became available starting May 1, 2012 through December 31, 2013 for a limited number of eligible children. Starting January 1, 2014 families with an income between 100-133 FPL were transitioned to Medicaid. Family's with an income of more than 133% FPL were sent notice of their need to apply for coverage under the Federally Facilitated Marketplace. For families who needed to use the marketplace, KidsCare II was extended and expired on January 31, 2014 to provide time to transition. Regular KidsCare remains in effect with frozen enrollment. Enrollment for KidsCare II was frozen in September 2012 and reopened in November 2012. Beginning May 6, 2013, AHCCCS increased the income limit to 200% FPL. The percent of SCHIP enrollees whose age is less than one year during the reporting year who received at least one periodic screen in 2013 is similar to that from 2009, prior to KidsCare being frozen. 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. 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. Narrative: Health System Capacity Indicator #03 looks at the percent of State Children's Health Insurance Program (SCHIP) enrollees whose age is less than one year during the reporting year who received at least one periodic screen. For reporting year 2013, 78.9 percent of SCHIP enrollees whose age is less than one received at least one periodic screen, a decrease from previous years but more worrisome are the changes going forward. While the number of children served increased as children were able to enroll in Kids Care II during this reporting period, this will change going forward as Kids Care II enrollent has been eliminated. BWCH will monitor this closely. 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. The numbers of children decreased from 2009 to 2010 and then 2011 dramatically. In April 2012, a temporary extension of SCHIP was funded through a cost sharing agreement between three local hospitals and the 49 federal government. This arrangement ended however January 1, 2014 with the beginning of the Affordable Care Act. Sixty percent of the children enrolled at that time were transitioned to Medicaid as the result of the Medicaid Expansion and the rest are being directed to the ACA Marketplace. Children enrolled on January 1, 2014 can remain in KidsCare until they turn 19 as long as their application stays current and they continue to qualify. BWCH will closely monitor the enrollment of children into health insurance. The home visiting programs give us a unique opportunity to connect on an individual level with families. One of the important roles of early childhood home visitors is to help families to understand the importance of a medical home and to assist families to understand their options. We will be monitoring enrollment into both Medicaid and the marketplace. Health Systems Capacity Indicator 07B: The percent of EPSDT eligible children aged 6 through 9 years who have received any dental services during the year. Health Systems Capacity Indicators Forms for HSCI 07B - Multi-Year Data Annual Objective and Performance Data 2009 2010 2011 Annual Indicator 62.9 66.5 65.3 Numerator 96768 109672 109808 Denominator 153910 164910 168082 Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? 2012 62.4 107150 171713 2013 62.5 108866 174102 Final Final Narrative: Health System Capacity Indicator #07B looks at the percent of EPSDT eligible children aged 6 through 9 years who have received any dental services during the year. Arizona's indicator has remained fairly consistent the last two reporting year, 2012 and 2013 at 62.4 and 62.5 percent respectively. The state Medicaid agency, AHCCCS, has formed a Quality Initiative Collaborative working with the contracted dental plans to address improvement in all EPSTD dental indicators. 50 IV. Priorities, Performance and Program Activities A. Background and Overview Priorities Arizona's selection of state Title V priorities for 2011-2016 was grounded in review of quantitative and qualitative data, as well as careful consideration of capacity and public input. Input was gathered through multiple means -- surveys, focus groups, and special public sessions. Process for Priority-Setting -- General Maternal & Child Health In selecting the general maternal and child health priorities, the Bureau of Women's & Children's Health conducted a priority-setting session on May 7 that involved multiple stakeholders and partners. Participants in the session not only included the BWCH leadership, epidemiologists and program managers, and Children with Special Health Care Needs, but also included key partners from county health departments, community health centers, March of Dimes, county hospital system, and Academy of Pediatrics; and leadership from other parts of ADHS (Behavioral Health Services, Local Health, Tobacco & Chronic Disease, Health Systems Development, Nutrition & Physical Activity, Immunizations, and Epidemiology & Disease Control.) In order to help prioritize the group considered the following decision criteria: 1) the need is supported by the data (disparity, magnitude, severity, trend); 2) interventions are available and effective/action will have an impact on the target population (within five years); 3) the issue is feasible to address/ADHS has the ability to address it; and 4) the issue is complementary (action on this issue can be leveraged by or leverage action on other issues). Participants reviewed the list of current MCH priorities, which are: 1) teen pregnancy and access to reproductive health services; 2) obesity/overweight among women and children; 3) preventable infant mortality; 4) injuries, unintentional and intentional; 5) prenatal care among the underserved; 6) oral health; and 7) mental health (integration with general health care). To this list, they added: 8) preconception health/internatal; 9) substance abuse (alcohol and other drugs); 10) preventive health for children; 11) post-partum depression; and 12) breastfeeding. Participants then utilized the scoring criteria and rated the issues ‘low,' ‘medium,' and ‘high'. The issues that ranked the highest were: i) preventive health for children; ii)obesity/overweight among children; iii) preconception health/internatal, and injuries; and iv)unintentional and intentional injuries The group also discussed the different ways in which some of the issues could be combined with one another, but final determination was left to Bureau of Women's & Children's Health with the understanding that all issues would be addressed even if not specifically identified as a priority. For example, there are national performance measures related to breastfeeding and prenatal care, so those issues are certain of being addressed in the annual application. The Bureau also considered any national or federal priorities that may support and contribute to the state's capacity to address the issues. The following priorities will be continued: teen pregnancy, oral health, injury prevention, and obesity/overweight. The previous priority of integration with mental health was broadened to encompass behavioral health to include substance abuse as well as post-partum depression and mental health. The two new priorities are preventive health for children and preconception health. Two previous priority areas will be addressed as part of preconception health: access to reproductive health services will be a primary strategy under preconception health, and preventable infant mortality is expected to be an outcome of improved preconception health. PROCESS FOR PRIORITY-SETTING -- CHILDREN WITH SPECIAL HEALTH CARE NEEDS 51 The OCSHCN needs assessment team compiled suggested priorities from community partners into an evaluation tool. The needs assessment team plus key staff and community partners convened a meeting in which each of the suggested priorities was rated. A list of priorities was compiled and evaluated, with numerical ratings of 0 through 3 for each dimension: numbers affected, severity or importance, known interventions, resources to implement intervention, interest of partners, likelihood of impact, and annually measurable. Potential topics included early identification of special needs, hearing, access to follow up services, health insurance that adequately covers special health care needs, mental health services, therapies, childcare, inclusion, fragmentation of the system of care for CSHCN, the need for care coordination, genetics testing, and transition. After all topics were rated, scores were summarized, and the topics with the highest scores across all areas evaluated were hearing, inclusion, and transition. Three priorities were selected as the top priorities for CSHCN, which are newly defined priorities since the last needs assessment. In general, OCSHCN's community partners are more likely to perform enabling services around each of these priorities, while OCSHCN's role for each can best be described as infrastructure building. OCSHCN efforts for each priority are centered around analysis, policy and guideline development, and developing resources and training. B. State Priorities The following is a description of State Title V priorities for 2011 -- 2016 for Arizona's maternal and child health population, including children with special health care needs. Priorities not presented in any particular order; each is of equal importance. /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 population-based strategy through education and youth development services, with infrastructure support to local providers through provider training and technical assistance. Arizona will measure and report on progress through national performance measure #8, which measures the rate of birth for teens ages 15 -- 17 years. /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 52 as a priority. Public support, as well as national and state momentum to address this priority has clearly been increasing. Arizona is working on policy initiatives to address obesity through federal funding as well as state actions such as the Empower Program. There is little funding to address strategies to improve the percentage of children and families at a healthy weight, especially on a local level. Title V funds can be used to help support critical infrastructure and population-based strategies to implement this priority. Progress will be measured through the national priority measure on percentage of children, ages 2 to 5 years, receiving WIC services with a Body Mass Index (BMI) at or above the 85th percentile, and the state performance measure on the percent of high school students who are overweight or obese. /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// /2015/ The ADHS division of Public Health Prevention Services collaborated across bureaus to introduce the innovative Health in Arizona Policies Initiative (HAPI). 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 and community based organizations to specifically create opportunities for CYSHCN incorporate wellness into everyday life. Building on the Empower program for early care and education centers, ADHS has initiated Empower Schools and Empower Home Visiting. The goal of Empower Schools is to identify and implement opportunities for school health improvements that may positively impact the long term health of students. During the next four years selected LEAs, with assistance from stakeholders, will incorporate each of ten identified standards into their local wellness policies, implement these policies and then continuously measure the health impact that they are having. Empower Home Visiting highlights best practices and strategies to support healthy eating and active living for obesity prevention in high-risk populations with a focus on both behavioral and environmental approaches. Through Empower Home Visiting, home visitors are equipped with the tools and resources to implement these strategies with the families they serve. //2015// PRIORITY 3: IMPROVE THE HEALTH OF WOMEN PRIOR TO PREGNANCY. Since 2006 when the Centers for Disease Control issued its recommendations on how to improve the health of women prior to pregnancy -- known as preconception health -- there has been growing attention both nationally and in Arizona about the critical nature of preconception health. Participants of public input sessions identified this as a priority area, and stakeholders recommended preconception health be added as a state priority area during the May 7 prioritysetting session. Preconception health comprehensively addresses multiple areas of women's health, including reproductive health, nutrition, physical activity, tobacco use, substance abuse and mental health. Because it is so comprehensive, Arizona has great potential and opportunities to improve preconception health. However, the state lacks resources dedicated specifically to preconception health. ADHS is leading development of a statewide preconception health action plan, which will provide direction on future strategies. Strategies are likely to be population-based and infrastructure-building. Progress on preconception health will be measured through multiple performance measures, including the national performance measure on smoking during pregnancy, and the state performance measure on percent of high school students who are 53 overweight or obese. In addition, a new state performance measure has been developed to help measure the important strategy of birth spacing; Arizona will measure the percent of women having a subsequent pregnancy during the inter-pregnancy interval of 18-59 months. Lastly, health status indicators related to low birth weights will also serve as indicators of preconception health. /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. Injuries are the leading causes of death for Arizonans ages 1 -- 44. Homicides and suicides remain a significant issue for teens and young adults, and dating violence among Arizona high school students increased significantly between 2003 and 2007. Arizona has strong infrastructure at the state level to implement injury prevention through the state's injury prevention program, domestic violence programs in ADHS and other state agencies, and sexual violence prevention programs. Capacity at the local level, especially for unintentional injury, could be strengthened. Capacity for violence prevention is weakened by lack of funding. Strategies to prevent intentional and unintentional injuries are population-based and infrastructure-building, and all maternal and child health population groups will be addressed. Multiple performance measures will be used to assess progress on this priority area, including the national measures of the rate of deaths of children ages 14 years and younger caused by motor vehicle crashes and the rate of suicide deaths among youths aged 15-19. Arizona will continue to use state measure on emergency department visits for unintentional injuries among children 1-14. In order to monitor progress and report on violence prevention efforts to reduce unintentional injuries, Arizona will be using a new state measure on dating violence among high school students. /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 newborns who received timely follow-up by the newborn screening program; percent of 19 to 35 months olds who received full schedule of age appropriate immunizations; percent of third grade children who received protective sealants on at least one permanent tooth; percent of children without health insurance; and percent of very lowbirth weight infants delivered at facilities for high-risk deliveries and neonates. The state 54 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. 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 55 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 12-hour 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 services, they have not been able to develop their analytic capabilities to support strategic planning. OCSHCN will support this aspect of their strategies, as well as extend their reach through making the e-Learning platform available for training, and through the use of the telemedicine system. Training and technical assistance will be provided through community health centers, physician offices, and Early Head Start. OCSHCN will also work with First Things First, who will assist with ensuring that children receive needed second screenings and audiology services. OCSHCN will monitor progress on this priority by creating a state performance measure, which will track the percent of newborns who fail their initial hearing screening who receive appropriate follow up services. The baseline for this measure in 2008 is 72%. The fiveyear goal for this measure is to reach 90% by 2013. /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 adolescence into adulthood. The Arizona's Community of Practice on Transition (AzCoPT), actively 56 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 preconception health, injury prevention, healthy weight, oral health, and children with special health care needs. Title V also helps to fund the children's preventive health services of immunization outreach and education, newborn hearing screening follow-up, High-Risk Perinatal Community Nursing, and Children's Information Center. BWCH Strategic Plan is attached.//2012// 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 2009 2010 2011 2012 2013 100 100 100 100 100 100.0 115 100.0 113 100.0 102 100.0 131 100.0 102 57 Denominator Data Source 115 AZ Office of Newborn Screening 113 AZ Office of Newborn Screening 102 AZ Office of Newborn Screening 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 2014 100 2015 100 2016 100 131 AZ Office of Newborn Screening 102 AZ Office of Newborn Screening Final Final 2017 100 2018 100 a. Last Year's Accomplishments In 2013, approximately 95% of babies born in the state had a documented first bloodspot screen collected and approximately 89% had a documented second screen. Since the number of hearing screenings provided on newborns was 98.6% for this same period, targeted efforts were ongoing to address this disparity. One successful strategy has been to continue outreach efforts by pairing bloodspot and hearing messages to hospitals, community health centers and providers' offices in collaboration with the EAR Foundation of Arizona (EFAz). Strategies included organizing regional site visits to communities in the state that had a low percentage of second screens collected, less than ideal samples collected, or a high number of unsatisfactory samples submitted for testing. Printed resources and site-specific quality indicator data were provided. Hospitals, midwives, clinics, and physicians serving the local community were asked to implement best practice recommendations including: providing educational materials at the bedside and subsequent wellbaby visits about the importance of newborn screening, ensuring two screens were collected for every newborn within 30 days, completing hearing screenings within 30 days, documented in the chart and on the immunization record, and timely sharing of results with families. Additional training was provided on collection technique, timing, handling and shipping practices to minimize treatment delays for babies affected with a newborn screening condition. Continuing to outreach to a wider audience through social media outlets such as Twitter and Facebook remained a high priority. Additionally, the creation of a targeted newborn screening listserv utilizing Constant Contact™ was established in 2012 and grew to greater than 300 members last year. In partnership with The AZ Academy of Pediatrics (AzAAP), information related to process improvements and testing changes for pediatricians was disseminated through their newsletter and listserv. In an effort to increase testing specificity, reduce false positives and identify interfering agents, in January 2013 a new laboratory pilot project adding secondary markers and ratios to five disorders by tandem mass spectrometry was implemented. Methods and data were validated and in early May the process was implemented. Data analysis, process refinements, and cutoff evaluation continue in 2014. The primary project goals are to minimize the laboratory workload, raise physician confidence as many fewer abnormal results are unnecessarily reported, and most importantly diminish parent anxiety with fewer false positive cases. Ongoing partnerships with State and National agencies, in addition to the Mountain State 58 Genetics Regional Collaborative (MSGRC) and the National Newborn Screening & Genetic Resource Center (NNCGRC), continued to provide innovative means to identify national trends and standards. The Newborn Screening Technical assistance and Evaluation Program (NewSTEPS) launched in 2013 as the culmination of several years' of work on standardizing newborn screening programs & data. As regular attendees in technical training webinars and conferences and members of quality improvement listservs with the Association of Public Health Laboratories (APHL) and Clinical and Laboratory Standards Institute (CLSI), programmatic improvement guidance is ongoing. Collaboration with state non-profits such as Arizona Perinatal Trust (APT) provides a means through which hospital-specific quality indicators are shared and outcomes discussed, leading to sustained improvements. Partnerships with AzAAP and the Arizona Hospital and Healthcare Association (AzHHA) raise awareness of newborn screening as a successful public health initiative. Pediatric subspecialists in Endocrinology, Pulmonology, Hematology, Biochemical Genetics and Nutrition, and Hearing are under contract with the ONBS to provide technical expertise, including the review and approval of all confirmed case files, evaluation of diagnostic reports, and establishment of care plans for long term follow-up after diagnosis. Additionally, for all high abnormal screens, the sub-specialists receive a fax notification, including information about the baby's primary care provider, whom they will contact to establish a care plan; parents may be contacted as well to minimize delays to diagnosis 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. All home visitors educated families about the importance of a second newborn screen. 4. 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. 5. OCSHCN supports training and technical assistance to medical providers and early education programs. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X b. Current Activities Recent national coverage of bloodspot specimen transit time has resulted in a statewide push to decrease the amount of time it takes bloodspot samples to reach the Arizona State Laboratory. A Transit Time Taskforce within ADHS was created in January 2014 to evaluate data and determine the scope of the problem. Baseline data for 2013 showed that only 67% of samples were being received within 3 days. A training curriculum was developed, a website established, and partnerships enhanced with hospitals to ensure their access to tools and resources related to shipping and handling. A new 59 local courier contract was established in April to augment the existing courier service delivery schedule; early data validated the strategies as effective. As of May 1, 89% of all first screen samples were being received within 3 days, including weekends and holidays. The ADHS director established a goal of 95% of first screen samples received within 3 days by July 1st. Top performing hospitals are recognized monthly on the website and receive a certificate of appreciation. The achievements are posted through Twitter posts and on the ADHS Facebook wall. Techniques for training include webinars and site visits. Site visits continue to hospitals and clinics where opportunities for improvement exist. The contracted metabolic subspecialists recently hired a Doctor of Nursing Practice to assist in increasing nursing staff awareness of the criticality of metabolic disorders. c. Plan for the Coming Year The ONBS is planning to establish a quality indicator scorecard for facilities submitting bloodspot cards to improve the quality of samples received and further minimize delays in the follow-up of newborns that screen positive. The Newborn Screening Advisory Committee will meet to update the program protocols in the coming year ensuring that positive changes in program practice are cemented into program policy. Based on recommendations from the NBS Partners in 2014, as well as other stakeholders, ONBS is considering expanding Partners' group to include more community stakeholders. During the 2014 legislative session, the Critical Congenital Heart Defects (CCHD) screen was added to the core NBS panel with screening scheduled to begin in 2015 after rules are developed. Statute also called for the creation of an advisory panel of community partners and stakeholders to consider adding severe combined immunodeficiency disorder (SCID) and Krabbe disease. If the group agrees to add these two disorders, it is anticipated that they will be added to the core panel of disorders screened for in 2015. 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 will continue to prepare a report on the hospital's NBS results and we will continue to review these data 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 evaluating parent participation and continuing to expand 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. The Transit Time Project will continue where the results of the time of transport of NBS specimens to the state lab will be published on the ADHS web site by hospital and by level of care; highly performing hospitals will be highlighted and information and updates will continue to be posted. 60 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 Congenital Adrenal Hyperplasia Cystic Fibrosis Homocystinuria Maple Syrup Urine Disease betaketothiolase deficiency Tyrosinemia Type I Very LongChain Acyl-CoA Dehydrogenase Deficiency Argininosuccinic Acidemia Citrullinemia Isovaleric Acidemia Methylmalonic 86586 2013 (A) Receiving at least one Screen (1) (B) No. of Presumptive Positive Screens (C) No. Confirmed Cases (2) No. 84917 % 98.1 No. 103 No. 5 (D) Needing Treatment that Received Treatment (3) No. % 5 100.0 84917 98.1 1048 55 55 100.0 84917 98.1 32 1 1 100.0 84917 98.1 15 10 10 100.0 84917 98.1 175 1 1 100.0 84917 98.1 176 2 2 100.0 84917 84917 84917 98.1 98.1 98.1 253 702 291 17 0 0 17 0 0 100.0 84917 98.1 0 0 0 84917 98.1 90 0 0 84917 98.1 6 3 3 84917 98.1 0 0 0 84917 84917 98.1 98.1 3 197 1 3 1 3 84917 98.1 138 0 0 100.0 100.0 100.0 61 Acidemia Propionic Acidemia Carnitine Uptake Defect 3MethylcrotonylCoA Carboxylase Deficiency Multiple Carboxylase Deficiency Trifunctional Protein Deficiency Glutaric Acidemia Type I Medium-Chain Acyl-CoA Dehydrogenase Deficiency 3-Hydroxy 3Methyl Glutaric Aciduria Hydroxy AcylCoA Dyhydrogenase Deficiency Pap test Hearing Pregnancy Test 84917 98.1 138 0 0 84917 98.1 4 0 0 84917 98.1 3 0 0 84917 98.1 138 0 0 84917 98.1 0 0 0 84917 98.1 101 0 0 84917 98.1 14 6 6 84917 98.1 3 0 0 84917 98.1 0 0 0 0 13906 510 0 1425 0 0 1425 0 2106 623618 2881 100.0 100.0 Performance Measure 02: The percent of children with special health care needs age 0 to 18 years whose families partner in decision making at all levels and are satisfied with the services they receive. (CSHCN survey) Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2009 55 53.6 2010 54 53.6 2011 57.4 66.2 SLAITS 2012 57.4 66.2 153623 231913 SLAITS 2013 67 66.2 153623 231913 SLAITS SLAITS SLAITS 2014 67 2015 67 2016 67 Final 2017 67 Final 2018 70 62 Notes - 2013 For 2011-2015, indicator data comes 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 - 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 survey design flaws, respondent classification and reporting errors, and data processing mistakes. a. Last Year's Accomplishments OCSHCN used its Building Partnerships for Quality Care contract with Raising Special Kids (RSK) to support leadership development through recruitment, training and compensation of families of children and youth with special health care needs (CYSHCN) and consumers. Forty one Family and Youth Advisors participated in stakeholder groups; program and policy development; strategic planning and performance improvement committees; emergency preparedness planning; educational training; curriculum development and review; program evaluation; served as co-trainers at conferences/workshops and provided leadership development/mentoring to families and YSHCN assuming leadership roles within ADHS or other agencies. OCSHCN collaborated with United HealthCare-CRS in reviewing notices, training and documents and disseminating information on the new CRS health contract, AZ's first integrated, physical and behavioral, pediatric health program. OCSHCN also supported two consumers to participate in AZ's Medicaid Infrastructure Grant, Employment and Disability Partnership to develop or enhance existing infrastructure supporting individuals with disabilities to secure/sustain competitive employment. 63 OCSHCN hosted a Sickle Cell Disease and Trait (SCD/T) Stakeholders meeting through an independent facilitator, bringing together 39 stakeholders including 8 individuals and family members, 9 professionals as well as representatives from agencies and organizations, related to SCD/T. Stakeholders provided a "snapshot" of how AZ currently meets the needs of families and individuals, identified areas of improvement and unmet need. Three Family Advisors participated on respite registry, voucher and volunteer respite committees to help shape a system of respite for families whose children do not meet respite eligibility requirements within the system of care. Two family members participated in the State Family Support Alliance recognizing the critical need to support parents including parents of CYSHCN in their key role to develop every aspect of their child's growth and learning. ADHS' Maternal Infant Early Childhood Home Visiting (MIECHV) program partnered with OCSHCN to develop a plan to identify, recruit, train and reimburse families to participate in county level coalitions. Family Advisor Helen Cartwright represented AZ as a family delegate at the 2013 AMCHP Conference and debriefed with OCSHCN staff upon her return. OCSHCN partnered with Mountain States Regional Genetic Collaborative (MSGRC) and identified a Youth Advisor to represent MSGRC at the 2013 American College of Genetics and Genomics Meeting and provide a report. Catholic Social Services, Refugee Relocation Program partnered with OCSHCN who identified and supported a Family Advisor to facilitate several meetings that provided information, resources and linkages within the system of care, for families who speak Arabic. In partnership with AZ's Birth Defects Monitoring Program, OCSHCN identified and supported two Family Advisors to provide insight and personal perspectives on receiving a difficult diagnosis as part of the "Delivering a Diagnosis" presentation at the Navajo Maternal Child Forum. Two Family Advisors, from the AZ Early Intervention Program (AzEIP), Interagency Coordinating Council on Infants and Toddlers, were supported by OCSHCN in developing a presentation for families describing the state IDEA, Part C program's new team-based service model. They also participated in development of an FAQ and brochure, "What Team Based Early Intervention Means to You." One Family and two Youth Advisors participated in development of AZ's respite registry web pages on the Rewarding Work platform; they also developed transition pages, behavioral health resources and provided input for AZ's Medical Home Care Coordination Manual annual update. OCSHCN developed a new SSI brochure and updated SSI letter, with input from three Family Advisors. Three Family Advisors reviewed and provided input during development of an online evaluation tool for the Transition Resource. One Youth Advisor was identified to participate in the OCSHCN website revision. OCSHCN partnered with RSK to support three Family Advisors to present emergency preparedness content related to CSHCN during the Office of Emergency Preparedness, Access and Functional Needs Seminar and Statewide Emergency Exercise with state, county, tribal and local government planners. 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. Pyramid Level of Service DHC ES PBS IB X X X 64 4. Family and youth leadership curriculum and training supports the development of family, consumer and youth involvement in decision-making. 5. OCSHCN sponsors resident and physician training so they can learn how to make decisions with families as partners. 6. 7. 8. 9. 10. X X b. Current Activities OCSHCN works closely with the UHC-CRS Ombudsman to support family/youth involvement in review of member notices, resource materials, training and development of a member advisory council. OCSHCN collects family input, by numerous online surveys on family/youth engagement, Medical Home and Transition resources, and hearing screening and referral through the EAR Foundation contract, which helps inform future work. OCSHCN supports family members in county level home visiting coalitions, providing technical assistance on policy, webpage, documents, outreach materials and family experience related to home visiting; and informing training development. OCSHCN collaborates with AzEIP, to identify and support a family member to co-facilitate "Hospital to Home: Caring for Medically Fragile Children at Home" training for Community Health Nurses at the 2014 High Risk Perinatal Program Conference. One Youth Advisor participates in OCSHCN's website revision, ensuring responsiveness to transition aged youth, accessible by individuals with disabilities and conducive to mobile device navigation. OCSHCN collaborates with MSGRC to identify a genetics consumer to represent MSCRC at the 2014 Conference and provide a report to MSGRC Workgroups and leadership. OCSHCN supports Family Advisors in Maricopa County Department of Public Health, in the new CYSHCN Coalition Steering Subcommittee, currently defining group roles, expectations, and responsibilities of all members including professionals. c. Plan for the Coming Year OCSHCN will continue to work closely with the CRS Ombudsman to support family/youth/young adult involvement in review of member notices, resource materials, training and development of a member advisory council. OCSHCN will also continue to collect family input by numerous online surveys related to our NPM, the Medical Home and Transition resources, and hearing screening and referral through the EAR Foundation contract. OCSHCN will continue to support Family Advisors in Maricopa County Department of Public Health, CYSHCN Coalition, a 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 partner with Sickle Cell Disease/Trait (SCD/T) Stakeholders, to identify next steps in improving access to care and community-based supports, for individuals and families affected by SCD/T. OCSHCN will explore interest and opportunities for a father stakeholder focus group with a potential Family Advisor in Tucson. OCSHCN will continue to support family members to participate in the MIECHV Strong Families Home Visiting Coalition, local coalition meetings at the county level, providing technical 65 assistance on policy, webpage, documents and outreach materials, providing family experiences related to home visiting and informing training development. OCSHCN will continue to promote the integral role families play in the care of their CYSHCN as decision-makers, 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. In collaboration with Arizona Department of Education, families of CYSHCN, youth/young adults, early childhood educators, physical activity and recreational activity professionals; OCSHCN will explore development of state guidelines for inclusion of CYSHCN in physical activity opportunities across the life course. OCSHCN will seek to enhance this resource development with participation of some of the families and/or young adults involved in the Sickle Cell Disease Stakeholders group. OCSHCN will continue to promote decision-making at all levels through development of an Arizona specific resource using 2009/10 NS-CYSHCN data related to families as decisionmakers. Family Advisors will participate in development of health briefs resulting from the appraisal available research evidence, of health promotion curricula, that include nutrition and physical activity components, effect on important health outcomes, and relevance to CYSHCN. Performance Measure 03: The percent of children with special health care needs age 0 to 18 who receive coordinated, ongoing, comprehensive care within a medical home. (CSHCN Survey) Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2009 41 40.4 2010 40 40.4 2011 47.1 36.1 SLAITS 2012 47.1 36.1 81306 225115 SLAITS 2013 47.1 36.1 81306 225115 SLAITS SLAITS SLAITS 2014 47.1 2015 47.1 2016 47.1 Final 2017 47.1 Final 2018 47.1 Notes - 2013 For 2011-2015, indicator data comes 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 66 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 - 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. a. Last Year's Accomplishments As a result of the integration of primary, specialty and behavioral health services within the Medicaid Children's Rehabilitative Services (CRS) program; OCSHCN partnered with CRS in development and dissemination of information and resources related to benefit and service changes for providers, children, youth and young adults with special health care needs (CYSHCN) participating in the Medicaid CRS program. Through collaboration with community-based family support organizations, schools and agencies, OCSHCN provided Medical Home and Family Centered Care training and distribution of Medical Home Care Coordination Manual (MHCC) CDs to 1,399 physicians, providers, families, school nurses, home visitors, therapists 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 the manual was hosted on the OCSHCN website. The CD included a survey monkey soliciting ongoing input on improving the manual's content. A Family Advisor assisted in updating and revising the MHCC manual content to be reflective of whole health: physical and behavioral. OCSHCN collaborated with the Division of Behavioral Health Services' Family Involvement Subcommittee, focused on health care integration, and shared information on medical home, MHCC Manual and American Academy of Pediatrics' Emergency Information Card in English and 67 Spanish. OCSHCN provided copies of the AZ Transition Brochure: "Transition, What's Health Got To Do With It" to incorporate into the medical home workshop presented by the Medical Home Program Coordinator for the Sonoran University Center of Excellence in Developmental Disabilities at the 2nd Annual African American Disability Conference in Phoenix. OCSHCN's Health Care Organizer (HCO) was updated using Care Notebook resources with permission from the Seattle Children's Hospital as well as OCSHCN's Adolescent to Adult Transition training. The HCO training was updated to describe available health record applications for electronic devices. Staff partnered with Seattle Children's Hospital to use and translate their Care Notebook into Spanish, made plans to disseminate the related documents in English and Spanish on a OCSHCN website revision and provided the Spanish translation back to the Seattle Children's Hospital. In collaboration with Child and Family Services staff at Magellan, AZ's behavioral health contractor in Maricopa County, "AZ's CSHCN Medical Home Resource" and evaluation tool were developed. The MH Resource was disseminated, hard copy and online. It provided a snapshot of Arizona related to integrated Medical Home plus information and resources. OCSHCN facilitated inclusion of training on palliative care as a component of Medical Home, by Dr. Tressia Shaw, Phoenix Children's Hospital, for the High Risk Perinatal/Newborn Intensive Care Program annual meeting that included Community Health Nurses, care coordinators and home visitors. OCSHCN collaborated with Mountain States Genetics Resource Collaborative (MSGRC) Emergency Planning Workgroup to develop and pilot a survey to 40 primary care providers in Montana, to assess the level of support given families, around emergency planning by PCPs; of the 40 providers in the pilot none provided emergency planning information or resources to families. OCSHCN staff participated in Emergency Preparedness, Medical Home, Newborn Screening and Consumer Advocacy workgroups and the annual meeting with MSGRC, For the Newborn Screening Partners group, OCSHCN facilitated and professionally video-taped "Medical Home: A Primary Car Perspective" training by Drs. Berger and Golner, Phoenix Pediatrics. OCSHCN collaborated with Arizona's Children Association to provide "Advocacy" and "Medical Home" training for over 25 families monthly, who completed Foster/Adoptive/Kinship Care certification. Table 4a, National Performance Measures Summary Sheet Activities 1. OCSHCN’s information and referral helps families identify aspects of a medical home and communicate their needs, preferences and expectations to providers. 2. The medical home concept is integrated into all training, presentations, published materials, and resources. 3. Arizona’s Medical Home Care Coordination Manual is adapted yearly to reflect changing systems of care and distributed to other ADHS offices, state agencies, providers, community partners and family organizations. 4. OCSHCN offers technical assistance and training to health Pyramid Level of Service DHC ES PBS IB X X X X 68 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. 7. 8. 9. 10. X X b. Current Activities OCSHCN is supporting the Opening the Doors to People with Special Needs: Solutions to Prepare Your Practice" Conference, an ADHS-UHC collaboration intended to build capacity of 300 primary care physicians on innovative best practice approaches to planning, delivering and evaluating care for children and youth with special healthcare needs and disabilities and their families. The conference offers primary care physicians continuing medical education credit for participation in sessions related to integrated services, cultural competence, Americans with Disabilities Act accommodations, transition age young adults and telemedicine. Staff is working with MSGRC's Consumer Advocacy workgroup to provide condition specific consumer stories and a resource for families on using health insurance effectively for the MSGRC Facebook and webpage; with the Emergency Preparedness workgroup, developing and disseminating a family and provider Emergency Planning (EP) Arizona specific resource and disseminating the EP Provider Survey, developed and piloted in 2013. OCSHCN is partnering with the Creating a "Picture of a Life" for Transitioning Foster Youth with Developmental Disabilities to train facilitators and self-advocacy coaches on using the Heath Care Organizer (HCO) through a "train-the-trainer" model and incorporate the HCO curriculum into the basic Person-Centered Planning facilitator training. Data collection methods, to assess the benefits of using the HCO, are being explored. c. Plan for the Coming Year OCSHCN will explore supporting a future conference in collaboration with UHC intended to build capacity of primary care physicians, not attending the first Opening the Doors to People with Special Needs: Solutions to Prepare Your Practice" Conference, on innovative best practice approaches to planning, delivering and evaluating care for children and youth with special health care needs and disabilities and their families. The conference will again offer primary care physicians an opportunity for interaction, networking, and continuing medical education credits to discuss aspects of providing care; integrated services; cultural competence; Americans with Disabilities accommodations; transition age young adults and telemedicine. 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 explore the potential of working with an intern to assist OCSHCN in assessing the models of care coordination in Arizona for CYSHCN. OCSHCN will explore partnering with Mercy Maricopa Integrated Care in conjunction with Jewish Family & Children's Services to revisit development of a 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. Creating a "Picture of a Life" for Transitioning Foster Youth with DD (POL) is a collaborative 69 project between the Sonoran University Center for Excellence in Developmental Disabilities at the University of Arizona, the Arizona Division of Developmental Disabilities, the Arizona Developmental Disabilities Planning Council, and state independent living centers. The POL project serves to better prepare some of our most vulnerable youth to live as independently and successfully as adults through a person-centered planning process and selfadvocacy/determination workshops. OCSHCN will continue to partner with the POL project to train facilitators and self-advocacy coaches on creating Heath Care Organizers, as well as "trainthe-trainer" in order to incorporate the organizer curriculum into the basic Person-Centered Planning facilitator training. The POL program will assist in collecting data on the benefits of the utilization of the Organizers by POL youth participants. OCSHCN will explore the potential of convening a stakeholders' group to create mutually beneficial relationships, assess and analyze current status and capacity in AZ related to patientfamily centered medical home using the National Consensus Framework for Systems of CYSHCN developed by a national workgroup and funded by the Lucille Packard Foundation to provide core standards for a system of care for CYSHCN. OCSCHN will continue to collaborate with AZ's 2015 AZ Youth Leadership Forum related to health and wellness with a focus on medical/health home. 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 2009 59 58.1 2010 58 58.1 2011 62 52.9 SLAITS 2012 62 52.9 121804 230201 SLAITS 2013 62 52.9 121804 230201 SLAITS SLAITS SLAITS 2014 62 2015 62 2016 62 Final 2017 62 Final 2018 62 Notes - 2013 For 2011-2015, indicator data comes 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. 70 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, 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. a. Last Year's Accomplishments OCSHCN participated as a member of the Central Cover Arizona Coalition with representatives from the CMS, AZ Medicaid Program, 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 was convened on October 1, 2013, as a result of the Patient Protection and Affordable Care Act (ACA) to help inform Arizonans of the importance of health insurance, how to use the federally facilitated exchange or Marketplace to shop for and enroll in a health insurance plan. The Coalition received education and information as the health care Marketplace was implemented in Arizona; collected and analyzed community statistics to determine best methods to reach target audiences; identified partners to assist with community education; and assisted in disseminating Marketplace information. Workgroups were being formed to focus on one or more of these areas. OCSHCN also used 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. Nine-hundred and eight six (986) 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 identified by the Newborn Screening Program and for others who did not qualify for Medicaid. Nine hundred and thirty six 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. Families not eligible for Medicaid and seeking health coverage were provided information on other insurance options, including the Federally Facilitated Marketplace and Medicaid expansion, KidsCare II elimination, ongoing KidsCare enrollment freeze, updated application processes, eligibility and sources of application assistance. OCSHCN provided information and resources specific to changes to KidsCare and KidsCare II to providers, families, child serving agencies, and community organizations; and provided information and resources to assist families in 71 accessing insurance options through the Marketplace directly or through navigators and assisters. The School Nurses Organization of Arizona posted OCSHCN's contact information as a health resource on their website. OCSHCN informed 243 medical staff, 1,379 educators, 121school nurses, 640 home visitors, 224 social services staff, 49 health plan staff and other community partners of eligibility requirements and services available to CYSHCN. OCSHCN supported the Bureau of Women's and Children's Health Children's Information Center and the Community Health Nursing Program through funding and training about public and private health insurance options, services and programs for CYSHCN. Charitable funds, that help families offset medical costs, were identified such as the United Healthcare Children's Foundation and Arizona Funeral, Cemetery and the Cremation Association Foundation for Children which assists families through applications initiated by a child's school nurse. During this reporting period, OCSHCN traced over 200 contacts on the call log and when asked about their health insurance, 44% reported they had Medicaid, 13% reported being uninsured, 17% had private and insurance and 27% did not want to say. Of the total contacts, 38% identified barriers accessing services and health insurance. OCSHCN funded the Ronald McDonald Houses in Phoenix and Tucson and data was collected on the CSHCN's source of insurance. The RMH in Phoenix reported that 100% of the families that stayed with them were on Medicaid and Tucson reported 69% were on Medicaid, 19% had private insurance and 13% had no insurance. OCSHCN researched, developed and disseminated an ACA callers' response flowchart for the Bureau of Women's and Children's Health use and provided ACA updates at ICC, Genetics Services, Newborn Screening Partners and internal agency meetings. 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 state Medicaid, including expansion and the Marketplace. 3. OSCHCN maintains 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. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X X 72 b. Current Activities OCSHCN continues to work to disseminate information on Arizona's Medicaid expansion, integrated CRS program including physical and behavioral health, changes to AzEIP service delivery model and cost participation, and the new Medicaid behavioral health contractor in Maricopa County. OCSHCN partners with Cover Arizona to disseminate information regarding Federally Facilitated Marketplace deadlines for application, extension, Special Enrollment Periods, Disability Navigator Training; and clarifying with Cover AZ staff, EAR Foundation and Early Hearing Detection and Intervention Coordinator, hearing screening services and diagnostics coverage under the Arizona Benchmark plan following passage of legislation mandating hearing screening. OCSHCN continues to identify charitable sources of funding to offset family costs; this is particularly important for families who in the past would have qualified for KidsCare; however are experiencing greater cost sharing with Marketplace health plans. Families are informed about the application processes for (SSI), AHCCCS, medical coverage and early intervention services through letters informing them of programs or services for which their CYSHCN may be eligible. Families are assisted with applying for services and identifying community resources for needs such as prescription medications and therapy services. c. Plan for the Coming Year OCSHCN will continue to work with Cover Arizona to disseminate information regarding Federally Facilitated Marketplace deadlines for application, Medicaid extension, Special Enrollment Periods and Disability Navigator Training. OCHSCN will continue to clarify with Cover AZ staff and the EAR Foundation and Early Hearing Detection and Intervention Coordinator, hearing screening services and diagnostics coverage under the Arizona Benchmark plan following passage of legislation mandating hearing screening. OCSHCN will collaborate with EAR Foundation, Cover Arizona and Arizona Alliance for Community Health Centers in developing an insurance literacy toolkit to assist families in obtaining and using appropriate health insurance. OCSHCN will continue to inform and educate school nurses, providers, therapists and social service staff and other community partners on AZ's Medicaid expansion, KidsCare enrollment freeze, integrated CRS program, changes to AzEIP service delivery model and cost participation, and the new Medicaid behavioral health contractor in Maricopa County. Federally Facilitated Marketplace navigators have limited training and experience with CYSHCN, resulting in families seeking assistance through insurance brokers who are able to explain plans in the depth required. OCSHCN will explore the potential of developing a tool to help families assess levels of experience related to CYSHCN, among insurance brokers, in identifying insurance plans that meet the needs of individuals with SHCN. OCSHCN will explore opportunities to provide staff development training for AzEIP staff and providers, increasing their capacity to provide information and resources on accessing available insurance options and effectively using health insurance plans, for the families they serve. OCSHCN will continue collaborating with MIECHV and explore opportunities to provide staff development for care coordinators around insurance options and effective use to assist families of CYSHCN. The AZ Department of Education has expressed interest in applying for the Substance Abuse and Mental Health Services Administration, FY 2014 "Now is the Time" Project AWARE (Advancing Wellness and Resilience in Education) Local Educational Agency (NITT-AWARE-LEA) grants. If so, OCSHCN will explore the opportunity to partner in providing educational resources and training to young adults and their families on how to effectively use public and private insurance 73 coverage to access needed behavioral health services. Families will continue to be informed about the application processes for Supplemental Security Income (SSI), AHCCCS and early intervention services. OCSHCN will also continue to refer CSHCN to the EAR Foundation of Arizona for hearing aids, cochlear implant batteries, repairs and audiology testing for children identified by the Newborn Screening Program and for others who did not qualify for Medicaid. 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 2009 87 86.5 2010 86 86.5 2011 89.1 59.7 2012 89.1 59.7 SLAITS SLAITS SLAITS SLAITS 2013 89.1 59.7 139501 233755 SLAITS 2014 89.1 2015 89.1 2016 89.1 Final 2017 89.1 Final 2018 89.1 Notes - 2013 For 2011-2015, indicator data comes 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 - 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 74 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. a. Last Year's Accomplishments OCSHCN has implemented several strategies to promote improved organization of communitybased systems. The Health Advocacy contract with Special Olympics Arizona (SOAZ) completed its first full year in 2013. The contract aimed to increase the inclusion of CYSHCN in communitybased physical activities, provide health advocacy training to CYSHCN, ages 2-21 and their families related to nutrition, injury prevention and physical activity while linking families to needed community-based resources and supports. SOAZ developed Healthy Lifestyle Education and Practice (Healthy LEAP), built upon nationally recognized Health Promotion curriculum to include family-centered health promotion and advocacy trainings delivered and reinforced through multiple modalities including face-to-face, printed material, email and text. Healthy LEAP was offered in 41 schools across AZ, including rural and underserved areas such as the Navajo Nation, Mohave County, and border communities in Southern AZ. SOAZ trained 51 coaches to facilitate Healthy LEAP and provided inclusive sports activities, like track and field, basketball, golf, bowling and wrestling plus 8 health advocacy lessons, in English and Spanish, related to injury prevention, nutrition, sun and sports safety, for 733 CYSHCN. SOAZ partnered with AZ Interscholastic Association to allow athletes to letter in high school athletics through participation in SOAZ unified sports activities, including Healthy LEAP. OCSHCN disseminated to stakeholders the US Secretary of Education's letter on increasing access by CYSHCN to physical activity opportunities and sports available to other students both during and after the school day. OCSHCN staff successfully completed orientation and training with the AZ Coalition for Military Families Resource Network, established a profile and completed training as a military resource navigator for service members and families with CYSHCN. In collaboration with the Office of Injury Prevention, OCSHCN funded distribution of adaptive car seats for infants and toddlers to families who needed them through the Local Safe Kids Coalitions. In collaboration with the Office of Oral Health, OCSHCN provided technical assistance on the inclusion of CSHCN to the Oral Health Empower Standard, Implementing a Tooth Brushing Program to Promote Early Good Oral Health Practices & Prevent Tooth Decay. OCSHCN presented best practices on inclusion of YSHCN at the quarterly Teen Pregnancy Prevention contractor meeting and supported author/national expert, Terri Couwenhoven in presenting training on best practices in delivering teen pregnancy prevention curricula for youth with intellectual disabilities. OCSHCN piloted the online training, "Breaking the Diagnosis" with 15 Health Start contractors, 75 and collected evaluation data via survey and teleconference. OCSHCN collaborated with the High Risk Perinatal Program/Newborn Intensive Care Program to revise the policy and procedure manual in preparation for their new request for proposal, specifying OCSHCN's role in supporting CYSHCN OCSHCN collaborated with a) ADHS' Newborn Screening Office (NBS) provided information related to the National Collegiate Athletic Association requirement of Sickle Cell Trait status identification or all athletes, by reviewing and translating information for families into Spanish for their website as well as translating NBS notification letters and resources; b) Phoenix Children's Hospital Genetics, and CRS through the NBS Partners to identify barriers and strategize solutions to accessing needed genetic testing, including out of state laboratory testing for patients enrolled in Medicaid; and c) MSGRC in the Hemoglobinopathies Project and developed draft care guidelines for Sickle Cell Disease to inform and direct a national guideline compiled by the New York Mid-Atlantic Collaborative region. The Northern Arizona University, Institute of Human Development (NAU-IHD) was contracted to provide a literature review and identify evidence based curricula related to nutrition and physical activity for CYSHCN. OCSHCN received an initial report indicating several possible curricula and collaborated to identify four curricula for more thorough analysis and reporting. OCSHCN explored possibility of developing, with NAU-IHD, a tool to guide non-academics in identifying evidence based or evidence informed curricula. 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 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. 5. OCSHCN funds AZ Department of Economic Security to enable families/caregivers of CYSHCN to receive short-term respite. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X X b. Current Activities CRS partners with OCSHCN to disseminate program changes and updates for members and providers, particularly on behavioral health, health plan ID cards, primary care providers and the new opt-in for young adults to remain in CRS after turning 21. 76 OCSHCN identified that AZ does not currently have state guideline for inclusion of CYSHCN in physical activity opportunities across the life span so further discussions with ADE and AZ Health and Physical Education are being planned. Health Advocacy contractor, SOAZ Healthy LEAP expanded into young athletes ages 2 -- 7, they now recruit more schools, coaches and CYSHCN, and are increasing athlete/family referrals to community based resources. CSHCN specific information is incorporated for the first time in Empower Packs, provided to over 200 early care and education centers participating in the Empower Program. Childcare centers pledge to adopt 10 standards that support healthy lifestyle habits in exchange for reduced licensing fees. OCSHCN is providing technical assistance to one of the HAPI contractors, Maricopa County Department of Public Health in developing, implementing, evaluating and reporting data through the CYSHCN Needs Assessment and to the Bureau of Women's Health's Rural Safe Home Network which provides 24/7 domestic violence hot lines and temporary emergency safe shelter for families and children. c. Plan for the Coming Year In collaboration with ADE, early childhood educators, physical activity and recreational activity professionals and families, OCSHCN will explore development of state guidelines for inclusion of CYSHCN in physical activity opportunities across the life course in partnership with the AZ Health and Physical Education, an educational organization that achieves its mission by supporting, encouraging, and providing assistance to members statewide as they initiate, develop, conduct and promote programs of health, physical education, recreation, dance and other movementrelated programs. OCSHCN will continue to partner with MSGRC and the Medical Home, Emergency Planning, Consumer Advocacy and Newborn Screening Workgroups in supporting Family Advisor participation and improvement of services for children with genetic conditions. Staff will continue to explore opportunities to collaborate with and support Phoenix Children's Hospital genetics efforts to update Medicaid policy around genetic testing to reflect best practices for children and youth with genetic conditions. OCSHCN will explore opportunities to provide educational resources and training to YSHCN and their families on how to effectively use public and private insurance coverage for communitybased behavioral health services if the ADE receives "Now is the Time" Project AWARE (Advancing Wellness and Resilience in Education) Local Educational Agency grant. CSHCN specific information will continue to be integrated the Empower Pack, an information and resource toolkit, provided to all early care and education centers participating in the Empower Program. These centers pledge to adopt 10 standards that support healthy eating, encourage active play, prevent exposure to second and third-hand smoke, practice sun safety and promote good oral health habits in exchange for reduced licensing fees. OCSHCN will explore serving on the 2014 Empower Conference Planning Committee and delivering presentations on how providers can facilitate the inclusion of CSHCN. OCSHCN will continue to review "Empower Guidebook: Standards for Empower Child Care Facilities in Arizona," to incorporate consistent messaging for providers promoting a focus on inclusion of CSHCN. OCSHCN will continue to provide technical assistance to the Rural Safe Home Network, 24/7 domestic violence hot lines and temporary emergency safe shelter for families and children and the Maricopa County Department of Public Health in developing, implementing, evaluating and reporting data through the CYSHCN Needs Assessment. 77 OCSHCN will support additional training on healthy relationships for CYSHCN and disabilities at the 2015 ADE Transition conference to build upon the 2014 ADE Transition conference content. OCSHCN will continue to promote community-based inclusive nutrition and physical activity for CYSHCN through the development of health briefs resulting from the appraisal of health promotion curricula based on available research evidence. Performance Measure 06: The percentage of youth with special health care needs who received the services necessary to make transitions to all aspects of adult life, including adult health care, work, and independence. Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2009 40 39.4 2010 39 39.4 2011 41.2 35.6 SLAITS 2012 41.2 35.6 30347 85151 SLAITS 2013 41.2 35.6 30347 85151 SLAITS SLAITS SLAITS 2014 41.2 2015 41.5 2016 42 Final 2017 42.5 Final 2018 43 Notes - 2013 For 2011-2015, indicator data comes 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 2009-2010 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 - 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 78 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. a. Last Year's Accomplishments OCSHCN continued to partner with the Arizona Community of Practice on Transition (AzCoPT), an interagency state leadership team comprised of young adults, family organizations and representatives from AZ's Departments of Education (ADE), Economic Security- Division of Developmental Disabilities, Health Services - Division of Behavioral Health Services, Office of Children with Special Health Care Needs (OCSHCN), Navajo Office of Special Education and Rehabilitation Services Administration-Vocational Rehabilitation Program. In 2013, OCSHCN staff and Debbie Weidinger, Family Advisor and Executive Director of AZASSIST shared leadership as co-chairs, the first time a family member and community advocate assumed a leadership role in this CoP. AzCoPT presented a session on state agency processes and collaboration at AZ's ADE Thirteenth Annual Transition Conference, "I"s Focused on the Future: Invested, Involved, and Independent." OCSHCN funded scholarships for 55 youth/young adults, family members, mentors, or attendants to attend the conference (lodging and/or registration) OCSHCN hosted an exhibit table at the conference that provided information and resources to 876 families, educators, agency staff and young adults . OCSHCN partnered with CRS to disseminate information to families and young adults regarding the new option for members turning 21 to remain in the CRS program into adulthood, only during a limited timeframe before the 21st birthday; allowing members to continue receiving care and support from specialists in a multi-specialty clinic setting, while transitioning to adult PCPs. OCSHCN participated in the National Coordinating Center for the Genetics Regional Collaborative (NCC) Transition workgroup, to identify and disseminate projects, youth camp information, training, information and resources related to transition across the regions, including the AZ's CSHCN Transition Resource and Transition Brochure. OCSHCN partnered with the Teen Pregnancy Prevention (TPP) program and provided training on best practice around inclusion of young adults in (TPP) classes for program contractors, and supported a one-day contractor training by national expert and author, Terri Couwenhoven. Through the Health Advocacy contract and SOAZs Healthy LEAP program, OCSHCN supported inclusion of YSHCN in Arizona Interscholastic Association sanctioned unified sports, provided 79 opportunities to letter in sports alongside peers without disabilities and participate in inclusive health advocacy lessons covering subjects such as sports and exercise safety, sun safety, tobacco/alcohol prevention, and nutrition. OCSHCN updated the Health Care Organizer (HCO) training to include a summary of available health record electronic device applications developed with Jewish Family and Child Services and Magellan, a pilot HCO training for foster youth in group living situations. OCSHCN partnered with AZ Medicaid, Rehabilitative Services Administration (RSA), ADE and the Governor's Office on Children Youth and Families, with UT, MT, ND, SD, and CO, developing a multi-state grant proposal for the awarded Employment Disability Partnership Promise Initiative grant; focused on increasing the opportunities for SSI recipients ages 14 -- 16 and their families to obtain meaningful work. If this grant is funded OCSHCN has agreed to provide healthcare transition training for participating families and youth. OCSHCN disseminated to stakeholders the US Secretary of Education's letter to school districts regarding increasing inclusion of YSHCN in sports and physical activities available to students generally during and after school. This resource was also provided to the Health in Arizona Policy Initiative (HAPI) contractors, working 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. Chaparral High School staff and students partnered with OCSHCN who supported professional production of a health promotion video, "High Five for Hand Washing". Students with SHCN participated in development, filming, acting, producing and editing the video which was broadcasted within the school and well received by all students and available on ADHS' You Tube channel. 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 (Medicaid) programs. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X b. Current Activities 80 OCSHCN supports a presentation at the 2014 ADE Transition Conference by Terri Couwenhoven, on "Healthy Relationships", an inclusive approach to providing relationship education for young adults of all abilities. OCSHCN continues to support inclusion of YSHCN through the SOAZ contract in Arizona Interscholastic Association sanctioned unified sports alongside peers without disabilities, where athletes letter in their sport and participate in inclusive health advocacy lessons covering subjects such as sports and exercise safety, sun safety, tobacco/alcohol prevention, and nutrition. OCSHCN is partnering with the Creating a "Picture of a Life" for Transitioning Foster Youth with DD (POL project) to train facilitators and self-advocacy coaches on using the Heath Care Organizer (HCO) through "train-the-trainer" model and incorporate OCSHCN's HCO curriculum into the basic Person-Centered Planning facilitator training. The program assists in collecting data on the benefits of the utilization of the HCO youth participants. OCSHCN participates in the Statewide Transition meeting with the Division of Behavioral Health Services (BHS), offering technical assistance to contractors in developing and implementing transition programs for youth receiving BHS. OCSHCN is participating with MSRGC in developing a Sickle Cell Disease Care Plan promoting youth transition representative of best practice in the region, which informs a national Sickle Cell Disease Care Plan for the NCC. c. Plan for the Coming Year OCSHCN will explore supporting a future conference in collaboration with UHC intended to build capacity of primary care physicians, not attending the Opening the Doors to People with Special Needs: Solutions to Prepare Your Practice" Conference in 2014, on innovative best practice approaches to planning, delivering and evaluating care for CYSHCN and disabilities and their families. The conference offers primary care physicians an opportunity for interaction, networking, and certificate education to discuss aspects of providing care; integrated services, and focus on transition from pediatric to adult care. Through the Health Advocacy for Children, Youth and Families contract and SOAZs Healthy LEAP program, OCSHCN will continue supporting inclusion of YSHCN in Arizona Interscholastic Association sanctioned unified sports, providing opportunities to Letter in sports alongside peers without disabilities and participate in inclusive health advocacy lessons covering subjects such as sports and exercise safety, sun safety, tobacco/alcohol prevention, and nutrition. OCSHCN will continue to participate in the National Coordinating Center for the Genetics Regional Collaborative (NCC) Transition workgroup, to identify and disseminate information and resources around best practices in transition for youth with genetic conditions. OCSHCN will continue to participate in the Statewide Transition Meeting with ADHS' Division of Behavioral Health Services, and offer technical assistance to contractors in developing and implementing transition programs for youth receiving behavioral health services. OCSHCN will partner on a collaborative project with AZ's Sonoran UCEDD at the University of Arizona, Division of Developmental Disabilities, Developmental Disabilities Planning Council, and state independent living centers on the Creating a "Picture of a Life" for Transitioning Foster Youth with Developmental Disabilities (POL project) to train facilitators and self-advocacy coaches on using OCSHCN's Heath Care Organizers through "train-the-trainer" in order to incorporate the organizer curriculum into the basic PCP facilitator training. The POL program will assist in collecting data on the benefits of the utilization of the organizers by POL youth participants. 81 OCSCHN will continue to collaborate with AZ's Statewide Independent Living Council and Rehabilitation Services Administration will be coordinating a 2015 AZ Youth Leadership Forum (AZYLF) an intensive five-day training program focused on independence, leadership, responsibility, and positive outcomes for up to 20 high school sophomores, juniors, and seniors who have disabilities. OCSHCN will continue to promote decision-making at all levels including through the development of health briefs resulting from the appraisal of health promotion curricula that include nutrition and physical activity components according to their available research evidence, effect on important health outcomes, and relevance to YSHCN. Performance Measure 07: Percent of 19 to 35 month olds who have received full schedule of age appropriate immunizations against Measles, Mumps, Rubella, Polio, Diphtheria, Tetanus, Pertussis, Haemophilus Influenza, and Hepatitis B. Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source 2009 2010 2011 2012 2013 80 80 80 80 75 76 71.9 77.5 70.7 71.4 National Immunization Survey National Immunization Survey National Immunization Survey National Immunization Survey National Immunization Survey Final Final 2017 2018 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? 2014 2015 2016 82 Annual Performance Objective 75 80 80 80 80 Notes - 2013 The confidence interval is + or - 7.1%. Estimates for 2013 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 - 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. 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 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 along with information regarding measles and an outbreak of mumps. The page www.tapi.org was updated and maintained with links 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 2013 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 8) a family friendly flyer with information about every age and recommendation was developed to include family pets as a way to normalize vaccines for hesitant parents 9) a simple to use instruction guide for foster families was developed for kids that are not on schedule for immunizations 10) a "growing Healthy Babies and Healthy Babies Growing up" growth chart was developed with many maternal and child health agencies to 83 include advice on steps for a healthy pregnancy and child development from 0-6 years. Over 100,000 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 2013. 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. TAPI conducted eight regional immunization programs with the Vaccines for Children Program and the Arizona State Immunization Information System for providers statewide. 650 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 Adelante Health Care obstetrics and pediatrics departments to promote healthy kids through healthy families. TAPI worked with Mohave County to teach immunization best practices to share with the offices during site visits and trained several clinics sites that were involved in a community wide pertussis outbreak impacting babies and toddlers. 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. Home visitors educate pregnant and postpartum women about the importance of immunization and monitor the immunization status of enrolled infants. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB 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. Implementation of ACA has caused a shift in where kids access 84 vaccines and TAPI is making sure safety net services are still available in underserved areas. 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. Child Care Health Consultants continue to provide immunization education and support to centers. 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 explore, 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. 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. Health Start Program will obtain the most current immunization requirements and distribute to contractors. A new immunization checklist will be required as part of the child's information in the client chart. Program will continue to review each immunization record of each woman and child up to age two to ensure immunizations are up to date. The Community Health Workers will continue to provide education on the importance of immunizations for the whole family and will direct them to immunization providers and other resources within their community. The HRPP Community Health Nurses will continue to monitor the immunization status of the 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. 85 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 2009 2010 2011 2012 2013 32 23.5 23 18 17.5 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 15.0 1985 132356 AZ Birth Certificates Final Final 2017 11.5 2018 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? Annual Performance Objective 2014 14 2015 12.5 2016 12 Notes - 2013 The rate of birth (per 1,000) for teenages aged 15-17 years continues to decrease. This aligns with the national trend. a. Last Year's Accomplishments Arizona's teen pregnancy rate continues to decline. In 2013, the Bureau of Women's and Children's Health Teen Pregnancy Prevention Program (TPP) funded 13 Arizona county health departments, and five tribes (Tohono O'odham San Lucy District, Fort McDowell, Hopi, White Mountain Apache, and Pascua Yaqui) through a contract with the Inter-Tribal 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 10,212 youth and 241 parents received services in 2013. Programs implemented evidence-based or promising practice curricula and many 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. 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 86 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 22,069 youth and 1,170 parents received services in 2013. TPP began implementation of a statewide cross-site program evaluation to collect data on the Teen Pregnancy Prevention programs that are being conducted throughout Arizona in order to provide an assessment of the impact of the programs on the youth in the programs. Outcome data will be available in October 2014. In 2013, the Teen Pregnancy Prevention Program began collaborating with the Arizona Department of Economic Security (DES) Teen Pregnancy Prevention Task Force to develop partnerships to reach youth in foster care with pregnancy prevention messaging by connecting group homes with pregnancy prevention providers. After partnering with the Office for Children with Special Health Care Needs to develop a teen pregnancy prevention curricula supplemental guide for youth with intellectual disabilities, TPP sub-awardees received training on how to implement the guide as well as how to work with this population. Table 4a, National Performance Measures Summary Sheet Activities 1. The Teen Pregnancy Prevention Program provides parent education on how to talk to teens about responsible sexual behavior. 2. The Teen Pregnancy Prevention Program developed a Tool Kit for foster parents and case managers 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. Home Visitors educate teens about the importance of a reproductive life plan. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X X b. Current Activities The Program continues to use lottery dollars to fund 13 county health department projects, five tribal projects and seven abstinence programs. The TPP program also funds 11 communitybased projects with federal PREP and Title V funding. TPP is collaborating with the Department of Economic Security (DES) TPP Task Force to develop a sexual health toolkit for youth in foster care. The toolkit will serve as a means for foster care 87 case managers to initiate sexual health conversations with youth prior to providing them with a take-away copy of the kit. A toolkit is also being developed for parents/guardians of youth in foster care with information to help them navigate conversations with their youth. TPP in collaboration with DES and MIECHV will host an Adolescent Health summer conference. The two-day training will provide teen pregnancy prevention health educators, CPS caseworkers and home visitors with information on: how to address adolescent health risk factors in-school and community-based settings; development of leadership and group facilitation skills; adolescent development and classroom management. Effective August 1, 2014, TPP will implement revised statewide cross-site program evaluation tools to collect data on the TPP programs that are being conducted throughout Arizona. After the initial pilot launch of the evaluation tool, it was determined that two tools needed to be developed; one more age appropriate for middle school youth and the other for high school youth. c. Plan for the Coming Year Lottery revenue is expected to continue at current rates 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 address teen pregnancy prevention with youth with intellectual disabilities. The development of the toolkit for youth in foster care and their parents/guardians will be completed and implementation will begin. The toolkit use and usefulness of the toolkits will be assessed 6 months after implementation. Six months following the implementation of the toolkit, TPP and DES staff will work with youth in foster care to assess the use and usefulness of the toolkit. The Teen Pregnancy Prevention Program will continue to implement medically accurate, culturally diverse, evidence-based and/or promising practices, abstinence-plus and abstinenceonly 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 begin a new contract cycle with the Navajo Nation TANF program to provide teen pregnancy prevention services on the reservation. 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. ADHS home visiting programs; Health Start, the High Risk Perinatal Program and the alliance of Arizona's home visitors StrongFamiliesAZ will continue to address pregnancy spacing with clients 88 as part of interconception health care education. 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 2009 2010 2011 2012 2013 36.5 47.1 47.1 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 AZ Office of Oral Health AZ Office of Oral Health AZ Office of Oral Health 2014 47.1 2015 47.1 2016 47.1 Final 2017 47.1 Final 2018 50 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 - 2013 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. The most recent results are from the 2009/2010 survey and are therefore unchanged since 2009. 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 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. 89 a. Last Year's Accomplishments During the 2012-2013 school year, the Arizona School-based Sealant Program provided dental screenings and referrals to 8,318 children attending eligible public schools. As a result, 5,219 children received 18,421 dental sealants. The sealant program provided services to children in ten of the fifteen Arizona counties. This was an increase from five counties the previous year. Partnerships with community clinics have provided outreach to these three additional counties. Students who attend eligible schools, in 2nd or 6th grade, and have informed parental consent were able to receive 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 although there are more counties involved, there is evidence that there has been a leveling off in the number of children participating in 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. As part of the sealant program, the Office of Oral Health (OOH) collects oral health status information using the Association of State and Territorial Dental Directors' Basic Screening Survey (BSS). This information provides guidance on referrals for care and surveillance on oral health status. In addition, school nurses and parents are notified on the day of the screening if any screened child has urgent or early treatment needs. Data analysis and reporting of program services are generated for the state, county and school levels. Oral health surveillance findings from the 2012-2013 school year indicate that 30% of children had untreated tooth decay, 74% had decay experience and 7% had urgent dental treatment needs. The Office of Oral Health collaborates with the Arizona Health Care Cost Containment System (AHCCCS) to identify opportunities to link Medicaid eligible children to dental homes. As a result, referral connections have been made with AHCCCS contracted health plans to help establish follow-up care for children in need. The OOH conducted 16 professional development workshops and continuing education events which offered 64 instructional hours on oral health disease prevention programs. These educational workshops reached a total of 950 participants (including dentists, dental hygienists, dental/dental hygiene students, physicians, nurses, childcare providers and administrators). Training focused on the following topics: Community Dental Health, Promoting Oral Health Practices in Childcare Setting, Early Childhood Tooth Decay, Oral Observations and Prevention, and Disease Disparities. These training events included an evaluation component which helped identify participant's satisfaction and knowledge levels gained. The OOH collaborated with the Arizona School of Dentistry and Oral Health and Oral Health America to continue and expand 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 funds the provision of 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. Pyramid Level of Service DHC ES PBS IB X X X 90 5. 6. 7. 8. 9. 10. b. Current Activities The Office of Oral Health continues to provide a school-based sealant program in ten 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 licensed dental providers, dental faculty and dental students. This program has expanded to include a partnership with local community dental clinics in Pinal County. This partnership has the potential to reach 15 eligible schools that have never had a school-based sealant program. OOH is partnering with the Arizona Alliance for Community Health Centers, the Inter-tribal Council of Arizona and the Greater Valley Area Health Education Center to provide professional development opportunities for dental providers and program administrators on dental public health issues. The OOH has a partnership with First Things First, the Early Childhood Development and Health Board to implement a fluoride varnish program for preschool children in underserved areas of south Phoenix. The Medical Services Project actively recruits dentists to provide oral health services for free or a nominal fee 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 and charter schools throughout Arizona. The Office of Oral Health will maintain Intergovernmental Agreements with counties, community dental clinics, and dental/ dental hygiene schools to provide school-based dental screenings, referrals and sealants to children in low-income 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 2014-2015 school year. The Office of Oral Health will continue to 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 91 opportunities for dental providers, community stakeholders 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 2009 2010 2011 2012 2013 3.8 3.5 2.5 2.4 1.9 3.5 50 1434985 AZ Death Certificates 2.7 36 1358059 AZ Death Certificate 2.5 34 1368206 AZ Death Certificate 2.8 38 1358070 AZ Death Certificate 3.4 46 1364423 AZ Death Certificate Final Final 2017 1.8 2018 1.8 Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2014 1.9 2015 1.9 2016 1.8 Notes - 2013 The rate of deaths to children aged 14 years and younger caused by motor vehicle crashes per 100,000 children increased 21.4% from 2.8 in 2012 to 3.4 in 2013. Numerator for 2012 was updated 07/08/014. Notes - 2012 Numerator updated on 07/08/14. The coding used in 2012 was missing some ICD codes and has been updated to be comparable to other years. a. Last Year's Accomplishments 92 Although this indicator from Arizona's Death Certificates shows the increase in the rate of deaths of children less than 14 caused by motor vehicle crashes, Arizona's Child Fatality Review paints a different picture. 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 3.9 deaths per 100,000 children in 2012. (Last year available at this time.) Motor vehicle crashes were the cause of 84 deaths among Arizona's children in 2012. There were only four child deaths related to off-highway vehicle (OHV/ATV) crashes. Eighty three percent of motor vehicle-related deaths were determined to have been preventable (n=73). Lack of vehicle restraints was identified as a preventable factor for 35 percent of motor vehicle crash fatalities (n=31). 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 through policy. For 2013, 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. Additionally, they provided car seat technician training and certification, recertification. Yavapai County Health Department assisted teachers in the implementation of Safe Dates curriculum in 7 classrooms reaching 206 students. Promoting Safe Dates in schools has allowed them to further teach other curricula such as drug education. Yavapai County Health Department conducted Teen Mazes including interactive information on motor vehicle crashes, driving under the influence of substance, and bullying. Navajo County Health Department provided input on stricter motor vehicle laws on the Hopi reservation and they were incorporated into a seatbelt law. Maricopa County Department of Public Health staff has been active members of the Livable Communities Coalition, as well as the Advocacy Subcommittee. It was through this group that work on the City of Phoenix Complete Streets Policy began. In addition, much of the work on City General Plans has been an effort of this group. As a result of this, the City of Tempe and Mesa requested staff input on their cities General Plans this year. Through Arizona State Lottery funding, the Health Start Program received and distributed to 13 contractors, 265 infant seats and 470 convertible car seats 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 checkup events, training, and offered a training on using car seats for Arizona's Child Passenger Safety Technicians which provided CEUs. In addition, the Office of Injury Prevention (OIP) participated in the Four Corners meeting, which focused on improving child restraint use, law enforcement education, and parent education on the Navajo Nation. The OIP distributed 5,000 child safety seats to community partners to use in their educational classes. The OIP provided technical assistance to Title V County Health and Prevention grants on their Battle of the Belt initiatives to increase seatbelt use in the teen population. 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 Pyramid Level of Service DHC ES PBS IB 93 1. Child Fatality Review Program reports on motor vehicle crashes among children. 2. Title V County Health Prevention contracts build local infrastructure for injury prevention including motor vehicle safety. 3. Injury Prevention Program provides car seat safety technician training 4. Title V funded the provision of car seats in many areas throughout the state. 5. 6. 7. 8. 9. 10. X X X X b. Current Activities The Office of Injury Prevention (OIP) continues to build capacity for child passenger safety through providing certified training and continuing education for recertification. Courses will add 40-50 more technicians Arizona this year. For 2014, OIP is focused on increasing the number of Battle of the Belt school sites and facilitating our Safe Sleep partnership and our collaboration with Sonora, MX. The Community Health Grants continue to provide injury prevention activities including community education, building coalitions, changing organizational practices, and developing policies. Five participating counties are providing car seats, education on installation of car seats and car seat technician training and certification, recertification. In 2014 the Counties are focusing on implementing Battle of the Belt. Coconino County's Board of Supervisors banned use of mobile communication devices and texting while operating a motor vehicle to protect the public health. The ordinance calls for a 30-day education period to allow the public to become familiar with the new ordinance. During the first 60 days of it being in effect, area law enforcement are only allowed to issue warnings to motorists found violating the ordinance. The Maternal Infant Early Childhood Home Visiting Grant (MIECHV) is providing support 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 surrounding these deaths. The 21 st annual report will be produced this year and will include information on the deaths that occurred in Arizona during 2013. 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. 94 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 support policy change at the local level.. 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. The Injury Prevention Program will continue to collaborate with Office of Children with Special Health Care Needs to ensure APIPA-Children's Rehabilitative Services Program is connected to car seat safety technicians trained in special needs child safety seats. 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 2009 2010 2011 2012 2013 50 53 51 53 49 45.3 49.6 52 43.3 49.7 CDC National Immunization Program 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 1.There are fewer than 5 events over the last year, and 2.The average number of events over the 95 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 2014 53 2015 57 2016 59 Provisional Provisional 2017 61 2018 61 Notes - 2013 Source: Centers for Disease Control and Prevention National Immunization Survey, Provisional Data, 2010 births. http://www.cdc.gov/breastfeeding/data/NIS_data/index.htm Data was obtained from the 2013 CDC Breastfeeding Report Card, which used 2010 provisional National Immunization Survey (NIS) data. The NIS webpage did not contain 2010 state data due to website format changes that are to take place. http://www.cdc.gov/breastfeeding/pdf/2013breastfeedingreportcard.pdf 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 06/20/14- The 2009 data is still listed as provisional because the NIS webpage did not contain finalized 2009 state data due to website format changes that are to take place. Notes - 2011 The CDC National Immunization Survey data for 2011 (2008 birth cohort). The HP 2020 Goal is 60.6%. a. Last Year's Accomplishments During Federal Fiscal Year (FFY) 2013, the Arizona Department of Health Services breastfeeding programs achieved a number of significant accomplishments which enabled us to improve our performance on this measure. The Arizona WIC Program had a rate of 83.2% for ‘ever breastfed' (CDC Breastfeeding Report Card 2013) with a target rate of 81.9%. The areas of outreach activities, training, and expanded access to services improved in FFY2013. 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 realized 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. The course was also made available to all Bureau of Women's and Children's Health (BWCH) contract service providers including Strong Families AZ Home Visitors. There were 97 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 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 96 week-long breastfeeding course within six months of satisfying employment probation requirements. WIC staff from Arizona successfully completed "Breastfeeding Boot Camp", a 35-hour WICfocused 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 2013, 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 66. 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 a means for WIC staff to network with community partners interested in lactation. Topics included ""Infant formula ... you're kidding, right?" "How much Protection does human milk give", "Probiotics, Prebiotics and Symbiotic" and "Mastitis". The Arizona Breastfeeding Hotline continued to provide access to skilled lactation help 24-hours a day, seven days a week. In 2013, during business hours, the Hotline answered 1,400 calls related to breastfeeding issues. Approximately 350 mothers per month have reached out during non-work 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 10 of its Local Agencies, including six county health departments and four community health centers. 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. The home visiting programs continue to support breastfeeding. Table 4a, National Performance Measures Summary Sheet Activities 1. Home Visitors educate pregnant and postpartum women about breastfeeding. 2. Bilingual Certified Lactation Consultants answer the pregnancy and Breastfeeding Hot Line during the business day. 3. A bilingual ICBLC answer the Pregnancy and Breastfeeding Hot Line after business hours and on weekends and holidays. 4. MIECHV funding sponsors breastfeeding professional development for home visitors. 5. MIECHV funding is supporting certification of ICBLCs in rural areas. Pyramid Level of Service DHC ES PBS IB X X X X X X X 97 6. 7. 8. 9. 10. b. Current Activities Arizona continues to offer the Breastfeeding Boot Camp Training to WIC staff. A statewide Breastfeeding Coordinator Meeting was held in April 2014, the representatives from each county focused on the effects of the Affordable Care Act on lactation, how childcare centers are working to support breastfeeding women, how to better collaborate with Strong Families AZ home visitors and integrating the WIC Nutrition Standards into current practice. 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 over 150 home visitors. Basic Training I is a two-day course where participants will learn how to use evidence-based practices to support breastfeeding from conception to wean. Topics include latch and position, newborn feeding patterns, myths and community breastfeeding resources. Basic Training II is a two-day course where participants will learn how to use evidence-based practices to help clients overcome breastfeeding challenges, such as engorgement, mastitis, low milk supply and teething. The class will provide additional education hours for any home visitor who plans on taking the IBCLC exam. Topics may cover: supporting the family with the baby in the NICU, and maternity care practices and their impact on breastfeeding. The Health Start Program and High Risk perinatal Program continue to support breastfeeding education training for Community Health Workers. 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, continue to offer the 2-day Breastfeeding Basic Training I, the 2-day Breastfeeding Basic II, and 1-day Current Trends in Breastfeeding to Home Visiting Staff. Baby Behaviors training will continue to 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 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 provide five 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 more comprehensive mentoring for additional home visitors who are interested in to sitting for the International Board Certified Lactation Consultant exam. Breast feeding training will be included in the annual Strong Families Home Visiting conference for over 600 participants. 98 Through Title V funding, te MCH hotline will continue to be staffed by one bilingual Certified Lactation Consultant who answers 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 2009 2010 2011 2012 2013 98 100 100 100 100 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 98.4 85151 86496 AZ Early Hearing Detection and Intervention Progra Final Final 2017 100 2018 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 2014 100 2015 100 2016 100 99 a. Last Year's Accomplishments The Office of New Born Screening (ONBS) High Risk Coordinator continued to provide targeted follow-up to those infants who were in the NICU greater than 5 days, many with risk factors for hearing loss, to ensure completion of the appropriate screen (A-ABR) prior to discharge and for those who fail, receipt of a diagnostic evaluation or other referrals. Targeted efforts have reduced LTFU of high risk babies to < 10% for 2013 and are sustained this year. The most successful change in the follow-up program was the implementation of the Fax Back Form to primary care physicians (PCP). Instead of letters being mailed to PCPs, a form is faxed to the PCP asking for hearing results and/or additional information as to where and when further testing will take place. Most primary care providers complete the Fax Back Form and provide the information requested within the mandatory 7 day time period. The data reported via HiTrack indicated a 98.4% of newborns received their hearing screening prior to discharge. Of them, 99% were screened by one month of age, meeting the CDC's Universal Newborn Hearing Screening guideline. All birth hospitals have access to the web-based data system through a secure login protocol and upload data at least once per week. Technical assistance to hospitals continued through on-site training, conference calls and the distribution of best practice materials. Hospitals that reported abnormally low or high referral rates were contacted to determine if equipment issues, staff turnover, or systems interruptions were the source of the anomalies. At that point, guidance on corrective action was provided. Midwives are provided similar technical assistance to ensure statewide standardization of screening and reporting practices. ADHS maintained 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. The newborn screening data link to Vital Records has a success rate of matching over 90% of records. All birthing hospitals have direct, real time and secure access to upload screening results and demographic information on their patients and can view and edit notes from our case management team. This allows for improved care coordination, reduced time to screening and diagnosis and streamlined database entry. The automated linkage between the Vital Record and the Hearing (HT) database is supported through a cooperative agreement with the CDC. Refusals are monitored each month including those who refuse in-patient screening versus those who subsequently return to receive an outpatient screen. A 2012 survey of Arizona families who refused inpatient screening revealed that the majority of hearing refusals were based on financial concerns and bloodspot refusals from a decision to have the initial screen performed at their physician office. An effort to reduce the number of in-patient hearing refusals was implemented by The EAR Foundation of Arizona (EFAZ). Funding was secured to provide a "voucher" for the baby to receive a screening via the contacted hospital screening vendor for those families who are low income and either do not have insurance coverage or have a high deductible plan. Many hospital systems have agreed to utilize foundation funds to ensure cost is not an obstacle for a family. In 2013, the Arizona Hands & Voices Guide by Your Side (AZ GBYS) program continued to provide trained parent to parent support to parents in the screening process by performing services such as follow-up with families when an infant misses an outpatient screen or diagnostic evaluation and onsite staffing at screening hospitals. The annual Hospital Screeners meeting was conducted; midwives and other out of hospital screeners attended the meeting and will be invited in future years. This meeting provided an update on how well the state was performing on reporting, updated screening practices and equipment. The e-learning training was updated to a web version and expanded to include more 100 screeners and is no longer limited to 2 screeners per hospital. A quarterly newsletter and listserv update 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 listservs. 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. Home Visitors continue to review hearing screening with parents. 6. BWCH continues to review site specific results during APT site vista. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X 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. Improved tracking systems have created more timely and complete follow up for those babies that might have otherwise not received the appropriate follow-up. By requesting hospital discharge summaries for those babies that either fail their inpatient screening or are missed, the HRC and consulting audiologists are able to guide the family to the most appropriate course. One new and one updated report will be issued to all birth hospitals beginning in early June. The first will be a revised hospital-based quarterly report card. The report will focus on quality indicators related to pass and refer rates prior to discharge, the number and percentage of well babies who return for an outpatient screen within 30 days and the number who are missed or refused inpatient screening. The second report being developed will be a weekly report sent to hospital data managers. The report will capture any missing data elements in the database for babies born in the previous two weeks giving the hospitals an opportunity to complete any missing information on a baby's record. The HiTrack database has enhanced reporting capabilities that allow the data managers to monitor and survey data real time; hospitals can be trained on how to better manage data integrity functions. c. Plan for the Coming Year Technical assistance to hospitals will continue to be provided through on-site training, conference calls and distribution of best practice materials. Hospitals who report <1% or >4% refer rates will continue to be contacted to gain an understanding of factors contributing to high or low refer rates. If issues are identified, recommendations and guidance will continue to be provided to 101 assist with program improvements. Data will continue to be closely monitored and ongoing technical assistance will be provided until measureable improvements are seen. On-site or telephone technical assistance will be provided to screening programs to ensure that screeners enter accurate demographics when screening a baby and that hospital data managers accurately record the screening status of all infants born at their hospital. ADHS will continue to 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 continue to be provided to screening programs incorporating strategies to ensure that screeners more accurately record the disposition of infants including transfers, deceased, parental refusals; scheduled rescreens and inpatient versus outpatient screening results. Efforts to improve turnaround times for diagnostic evaluation and better reporting of hearing testing from audiologists are underway. The NBS hearing screening program is exploring the implementation of performance report cards for audiologists and other measures that will reduce cases that are lost to documentation. The EFAZ will continue to provide vouchers beyond the initial period in order to ascertain how the Affordable Care Act impacts refusals due to high deductibles and copays. This area will be monitored closely. An e-learning module for standardized training, including pre/post testing, for newborn hearing screeners has expanded to allow more participants and will continue to be utilized. As part of ongoing training, all hospital and midwifery screeners will continue to be encouraged to take the web- based Newborn Hearing Screening Training Curriculum (NHSTC) on the NCHAM website and to use the hands-on accompanying skills checklist with new screeners. Updates to the curriculum will continue. Outreach activities including conferences, presentations and site visits will continue to hospitals, pediatricians, and midwives to ensure that the high level of compliance with inpatient hearing screening is maintained. Future plans include adding access to the HiTrack database 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 to documentation rate. Performance Measure 13: Percent of children without health insurance. Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source 2009 2010 2011 2012 2013 16 16 15.8 13.4 13.1 15 14 13.5 13 13.7 US Census U.S. Census U.S. Census U.S. Census U.S. Census 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 102 therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2014 13 2015 13 2016 13 Final 2017 13 Final 2018 13 Notes - 2013 Estimate from Table HI05 available at http://www.census.gov/hhes/www/cpstables/032013/health/toc.htm 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) 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, this 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 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, 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. In 2013, the Medical Services Project provided medical appointments to over 384 different children from approximately 140 different referring schools. In 2013, the Medical Services Project continued collaboration or developed new collaborative partnerships with Phoenix Urban League, 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, School Based Health Care Centers, 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. 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 as well 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 103 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. The Pregnancy & Breastfeeding/Children's Information Center Hotline assisted 12,670 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. OCSHCN participated as a member of the Central Cover Arizona Coalition, to provide technical assistance and obtain current information regarding ACA outreach and enrollment, federal resources and updates. OCSHCN used CMS and healthcare.gov as sources of information, resources and training on the Marketplace for families, providers, educators, social workers, school nurses, other child-serving agencies and ADHS programs. Additionally, nine hundred and thirty six letters were mailed by OCSHCN to SSI applicants under age 21 informing them about medical coverage and programs or services for which their CYSHCN may be eligible. Table 4a, National Performance Measures Summary Sheet Activities 1. Medical Services Project provides uninsured children with health care services. 2. Home Visitors educate the family on the importance of maintaining a medical home and assists families in accessing health insurance. 3. Hotline helps families seeking health care to apply for AHCCCS or find community services. 4. 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. 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 Arizona's Medicaid agency, to ensure families receive coverage as quickly as possible. The Title V Hotline staff assists callers with accessing Arizona's Medicaid health plan and links them to needed services. With the advent of the Affordable Care Act, as of January 1, 2014 families were no longer enrolled in KidsCare but either enrolled in Medicaid or guided to the marketplace. Programs are closely watching how this evolves. OCSHCN continues to partner with Cover Arizona to disseminate information regarding 104 Marketplace deadlines for application, extension, Special Enrollment Periods, and Disability Navigator Training. OCSHCN is working with Cover AZ, EAR Foundation and Early Hearing Detection and Intervention, to clarify hearing screening services and diagnostics coverage under the Arizona Benchmark plan following 2014 legislation mandating hearing screening. OCSHCN provides insurance options updates at ICC, Genetics Services, Newborn Screening Partners and internal agency meetings. c. Plan for the Coming Year In light of the changing environment 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, Health Start community health workers and all MIECHV funded, and in fact all StrongFamiliesAz home visitors 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. 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. OCSHCN will continue to work with Cover Arizona to disseminate information regarding Federally Facilitated Marketplace deadlines for application, Medicaid extension, Special Enrollment Periods Open Enrollment and Disability Navigator Training. OCSHCN will collaborate with EAR Foundation, Cover Arizona and Arizona Alliance for Community Health Centers in developing an insurance literacy toolkit to assist families in obtaining and using appropriate health insurance. OCSHCN will continue to inform families and young adults about the application processes for Supplemental Security Income (SSI), AHCCCS, as well as Special Enrollment Periods and Open Enrollment for the Marketplace. Federally Facilitated Marketplace navigators have limited training and experience with CYSHCN, resulting in families seeking assistance through insurance brokers who are able to explain plans in the depth required. OCSHCN will explore the potential of developing a tool to help families assess levels of experience related to CYSHCN, among insurance brokers, in identifying insurance plans that meet the needs of individuals with SHCN. OCSHCN will explore opportunities to provide staff development training for AzEIP staff and providers, increasing their capacity to provide information and resources on accessing available insurance options and effectively using health insurance plans, for the families they serve. OCSHCN will continue collaborating with MIECHV and explore opportunities to provide staff development for care coordinators around insurance options and effective use of insurance, to assist families of CYSHCN. 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. 105 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 2009 2010 2011 2012 2013 34.5 30.2 31174 103089 AZ WIC Program 34.5 29.3 31182 106318 AZ WIC Program 34 28.9 30018 103873 AZ WIC Program 28.5 27.8 27583 99071 AZ WIC Program 27 25.6 22911 89344 AZ WIC Program 2014 25 2015 24.5 2016 24 Final 2017 23.5 Final 2018 23 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 - 2013 The percentage of children, ages 2 to 5 years, receiving WIC services with a BMI at or above the 85th percentile continue to decline. Numbers reported before 2009 include duplicates by error and therefore over estimate the percentage of children with BMI at or above the 85th percentile and not comparble with numbers from 2009 and onward. 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. 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 one of Arizona's winnable battles. We seem to be making progress. According to our WIC data, there has been a reduction of the percentage of children at or above the 85th percentile of BMI from 30.2 in 2009 to 25.6 in 2013. The Bureau of Nutrition and Physical Activity (BNPA) completed the three-year Action Plan for Improving Arizonans WellBeing 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 also aligned programs across WIC, Arizona Nutrition Network (AzNN), and Empower to promote consistent core messaging in nutrition and physical activity education for infants, children and their families. Empower is a statewide initiative offered to licensed child care facilities that promotes wellness 106 for children in Early Care and Education (ECE) settings. Facilities participating in the Empower Program pledge to adopt 10 standards that support healthy eating, encourage active play, prevent exposure to second-and third-hand smoke, practice sun safety, support breastfeeding mothers, and promote healthy oral health habits in exchange for reduced licensing fees. As of January 2013, the standards were updated to include: (i) Provide at least 60 minutes of daily physical activity (teacher-led and free play) and not allowing more than 60 minutes of sedentary activity at a time, except when sleeping, or more than three hours of screen time per week; (ii) practice sun safety; (iii) provide a breastfeeding friendly environment (iv) determine whether a site is eligible for the USDA Child and Adult Care Food Program (CACFP), and participate if eligible; (v) limit serving 100% fruit juice to no more than twice a week; (vi) serve meals family-style and do not use food as reward; (vii) provide monthly oral healthcare education or implement a tooth brushing program; (viii) ensure that staff members receive three hours of training annually on Empower topics; (ix) make Arizona Smoker's Helpline (ASHLine) material available at all times; and (x) maintain a smoke-free campus. Monitoring of the policies is conducted through the Bureau of Child Care Licensing (BCCL). ADHS continued to enhance training and technical assistance for child care facilities around the Empower standards through regional trainings, annual conference, website and other means. Child care licensing regulations require child care facilities to offer meals family style, reduce juice consumption, and reduce screen time which reinforce the Empower standards. First Things First (FTF) Child Care Health Consultants (CCHC) continued to strengthen the Empower standards and offer technical assistance for facilities enrolled in FTF's Quality First! program, Arizona's Quality Improvement and Rating system (QIRS). The Arizona WIC Program provided regional trainings in FY13 for WIC staff. The purposes of the training were to increase competency around the identification of overweight/obesity using both new USDA WIC Risk Codes and individual assessment data, as well as how to have effective conversations regarding weight and growth. The FY 13 training focused mostly on infants. In this training, the new World Health Organization growth grids for children under 2 were presented. Training outcomes included staff being more confident discussing infant growth with caregivers and the incorporation of Baby Behavior messaging in assessment and counseling to lay the foundation for establishing healthy feeding relationships. The ADHS collaborated across prevention bureaus to introduce the innovative Health in Arizona Policies Initiative (HAPI). ADHS worked with 13 county health partners to implement public health strategies impacting healthy eating, active living, and healthy weight across the lifespan. Late in FY13, ADHS was awarded a grant through Nemours, funded by CDC to support selected child care centers to improve policy and practice related to health, wellness and obesity prevention. BNPA will partner with Nemours to implement the CDC-funded project that will assist Early Care and Education (ECE) providers in improving the healthy eating and active living practices, using a learning collaborative quality improvement method. The Empower PLUS first cohort will launch in FY14. 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. WIC continues to expand staff training and education around Pyramid Level of Service DHC ES PBS IB X X X 107 participant-centered weight counseling with WIC families 4. 5. 6. 7. 8. 9. 10. b. Current Activities Throughout FY 14, we have continued to provide ongoing activities, resources and support for WIC staff to increase their confidence in having participant centered nutrition discussions. We have also produced client reinforcement materials around infant nutrition and baby behaviors to support staff efforts in the work they do with families. During FY14 we are also conducting user acceptance, beta and pilot testing of our new automated system. This incorporates the participant centered conversational approach into the automation system that captures assessment data and issues food benefits. Finally we will conduct initial research and develop Nutrition Care Standards for each WIC participant category and Nutrition Risk Code as a reference for WIC staff to refer to for best practices. The Empower program implemented three regional trainings in an effort to reach out to as many providers as possible. The Empower program conducted its third annual conference on May 3rd, 2014 and provided training on all standards and launched the Empower tooth brushing guide. The tooth brushing guide was created by ADHS Office of Oral Health to guide child care providers who choose to implement a tooth brushing program. Child care licensing surveyors enhanced their monitoring of the Empower program by incorporating additional questions specific to each Empower standard into their monitoring system. The data informs the Empower program of training and technical assistance needs in the field. c. Plan for the Coming Year Empower Home Visiting will continue training on standards of breastfeeding, nutrition, and physical activity standards for young children including children with special health care needs. The Statewide Early Childhood Home Visiting Task force will continue to include nutrition and physical activity into early childhood home visiting curriculum. The Empower program will continue to provide technical assistance through trainings and webinars to child care providers to support the implementation of the 10 Empower standards. The program will work on creating on-line trainings to better reach a large number of providers across the state. The Empower website will also be used as a tool to provide comprehensive resources for ECE professionals including webinars, teacher and parent resources, websites, and sharing of success stories. ADHS Bureau of Child Care Licensing will continue to require child care facilities to offer meals family style, reduce juice consumption, and reduce screen time. In addition they will support facilities that choose to become Empower sites to follow the 10 standards supporting healthy eating, active living, oral health, and tobacco prevention. Licensing surveyors will continue to incorporate the additional questions on the implementation of the 10 Empower standards into their existing monitoring system. Empower PLUS will implement Cohort 2 during FY15 with 75 additional child care centers participating. The format includes 5 trainings, on-site technical assistance, provision of resources, assessments and developing and implementing improvement plans. Additionally, continued limited support for Cohort 1 programs will be provided through monthly technical 108 assistance and electronic communication. During the remainder of FY15, we will be developing curriculum for a week-long intensive "Nutrition Boot Camp" course for WIC staff. The course will focus on the maternal and child nutrition topics that WIC staff utilize in their daily work. This week-long course will be offered to all current staff, as well as become a requirement of the new employee training, with an expectation that staff repeat the course at least every 5 years to be updated on any changes in standards or best practices. The AzNN has identified nine potential evaluation strategies, eight of which will begin implementation in FY15. These include: direct education to children and caregivers, breastfeeding-friendly centers, development/implementation of healthy food/beverage policies, improve capacity in healthy food preparation, child care gardens, child care wellness councils, development/implementation of physical activity policies, and improving capacity in physical activity opportunities. The only strategy not selected by a contractor was with Farm to Child Care programs. State AzNN staff will work to improve capacity at the state level and coordinate with Arizona Department of Education (ADE) to support this strategy. 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 2009 2010 2011 2012 2013 4.2 4 4 4 3.9 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 4.4 3748 84963 AZ Birth Certificates Final Final 2017 3.5 2018 3.4 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 2014 3.8 2015 3.7 2016 3.6 Notes - 2013 109 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 2013 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). The percentage of women who smoke during preganancy increase slightly after being on the decline since 2008. The indicator is still lower than it was in 2008. 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. 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 2013, 9,296 women utilized Arizona Smokers' Helpline (ASHLine) services. Of these, 176 (or 1.9% of women using ASHLine) reported being pregnant. According to Arizona Department of Health Services Birth Certificate data for 2013, Arizona has a pregnancy tobacco use rate of 4.4%. ADHS does not collect data on the last three months of pregnancy specifically. Arizona's tobacco prevalence rate of adults is 17% and we are ranked 10th in the nation. 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 work towards system and policy change. Their preconception health activities included community education, building coalitions, changing organizational practices, and developing policies. Counties utilized toolkits on tobacco use and other preconception health topics. Five counties worked to assist other organizations to develop worksite wellness plans including the prevention of smoking onsite. Three 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. Six out of seven County contractors provided public education for teens and women related to tobacco use. The Bureau of Tobacco and Chronic Disease (BTCD) statewide youth coalition effort, Students Taking a New Direction (STAND) is still growing in recruitment and in work being accomplished. 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 date 110 we have 25 coalition chapters that fall under the STAND umbrella and all 25 coalitions are working on local policy in their communities to make tobacco less acceptable and accessible to youth. More information can be found on www.standaz.com. The Health Start Program expanded screening of women and families for tobacco use through the piloting of the Healthy @ Home Assessment Tool for postpartum clients and the expanded Alcohol, Tobacco and Other Drug screening of all prenatal clients. The Program continued to provide the Every Woman Arizona Preconception Health Education materials and "Are You Ready?" life plan booklets to contractors which are being utilized during family follow-up visits with the postpartum clients. The topics address risk factors related to smoking, a smoking survey and techniques to help women quit or cut down on smoking during and between pregnancies. Community Health Workers refer any pregnant or postpartum woman or family member who is using tobacco to local cessation programs and to ASHline's website www.ashline.org.to provide education on the health risks and steps to stop smoking. 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 collaborated with the county level Tobacco Education and Prevention Program to provide brief interventions and referrals for clients who were using tobacco. If a patient identified herself as someone who used tobacco during an exam or a pregnancy test, clinic staff provided information on smoking cessation and a referral to the county Tobacco Education and Prevention Program. Maricopa County Department of Public Health, through the Community Health Grants, worked with the Arizona for Smoke Free Living group as part of the Policy Committee. The role of staff was to assist in developing policy language to be adopted by multi-unit housing complexes that will become smoke free. This policy was developed, but then it was determined by the group that electronic cigarettes should be added to the policy language. Table 4a, National Performance Measures Summary Sheet Activities 1. BWCH bilingual Hotline staff refer pregnant women to ADHS tobacco education and cessation program. 2. Home Visiting and Family Planning Programs provided training to contractors on tobacco cessation. 3. 4. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X b. Current Activities 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 111 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. Six out of seven counties participating in Title V County Health grants 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. The Pima County Child Care Health Consultation Program is working with their tobacco cessation staff to become the formal Pima County ASHline referral site. Health Start has implemented the new Healthy @ Home Safety Assessment Tool at all sites which incorporates questions about tobacco and facilitate referral to the ASHline as well as a Chronic Disease Self-Management program. Health Start has implemented the new expanded Alcohol, Tobacco and Other Drug Screening Tool at all sites with all prenatal clients and making referral to the ASHline. 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 training workshops on the Healthy @ Home Assessment Tool and the expanded Alcohol, Tobacco and Other Drugs screening tool and brief intervention for the Community Health Workers and Coordinators for all contractors in 2015. The Program will use the Basic Tobacco Intervention Skills for Maternal and Child Health Guidebook developed by the University of Arizona Health Care Partnership and the Steps to a Healthier Baby guidebook. 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 continue to 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) will continue to increase outreach efforts to priority populations, like pregnant women, by partnering Community Health Centers statewide (CHCs). Rather than providing direct services to the clients, ASHline and BTCD are working to create a systemic change within all CHC's by working with the Arizona Association for Community Health Centers. The systemic change is a sustainable referral system created within CHC systems throughout the state. The Title V County Health and Prevention contracts will continue to include information on tobacco use in their preconception health activities. The HRPP/NICP will continue to provide the EveryWoman Arizona Preconception Health Education to contractors for family follow-up visits with the postpartum clients. 112 Health Start will continue to provide the new Healthy @ Home Assessment tool to all postpartum clients and provide the new Alcohol, Tobacco and Other Drugs screening tool to all prenatal clients and refer clients and family members as needed to ASHline, Chronic Disease SelfManagement Programs and alcohol and drug treatment providers. Based on the results of the feedback of contractors, the HRPP will determine the feasibility of the use of 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. This tool was more difficult to implement in this program because of the acuity of the baby and the reduced number of visits. Performance Measure 16: The rate (per 100,000) of suicide deaths among youths aged 15 through 19. Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source 2009 2010 2011 2012 2013 12 10 8.2 9.8 9.8 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 6.8 32 470793 AZ Death Certificates Final Final 2017 6.5 2018 6.5 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 2014 6.7 2015 6.7 2016 6.5 Notes - 2013 The rate (per 100,000) of suicide deaths among youth aged 15 through 19 decreased 34% from 10.3 in 2012 to 6.8 in 2013. This was a significant decrease (p<0.05). a. Last Year's Accomplishments While Arizona saw a reduction in the rate of suicide for youth 15-19 years old to 6.8 in 2013 down from 10.3 in 2012, much more needs to be done. In 2013, the 20th Annual Child Fatality Report was produced, summarizing reviews of child deaths that occurred in Arizona during 2012. This marks the eight year that the Child Fatality Review Program has reviewed 100 percent of child 113 deaths that occurred in Arizona. During 2013, Child Fatality Review Teams reviewed the circumstances surrounding the suicides of 33 children that occurred during 2012. Twenty four (73 percent) of the suicides were among children 15 through 17 years, and nine children (27 percent) were 14 years and younger. The most common methods of suicide were firearm injury and hanging. The most commonly identified contributing factor to child suicides was drug and/or alcohol use. The Division of Behavioral Health Services provided information to BWCH program managers regarding behavioral health resources for women and children in the ADHS Zero to Five workgroup. That information was shared with our other colleagues and contractors. 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. As of July 2014, over 10,000 individuals have been screened through a primary care physician. The early childhood home visiting programs screened women for postpartum depression and made referrals when appropriate. The Title V County Health and Prevention contracts work towards reducing the rate of injuries, both intentional and unintentional. Their injury prevention activities included community education, building coalitions, changing organizational practices, and developing policies. 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 working with emergency departments to address the issue of opioid prescription abuse established prescription guidelines for emergency departments. Table 4a, National Performance Measures Summary Sheet Activities 1. hild 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. Prescription drop off event details and how-to develop a Prescription drop off community event is available on the ADHS web page. 4. The Injury Prevention Program continues to work with ED to address opiod prescription abuse. 5. The Injury Prevention Program is working with stakeholders to develop Prescription Drug Guidelines for Providers. 6. 7. 8. 9. Pyramid Level of Service DHC ES PBS IB X X X X X 114 10. b. Current Activities Recommendations made based on the findings of the 2012 Child Fatality Review included: encouraging ADHS to train law enforcement to use the Suicide Investigative Checklist when investigating child deaths if suicide is suspected; that law enforcement us the checklist and for parents to learn the warning signs for suicide. Parents are cautioned to take threats and talk of suicide seriously. Parents were also encouraged to store firearms unloaded and in a secure location. If there is a family member showing signs of depression, substance abuse or mental illness parents are advised to consider removing the gun out of the home. 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. The Division of Behavioral Health (DBH) included a goal in the Fiscal Year 2014 Annual System of Care (SOC) Plan, calling for a reduction in the Arizona age-adjusted suicide rate from 17.2 to 15 per100, 000 by 2018. The SOC Plan outlines specific strategies and tasks aimed at achieving this goal. c. Plan for the Coming Year The Child Fatality Review Program will continue to review the deaths of all children to identify preventable factors and will continue to conduct surveillance of causes and circumstances surrounding child suicides in Arizona. The Child Fatality Review Program staff will continue to provide technical assistance to the local child fatality teams in the development and implementation of local, culturally sensitive teams and will identify and promote campaigns to educate the public on preventing suicide among children. The Annual Child Fatality Report will be produced in November and will include data on suicides and recommendations to prevent suicides among children. The Division of Behavioral Health Services will continue to participate in the ADHS Injury Prevention Advisory Council and the ADHS Internal Injury Prevention Workgroup. Programs in the Bureau of Women's & Children's Health will continue to collaborate with the Division of Behavioral Health Services to help partners understand existing resources and the service system. Bureau of Women's & Children's Health will work on promoting mental wellness messaging in existing maternal and child health programs in collaboration with Division of Behavioral Health Services. The Injury Prevention Program will continue to collaborate with the Division of Behavioral Health Services and medical professional organizations to establish statewide guidelines on prescription drug abuse for health care providers/prescribers. The Division of Behavioral Health (DBH) will continue to offer a Youth- Mental Health First Aid course for adults who live with youth and parents. It is a an 8 hour course that provides an overview of mental illness and substance use disorders and teaches attendees about the warning signs of mental health problems and common treatments. The classes are offered across the state and the calendar is posted on the DBH website. 115 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 2009 2010 2011 2012 2013 83 91 91.5 92 92.5 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 92.3 856 927 AZ Birth Certificates Final Final 2017 94 2018 94.5 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 2014 93 2015 93.5 2016 94 Notes - 2013 The 2013 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 - 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. 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 116 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. In the last several years, a number of hospitals have raised their level of designation and as a result there have been fewer maternal transports as more hospitals are qualified to keep their pregnant women in the community. 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 FY 2013, 797 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 women to appropriate level of care regardless of ability to pay. 2. The BWCH continues to partner with the Arizona Perinatal Trust on the review of maternal transports during site visits to hospitals. 3. The HRPP requires contracted hospitals to use contracted transport providers ensuring the highest quality care. 4. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X b. Current Activities The maternal transport component of the 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. 117 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. In 2014, the program held two regional meetings in the Phoenix metropolitan area and in Tucson for southern Arizona, to revisit the transport system and gather input from community stakeholders to ensure that program policies continue to reflect best practices and the needs of the community. 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. The transport program plans to hold another regional meeting in northern Arizona to gather input from community stakeholders. 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 2009 2010 2011 2012 2013 80 81 83 84 85 80.3 74331 92616 81.9 71331 87053 83.3 70953 85190 83.9 71882 85725 82.7 70255 84963 118 Data Source AZ Birth Certificates AZ Birth Certificates AZ Birth Certificates Check this box if you cannot report the numerator because 1.There are fewer than 5 events over the last year, and 2.The average number of events over the last 3 years is fewer than 5 and therefore a 3-year moving average cannot be applied. Is the Data Provisional or Final? Annual Performance Objective 2014 86 2015 87 2016 88 AZ Birth Certificates AZ Birth Certificates Final Final 2017 88 2018 88 Notes - 2013 The HP 2020 Goal is 77.9%. Notes - 2012 The HP 2020 Goal is 77.9%. a. Last Year's Accomplishments As a state, Arizona has surpassed the Healthy People 2020 goal of early prenatal care. In 2013, 82.7 percent of babies in Arizona were born to pregnant women who began their prenatal care in the first trimester. There are many program and efforts directed to this goal. 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 program utilized Community Health Workers (CHWs) 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 2013, Health Start provided educational services to 2,259 clients. The program provided a total of 12,865 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 53.2% of Health Start clients entered the program in their first trimester of pregnancy. Of the prenatal client enrollments, 71.6% were receiving prenatal care at the time enrollment. An earlier evaluation concluded that babies of Health Start mothers had higher gestational ages and/or full term when compared to non-Health Start mothers. Babies of Health Start mothers also had higher birth weights when compared to babies whose mothers were not in the program. Over 91.1% of clients had a baby within normal birth weight. The proportion of very low birth weight infants born to Health Start clients was approximately 1.9% and low birth weight was 7%. 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. 119 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 1,235 calls about eligibility for Baby Arizona in 2013. Table 4a, National Performance Measures Summary Sheet Activities 1. Bilingual Hotline staff referred to providers offering sliding scale rates for prenatal care for pregnant women who would not qualify for Medicaid. 2. Arizona's home visitors who see pregnant women encourage early and consistent prenatal care and support the women during the pregnancy. 3. 4. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X b. Current Activities The Health Start Program continued to identify pregnant women within their community and facilitate early entry into prenatal care, educate pregnant and postpartum women and their families about prenatal care, nutrition, the benefits of breastfeeding, danger signs of pregnancy, and home safety. This year, Baby Arizona was discontinued by Arizona Health Care Cost Containment System, our Medicaid program with children either now eligible for Medicaid or referred to the marketplace. However, the BWCH Pregnancy and Breastfeeding Hotlines are collecting information from physicians who are willing to continue to provide prenatal services to uninsured pregnant women. The Hotline is referring callers to the closest available physician. 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 continued 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 HS and Baby Arizona as well as external partners, on the importance of oral health during pregnancy. 120 Preconception health materials/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 refer uninsured pregnant women to physicians who are willing to provide low cost prenatal care. 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. The BWCH prepares an annual report for Arizona Perinatal Trust (APT) birthing hospitals from birth certificate data which include both demographic and process metrics. Each hospital is compared to other hospitals of the same level of perinatal care and to the state. One of the metrics is entry into prenatal care. During APT site visits hospitals are asked about community outreach including how they work in the community to facilitate early entry into prenatal care. D. State Performance Measures State Performance Measure 1: The percent of high school students who report having experienced physical violence by a dating partner during the past 12 months. Tracking Performance Measures [Secs 485 (2)(2)(B)(iii) and 486 (a)(2)(A)(iii)] 121 Annual Objective and Performance Data Annual Performance Objective Annual Indicator Numerator Denominator Data Source 2009 2010 2011 2012 2013 10.6 10.6 10.6 11.8 302 2557 Youth Risk Behavior Survey 11.4 326 2856 Youth Risk Behavior Survey 11.4 326 2856 Youth Risk Behavior Survey Final 10.1 161 1600 Arizona-Youth Risk Behavior Survey 2013 Final 2015 9.7 2016 9.5 2017 9.5 2018 9.5 Is the Data Provisional or Final? Annual Performance Objective 2014 9.7 Notes - 2013 The 2013 CDC YRBS wording of this question has changed compared to the 2011 survey. The CDC YRBS does not contain this data. Data was obtained from the Arizona Department of Education (www.azed.gov/preventionprograms/resources/data/yrbs). The state added question was "During the past 12 months, did your boyfriend or girlfriend ever hit, slap, or physically hurt you on purpose? 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%) a. Last Year's Accomplishments According to Arizona's Department of Education Arizona High School Survey Trend Analysis Report from the 2013 Youth Risk Behavior Survey, the percentage of teens who reported physical dating violence decreased from 11.4 percent in 2011 to 10.1 in 2013. 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. Staff from the seven shelters provided 92 healthy relationship presentations and/or workshops to a total of 3,567 youth and teens in rural communities. Topics included Domestic Violence 101, Teen Dating Violence, Building Self-Esteem, Power and Control, Emotion Regulation and Bullying and Cyber Stalking. The agencies also offered advocacy and support/counseling for domestic violence victims' children. The Rural Domestic Violence Services Network provided 399 awareness presentations to 18,770 adults, 236 presentations to 5,039 youth and attended 147 community awareness events in rural Arizona. Of the 63 youth less than 18 years of age that self-reported being a victim of intimate partner violence during a workshop, all received support services in the form of one-on-one counseling or in a group support/counseling program. The Centers for Disease Control (CDC) funded Sexual Violence Prevention and Education Program (SVPEP) provided sexual violence prevention multi-sessions across three counties. The target population included diverse youth, school staff, family and community members. 122 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. In 2013, ADHS maintained three contracts in rural counties. This allowed the continued funding of outreach, hotlines, and counseling services within those three counties and several rural communities. In 2013, a total of 383 victims/survivors and 46 collaterally victims/survivors affected received services. Health Start Program Community Health Workers and Community Health Nurses continued to attend training on domestic violence provided by the Arizona Coalition to End Sexual and Domestic Violence (AzCESDV) to learn how to effectively screen for domestic/dating violence. The Relationship Assessment Tool was provided to 394 Health Start clients as part of the Community Health Worker home visits of which 20% are teen mothers. Over 8% of the clients scored at risk for domestic violence. Yavapai County is providing education about healthy and abusive dating relationships using a Safe Dates course. Beginning January of 2013, all twelve Title V family planning clinics are contractually obligated to screen for domestic violence and reproductive coercion. Table 4b, State Performance Measures Summary Sheet Activities 1. Sexual Violence Prevention and Education Program provides education in key areas of sexual violence prevention in local communities. 2. The Rural Domestic Violence Services Network provided awareness presentations to adults, presentations to youth and attended community awareness events in rural Arizona. 3. The home visiting alliance, StrongFamilesAz provides professional development around domestic violence to Arizona's home visitors. 4. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X b. Current Activities RDVSN agencies continue to provide presentations, events, and/or workshops to youth around the state. Teen Mazes, fun interactive events designed to educate teens on topics of healthy relationships and wellbeing are also held by three of the seven DV agencies, over 500 teens participated in each teen maze. Agencies offer one time presentations or multiple week long programs in school settings, in after school programs and in detention centers throughout the state. Teen support groups and one-on-one counseling are also being held in specific locations. From February 1, 2014 through April 2014 SVPEP agencies have given 127 single/multi session presentations to a total of 1,063 attendees and have started piloting the new data collection tool. SVPEP has continued to provide education in key areas of preventing sexual violence to youth 123 and community members. All Arizona 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 professional development topics of home visitors. MIECHV has contracted with the Arizona Coalition to End Sexual and Domestic Violence to present to home visitors regionally and at the statewide conference. The StrongFamiliesAz Alliance and the Coalition are developing standards of practice for all home visitors to use. All twelve Title V family planning clinics continue to screen for domestic violence and reproductive coercion. c. Plan for the Coming Year The Title V funded Yavapai County project will continue to work with teachers in local schools so that the teachers can continue to provide education about healthy and abusive dating relationships using the 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 will 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. Health Start will continue to coordinate with the AzCESDV (Arizona Coalition to End Sexual and Domestic Violence) to provide training to Health Start staff on the Project Connect -- Futures without Violence education. Health Start will continue to collect the assessments and analyze the results in an effort to inform future program issues and professional development planning. During annual site visits, the Health Start Program Manager will continue to monitor to ensure that each client is screened for domestic/dating violence and that appropriate referrals are provided as needed. AzCESDV provides a list of resources to contractors who receive Project Connect training so clients can receive appropriate referrals. Health Start will provide the Futures without Violence safety planning cards to contractors. 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 to End Sexual and 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 and at the annual professional development conference. Yavapai County will continue to work with school teachers to become independent in providing education to youth about healthy and abusive dating relationships using a Safe Dates course. 124 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 2009 27.7 652 2354 Youth Risk Behavior Survey (2009) 2010 27.7 652 2354 Youth Risk Behavior Survey (2009) 2011 2012 2013 27 26.5 26 24.8 666 2687 Youth Risk Behavior Survey (2011) 24.8 666 2687 Youth Risk Behavior Survey (2011) Final 23.4 356 1520 Youth Risk Behavior Survey 2013 2017 24 2018 22.5 Is the Data Provisional or Final? Annual Performance Objective 2014 25.5 2015 24.9 2016 24 Final Notes - 2013 A student was obese if >=95th percentile and overweight if >=85th percentile but <95th percentile. In Arizona, 10.7% were obese and 12.7% were overweight. The HP 2020 Goal for adolescent obesity is 16.1%. 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% 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 to educate Arizona's state, county and local decisionmakers about the health implications of policy. Through the operation of this grant, counties have 125 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 and community based organizations to specifically create 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 have embedded 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 staff worked with the city of Goodyear, Mesa, Tempe, Scottsdale and Phoenix to incorporate Healthy Community Design principles into their General Plan. Table 4b, State Performance Measures Summary Sheet Activities 1. Through the Title V Community Grants, counties imbed preconception health, obesity prevention, and chronic disease prevention into their other programs. 2. 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. 3. OCSHCN supports Special Olympics Arizona to increase the participation of CYSHCN in physical activities and nutritional trainings. 4. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB 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 also 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 also 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 introduced a new school initiative that aligns and supports the existing work of the above 126 programs including direct partnership with the Arizona Department of Education Health and Wellness Team. Empower Schools is school-based pilot program that have 68 schools participating from around the state to update their local wellness policies using support from local and regional health programs (HAPI, AZNN, Department of Education). c. Plan for the Coming Year ADHS will continue to enhance department-wide strategies to reduce and prevent obesity throughout Arizona consistent with the ADHS strategic map and winnable battles. In the upcoming year Empower Schools will begin to implement the written Guidebook and coinciding ten wellness standards. This information was created in year one with support of the CDC's Coordinated School Health Model and input from pilot schools. Also data will begin to be collected using national surveillance surveys including YRBS and School Health Profile Surveys. This will determine if health improvements are occurring based on updated school wellness policies and improved school health environments. The success of implementation and correlated health improvements through 2018 could provide a state standard school-based model for updating school wellness policies and improving the school health environment. BNPA will continue to work on the 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 continue to 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. ADHS will continue to support the Memorandum of Understanding between ADHS, the Arizona Department of Economic Security, the Arizona Department of Education, and First Things First that supports consistent common messaging around obesity prevention across government departments. 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 Is the Data Provisional 2009 2010 2011 2012 2013 31.5 31 31 30.5 30 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 18.4 177 964 AZ Vital Records Final 127 or Final? Annual Performance Objective 2014 30 2015 29 2016 29 2017 29 2018 29 Notes - 2013 Updated: 09/12/14 The decrease in the percent of preventable fetal and infant deaths may be partially explained by the decrease in infant deaths in 2013. 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. a. Last Year's Accomplishments The Child Fatality Review Program issued an annual report in November 2013, with recommendations for prevention of infant deaths. Based on the results of the data analysis, Arizona's efforts to reduce the percentage of preventable fetal and infant deaths centers around three main efforts: making the sleep environment safer, car seat education and capacity and preconception and interconception health. According to the 2013 Arizona Child Fatality Report, in 2012, seventy seven infants died in Arizona as a result of their sleep environment. These infants died while sleeping on surfaces other than their beds, co-sleeping or lying on their sides or stomachs. In order to address this, under the guidance of the Bureau of Women's and Children's Health Office of Injury Prevention, in 2013 stakeholders from around Arizona gathered to for a Safe Sleep Task Force to unify efforts around the sleep environment. Current efforts from around the state were shared. The group agreed that the community should speak with ‘one voice' and have the same message for all families. That message was the Academy of Pediatrics' statement on safe sleep. After much discussion, as the state was making plans to develop a state plan on improving birth outcomes the group agreed to await the outcome of that planning meeting while continuing their individual efforts. The Bureau serves as a partner with the Arizona Perinatal Trust and in that capacity is able to review policies at certified hospitals about safe sleep. All home visitors have received extensive training about the necessity of reinforcing the safe sleep message in the home. The Office of Injury Prevention works to address the importance of car seats and car seat capacity. The Injury Prevention Manager serves as a liaison to Safe Kids Worldwide, and as such to the local coalitions. Efforts to improve car seat usage included providing certified car seat trainings, with a focus on the rural areas where there is reduced capacity or trained personnel. These efforts are discussed more fully in response to National Performance Measure 10: The rate of deaths to children aged 14 years and younger caused by motor vehicle crashes per 100,000 children. The Bureau of Women's and Children's Health is executing 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 with 63 participating agencies and local community partners. The grant has allowed Arizona the opportunity to create a robust professional 128 development system for all Arizona's home visitors. This professional development includes car seat safety, safe sleep and the importance of the health of the mother both before and between pregnancies. The Preconception Health Implementation Task Force completed and distributed an updated the Arizona Women's Health Status Report in 2013 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 in English and Spanish continues to be distributed for use with clients by Health Start, the High Risk Perinatal Program, the MIECHV funded home visitors and Community Health grantees. 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. The Child Fatality Review Program and Arizona Unexplained Infant Death Council continued to promote use of updated Infant Death Investigation Checklist. Table 4b, State Performance Measures Summary Sheet Activities 1. Child Fatality Review Program promotes use of the Infant Death Investigation checklist. 2. Child Fatality Review Program produces annual report on infant and child deaths, including recommendations for prevention. 3. ADHS programs promote use of folic acid and multivitamins. 4. BWCH promotes preconception health materials and strategies. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X X b. Current Activities Arizona held an Improving Birth Outcomes summit in January 2013 with over 160 people participating. The group identified four major goal areas: improving the health of women and girls, promoting safe and stable families, reducing premature births and reducing health disparities. Separate groups are moving forward to identify more specific goals and strategies including safe sleep and eliminating early elective inductions. The Bureau of Nutrition and Physical Activity continues to maintain the folic acid campaign Power Me A2Z. Women are encouraged to visit the Power Me A2Z website. 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 campaign is finishing the development of a new part of the website addressing birth spacing and family planning after the birth of a baby. The Emergency Medical Services for Children is expanding the pediatric designation system for 129 emergency departments to build the capacity of EDs to better care for infants and children. There are currently 18 hospitals that have received verification status. After it was identified that car seat usage is low on the border because of the cost to families, the Injury Prevention Program has worked with Safe Kids Arizona and the Arizona Mexico Commission- Health Services Committee to collect gently used car seats that were distributed across the border by local Arizona fire departments. c. Plan for the Coming Year The Preconception Health Alliance 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 and related training provided on the Strong Families Arizona website. The Home Visiting Talking Points for Folic Acid and Pregnancy Spacing developed in conjunction with the Bureau of Nutrition and Physical Activity will be distributed to all Community Health Workers and Community Health Nurses to use with clients during home visits. Programs will continue to educate clients and families regarding safe sleep environments and will participate on the Safe Sleep Task Force. 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. The work of the Title V County Health Prevention contracts will continue to 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. 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 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 will continue to work to expand the project to include rural and tribal health facilities. The Child Fatality Review Program will issue annual report in November 2014, 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. 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. 130 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 2009 2010 2011 2012 2013 7476 7000 7400 7250 7100 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 7,587.0 96422 1270886 AZ Hospital Discharge Data Final 7,118.2 90773 1275227 AZ Hospital Discharge Data Final 2014 6950 2015 6800 2016 6650 2017 6650 2018 6600 Is the Data Provisional or Final? Annual Performance Objective Notes - 2013 Updated 2012 numerator on 06/09/14. The rate of emergency department visits for unintentional injuries per 100,000 children age 1-14 decreased 6.2% from 2012 to 2013; this was significant (p<0.0002). Notes - 2012 Numerator updated on 06/09/14. 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. a. Last Year's Accomplishments The rate of Emergency Department visits for unintentional injuries for childre 1-14 decresed last year. 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. 131 Arizona's Emergency Medical Services for Children Program established a pediatric designation system for hospital emergency departments in 2012. This system's purpose is to identify minimum training and equipment a hospital needs to care for a pediatric patient.. The program contracts with the American Academy of Pediatrics, Arizona Chapter to act as the certifying body. In 2013, 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 rolled out the ED Prescribing Guidelines for Controlled Substances and partnered with sister state agencies to address the issue of prescription drug misuse/abuse. In 2013, the Office of Injury Prevention published their Injury Prevention Plan, 2012-2016, to guide state and community efforts to reduce the burden of injury throughout Arizona. 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 20th 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 safe storage of firearms, education on safe sleep, 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 certification. 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. Pyramid Level of Service DHC ES PBS IB X X X X X 132 6. 7. 8. 9. 10. b. Current Activities Emergency Medical Services for Children continues to work on the pediatric designation system for emergency departments. There are currently 18 hospitals that have received Prepared, Prepared Plus or Prepared Advanced certification status. These ED's will see approx. 300,000 children in 2014. The Office of Injury Prevention, along with the Arizona Criminal Justice Commission and other state agencies, continue to work together on the Arizona Prescription Drug Reduction Initiative. ADHS completed the activities in the ASHTO and Robert Wood Johnson Foundation (RWJF) Quality Improvement Integration Project. Health Start has incorporated the Healthy @ Home: Arizona Home Safety and Family Wellness Assessment into its contract requirements at all sites. The assessment integrates environmental health and chronic disease components in to the home visiting process. MIECHV will be discussing this tool with model developers. The MIECHV grant is funding .5 FTE in the Office of Injury Prevention to develop trainings for home visitors around injury prevention for the young child (car seats, safe sleep, safe homes). ADHS formed a Task Force to address safe sleep as a part of the larger Improving Birth Outcomes initiative. The group will use the Collective Impact model as a framework. 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. The Office of Injury Prevention will be expanding the "Battle of the Belt" program- a seatbelt campaign that targets increasing restraint use with high school students. Health Start Community Health Workers and Community Health Nurses will continue to conduct the Healthy @ Home assessments during home visits. The home visitors will continue to work with families to correct identified concerns and make referrals to ASHline and the Chronic Disease Self-Management Programs in their areas. BWCH will continue to implement the federal MIECHV 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 600 home visitors and managers are expected to attend this year's conference. The Injury Prevention .5 FTE working on home visiting will assist. BWCH will continue to utilize the standardized home visiting safety assessment tool developed through the Robert Wood Johnson CQI grant. Based on results of the pilot, changes were made to the tool. This assessment will be used by the two home visiting programs in the BWCH with the hope that the Early Childhood Task Force will eventually adopt the tool for all of Arizona's 133 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 this coming year, 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. Additionally, draft guidelines for prescribers are being vetted in the community. 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. 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 2009 41.7 24748 59309 AZ Birth and Fetal Death Certificates 2010 43.8 24330 55589 AZ Birth and Fetal Death Certificates 2011 2012 2013 45 45.5 46 44.2 24449 55265 AZ Birth Certificates 44.2 24797 56160 AZ Birth Certificates 43.3 24452 56483 AZ Birth Certificates Final Final 2017 48 2018 48 Is the Data Provisional or Final? Annual Performance Objective 2014 46.5 2015 48 2016 48 a. Last Year's Accomplishments BWCH staff chose to use a measure of inter-pregnancy intervals as an indicator of progress on the 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. Unfortunately, the percentage of women having a subsequent pregnancy during the recommended interval decreased from 44.2 in 2012 to 43.3 in 2013. Through the Reproductive Health/Family Planning Program (RHFP), 11 out of the 15 County 134 Health Departments and Maricopa Integrated Health Services (County) continued intergovernmental agreements (IGA's) funded with Title V dollars to provide reproductive health/family planning services that focused on women at or below 150% of the federal poverty level. Of the 5,012 women who received an initial or annual exam in 2013, 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 2013, 56% 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 reproductive coercion. The BWCH will continue to participate on the CDC's Preconception Health Consumer Workgroup. This will allow Arizona to be an active partner in national efforts to promote preconception health and health care. In addition, Arizona will continue to disseminate and utilize current marketing strategies for increasing public awareness of preconception health. The Power Me A2Z folic acid education and distribution program launched its campaign in August 2013 through on-air interviews and radio personality endorsements, online radio ads, television ads, online banner ads, social media posts. The program distributes Power Packs through the website powermea2z.org, and to other programs at the Arizona Department of Health Services who come in contact with the target audience of women ages 18-25. Additionally, efforts are aimed at pharmacies, community events, county health departments, outreach efforts at universities and employers of high numbers of the target audience in Arizona. The Power Packs contain a 3-month supply of multivitamins with folic acid, a reproductive life plan, a nail file depicting the campaign's call-to-action and pass-it-on cards to share with friends or family. Approximately 28,000 Power Packs were distributed in FY13. Arizona's home visitors continued to discuss reproductive life planning with mothers during home visits. 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. 5. 6. Pyramid Level of Service DHC ES PBS IB X X X 135 7. 8. 9. 10. b. Current Activities BWCH Office of Women's Health (OWH) continues to lead preconception health initiatives, including the work of the statewide taskforce and implementation of the preconception health plan. OWH participates on CDC's Preconception Health Consumer Workgroup. Six county health departments use Title V funds to implement preconception health activities with emphasis on coalition-building, organizational practices, and policy development. Because sexual coercion is a part of intimate partner violence, BWCH assists in training family planning providers to screen women for domestic violence in the clinic setting. Health Start contractors receive training on how they can conduct domestic violence screening in the home setting. "Every Woman Arizona" reproductive life plans are 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, STD and HIV testing. StrongFamiliesAz will develop a training on preconception health focusing on reproductive life planning and women's health in general for this fall. Health Start and the High Risk Perinatal Program Managers developed "Home Visitor Talking Points for Folic Acid and Pregnancy Spacing" handouts for their contractors. These are being used for all StrongFamiliesAZ contractors. Arizona's CoIIN efforts will address preconception health and reproductive life planning. c. Plan for the Coming Year The Power Me A2Z multivitamin distribution and marketing campaign will be promoted to women in the target audience and healthcare and social service providers that encounter those women. The Reproductive Health/Family Planning Program (RHFP) will continue to provide Title V funding to county health departments and Maricopa Integrated Health Systems to offer services to underserved populations. The program will continue to focus on women at or below 150% of the federal poverty level. The program will continue to seek out locations where underserved clients can be reached. 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. Home Visitors will provide "Home Visitor Talking Points for Folic Acid and Pregnancy Spacing" handouts to contractors to use during home visits to educate clients on the importance of taking a multivitamin between pregnancies and to space pregnancies between 18--24 months from birth to the beginning of the next pregnancy. 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. 136 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. BWCH will work with Arizona's Medicaid agency to explore opportunities to include preconception health topics in a well woman exam. The Power Me A2Z campaign will continue its development and dissemination of the interconception phase of the campaign. The powermea2z.org website will be enhanced to include pregnancy spacing information, resources and referrals on interconception health. All Arizona WIC clinic staff will conduct outreach in the clinics with women in the target audience through posters, campaign nail file distribution, talking points, Power Your Next Pregnancy brochures and buttons that staff wear to encourage women to visit the website. A birth control booklet is being adapted from the University of North Carolina to be distributed to women in Arizona through hospital discharge packs, doctors' offices, etc. 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 2009 2010 2011 2012 2013 48 49 50 42.9 240529 560823 AZ Medicaid 47.3 281134 594701 AZ Medicaid 47.9 285371 596114 AZ Medicaid 46.0 274712 596644 AZ Medicaid Final 47.3 280424 592259 AZ Medicaid Final 2014 51 2015 52 2016 53 2017 53 2018 53 Is the Data Provisional or Final? Annual Performance Objective a. Last Year's Accomplishments The Office of Oral Health (OOH) continued to work with stakeholders and partners to develop and promote policies for better oral health, establish integrated population-based interventions, set priorities and select appropriate strategies for target populations. The Office of Oral Health continued to work closely with the Arizona Health Care Cost Containment System, Arizona's Medicaid, in identifying opportunities to increase access to preventive services for eligible enrollees. As a result, referral connections have been made with AHCCCS contracted health plans to help establish follow-up care for children in need. The OOH continues to build community capacity to implement community-level interventions through support development of teledentistry demonstration models. During 2013, the Office or Oral Health launched a teledentistry video highlighting opportunities for partners and stakeholders to implement teledentistry practice in local communities. The Office of Oral Health is developed 137 contractual relations with Inter-Tribal Council of Arizona (ITCA) and the Sells Area Dental Service Unit to provide technical assistance and equipment for a teledentistry demonstration practice model on the Tohono O'odham Indian Reservation. The 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. The 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 essential information necessary to determine the availability and willingness of providers to provide quality care to underserved children ages birth to five and to participate in a referral database. The secondary purpose of the survey was to compare results to the 2003/2004 Arizona Dental Workforce Survey. The report findings indicated that challenges continue for Arizona in building the network of dental providers who are available and willing to provide services for underserved young children and special needs individuals. The OOH 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. In 2013, 15,960 children participated in the program. The OOH, Arizona Fluoride Varnish Program continued to provide services in 2013 as part of a grant from the First Things First South Phoenix Regional Partnership Council. 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. During 2013, 5,884 children received dental screening and oral health education at the South Phoenix and Maryvale WIC site. Of those screened, 5,621 children received fluoride varnish application and referrals for treatment needs. In 2013, OOH conducted a program evaluation of the Arizona Fluoride Varnish Program. The goal of the evaluation was to: document program accomplishments; better manage resources; document program development and activities to help ensure successful replication; improve the implementation and effectiveness of programs; and demonstrate program effectiveness to funders. The OOH participated in the ADHS Empower Program. As part of the program, OOH provides guidance, training and resources to childcare providers on promoting oral health activities in childcare centers and linking children to dental homes. The Empower Program reaches more than 200,000 children in licensed early care and education facilities throughout Arizona. The Office of Oral Health partnered with the Arizona Dental Association, Central Arizona Dental Society in the 2013 Dental Mission of Mercy (AZ MOM). This event was held in December of 2013 and with the help of 1,500 volunteers, more than 2,200 people received about $1.4 million in much needed dental care. Table 4b, State Performance Measures Summary Sheet Activities 1. The Office of Oral Health works closely with the Arizona Pyramid Level of Service DHC ES PBS IB X 138 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. 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 X X b. Current Activities The Office of Oral Health continues to build linkages with partners interested in reducing the burden of oral disease by active participation with the four regional oral health coalitions in Arizona. OOH began planning for the 2014-2015 Healthy Smiles Healthy Bodies Survey for ongoing monitoring of oral disease throughout Arizona. This survey will collect oral health status information on kindergarten and third grade children using the Association of State and Territorial Dental Directors' Basic Screening Survey. In addition, OOH is collaborating with the Bureau of Nutrition and Physical Activity to collect and height and weight information. Information will be used to track trends, inform programs and key stakeholders on directions for oral health prevention programs. Through a MIECHV Grant, the Office of Oral Health is developing oral health education and training models for the Strong Families AZ network of partners to integrate oral health messages into home visiting programs. The overall goal of the oral health training grant is to provide core skills, knowledge, and resources to home visitors while empowering them to encourage parents/caregivers of infants and toddlers to make healthy choices that will have a positive impact in their family members' oral health status and overall health. The oral health training grant will help Arizona in their development of best practices for oral health in home visiting for Strong Families AZ. c. Plan for the Coming Year The Office of Oral Health 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, the Arizona Dental Hygiene Association and the Arizona Alliance for Community Health Centers 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 and 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 139 dental sealant program will continue the current Intergovernmental Agreements with counties and seek to increase the number of children served. OOH will continue to provide guidance and technical assistance to the Empower program by providing resources and training for childcare providers across the state. 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 2013-14 school year, OOH has made significant adjustments to the implementation of the program and expects to increase the number of children served next year. Through the HRSA Workforce Grant and match support provided by First Things First, teledentistry sites will continue to expand to rural and underserved areas. Additionally regional coalitions will be facilitated to support training for both providers and community stakeholders. The OOH will work with other MCH programs in the Bureau of Women's Health to enhance integration of oral health strategies into existing programs, such as Health Start and WIC. 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 and to women of child bearing age with special health care needs. 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 2009 2010 2011 2012 2013 11 10.5 10 11.9 385 3239 AZ BRFSS 11.9 385 3239 AZ BRFSS 11.7 404 3451 AZ BRFSS 14.0 336672 2399700 AZ BRFSS 2011 Final 13.4 329300 2460206 AZ BRFSS 2012 Final 2014 9.5 2015 9 2016 8.5 2017 8.5 2018 8.5 Is the Data Provisional or Final? Annual Performance Objective Notes - 2013 The 2012 numbers were updated on 06/20/14. An error was found in last year's data analysis, this has been corrected and the numbers updated. Weighted frequencies have been reported for 2012 and 2013 to account for any sampling bias that could occur during the survey. Frequent mental distress is defined as having 14 or more mentally unhealthy days as measured 140 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 - 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. Number updated on 06/20/14. Notes - 2011 Frequent mental distress is defined as having 14 or more mentally unhealthy days as measured by the question: "Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?" a. Last Year's Accomplishments 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 continuing 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. The Edinburgh Postnatal Depression Scale was provided to 395 postpartum clients. Of those, 21% of Health Start clients scored at risk. Health Start Community Health Workers and Community Health Nurses provided referrals to behavioral health services. 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. The Division of Behavioral Health continued to provide Mental Health First Aid training. Mental Health First Aid ARIZONA was launched by the Arizona Department of Health Services' Division of Behavioral Health Services and its partners in 2011 - is a public education effort to teach the public to identify, understand, and respond to signs of mental illnesses and substance use disorders. The 8-hour course presents an overview of mental illness and substance use disorders. Students are introduced to risk factors and warning signs of mental health problems and common treatments. Mental Health First Aid training continued to help assist persons experiencing a mental health crisis, such as contemplating suicide. 141 Table 4b, State Performance Measures Summary Sheet Activities 1. Home Visitors provide postpartum depression screening and educate clients on signs of depression and perinatal mood disorders. 2. BWCH promotes strategies to enhance mental wellness among women. 3. StrongFamiliesAz provides professional development for all Arizona's home visitors. 4. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X b. Current Activities The Health Start Program continues to provide the Edinburgh Postnatal Depression Scale (EPDS) screening as part of the family follow-up visits for all postpartum clients. Community Health Workers and Community Health Nurses 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. The Health Start Program Manager continues to participate on the Division of Behavioral Health Women's Treatment Workgroup. HRPP/NICP Community Health Nurses continue to provide the Edinburgh Postnatal Depression Scale screening as part of the home visit made to infants, children and their families after discharge from the Neonatal ICU or Pediatric ICU. Each Community Health Nursing agency contracted with HRPP/NICP has developed a list of referral resource service providers for the community they serve. The community health nurses educate their clients on warning signs of postpartum depression as well as perinatal mood and anxiety disorders. c. Plan for the Coming Year ADHS will continue its department-wide effort to better integrate behavioral health and physical health. 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. Ongoing discussions regarding making cross referrals; linking pregnant behavioral health clients with home visitation services and linking Health Start clients with behavioral health services will continue as needed. Health Start will continue to implement the expanded alcohol survey tool which has added smoking and drug questions and the supplemental brief intervention materials for use by the Community Health Workers. 142 The Health Start Program will continue to provide a training workshop for Community Health Workers and Community Health Nurses 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. The Division of Behavioral Health will continue to provide Mental Health First Aid training. Trainees will continue to be taught how to apply a five-step strategy in a variety of situations, such as helping someone through a panic attack or assisting someone who has overdosed. 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. Each Community Health Nursing agency contracted with HRPP/NICP will continue to 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 Is the Data Provisional or Final? 2009 77.9 2110 2710 AZ Early Hearing and Detection 2010 85.4 2346 2747 AZ Early Hearing and Detection 2011 2012 2013 79 81 83 81.6 2240 2745 AZ Early Hearing and Detection 85.8 2389 2783 AZ Early Hearing and Detection Final 88.6 2920 3295 AZ Early Hearing and Detection Final 143 Annual Performance Objective 2014 85 2015 86 2016 86 2017 87 2018 90 Notes - 2013 Numerator and Denominator for 2011 and 2012 updated on 06/09/14 based on 09/17/13 email from Newborn Screening. Notes - 2012 2012 Number not ready by deadline of application. Numerator and Denominator for 2012 updated on 06/09/14 based on 09/17/13 email from Newborn Screening. Notes - 2011 Numberator and Denominator updated 06/09/14 based on 09/17/13 email from Newborn Screening. a. Last Year's Accomplishments The percent of newborns who needed and received follow up services increased this year. Hearing screening programs serving children 0-5 who were lost to follow-up from the newborn screen, as well as screening of some missed babies and identification of late onset and progressive hearing losses continued to be provided. Community screening programs included home visiting programs such as Parents as Teachers, Early Head Start and Head Start, Arizona Early Intervention Program; BASICS program Community Health Centers and others. Equipment has been purchased through OCSHCN for the Sensory program to provide short term loans to community providers. EFAz has received funding to provide short term equipment loans in the Phoenix region allowing providers of home visiting programs greater access to specific equipment for both hearing and vision screening in early childhood. ADHS partnered with the University of Colorado, National Early Childhood Assessment Project and the Arizona State Schools for the Deaf and the Blind to 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 was completed and standardized reports shared with state EHDI Coordinators. AzEHDI stakeholders reviewed outcomes. 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. 17 audiologists completed the training which covered diagnostic testing and hearing aid fitting. These additional providers impact the timeliness of appointments available to babies who fail their screen and may reduce the age at treatment for those diagnosed with hearing loss. The National EHDI meeting was held in Arizona in April 2013. More than 50 attendees participated including 28 community members who were able to attend free by providing service as room monitors. The state EHDI coordinator arranged room monitors from Arizona Hands & Voices, EFAZ, NBS follow-up staff and the ASDB part C providers. The AzAAP Chapter Champion, Dr. Bradley Golner presented at the annual pediatrics conference in June 2013 on EHDI medical home responsibilities to provide appropriate referrals and monitor high risk infants for hearing loss. AAP also developed an EQIPP (http://eqipp.aap.org/) module entitled Newborn Screening: Evaluate and Improve Your Practice which directly addresses the steps for ensuring all babies who fail a hearing screening receive timely follow up services through diagnosis and intervention. The outreach campaign to all pediatricians included encouragement to complete this quality improvement module. 144 ONBS collaborated with NCHAM and Boys Town to conduct a national survey of pediatricians assessing current knowledge, attitudes and practice related to EHDI. 700 AZ pediatricians were sent surveys with 71 responding (10%). Home Visitors continue to review hearing screening results with parents. EHDI Pediatric Audiology Links to Services (PALS), an online directory of audiology services developed by the CDC, was implemented statewide last year for providers and families to access regional information about audiology services available in their area. Audiologists have been registered and the system is operational. 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. An outreach campaign targeting licensed practitioners was initiated in August to raise awareness of this new service; letters were sent, posters were disseminated, listserv notices delivered and an entire newsletter dedicated to raise awareness of this new registry. The Bureau of Women's and Children's Health, Office for Children with Special Health Care Needs (OCSHCN) initiated a contract with EAR Foundation of Arizona (EFAZ), using Title V funds, designed to build infrastructure for screening beyond the newborn period, in collaboration with other Early Hearing Detection and Intervention (EHDI) stakeholders. Through EFAZ, two trainers became certified hearing screening trainers through Master trainer observation. Outcomes of Arizona's participation in the National Early Childhood Assessment Project were presented at the EFAZ Annual seminar. 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 and assist them with referral for follow up as necessary.. 4. 5. 6. 7. 8. 9. 10. Pyramid Level of Service DHC ES PBS IB X X X b. Current Activities The EAR Foundation of Arizona has screened more than 5,000 children between the ages of six months and five years of age under a First Things First grant for Central and North Phoenix. Master training observation of two trainers was completed. Thirty three medical home trainings were completed as well as fifteen trainings for midwives. Pure Tone and OAE training was provided to 158 Head Start/Early Head Start, tribal programs, Parents as Teachers and schools across Arizona. Guide by Your Side family and audiology partners also developed a comprehensive parent guide, 145 which was financially supported by ONBS. To replace outdated printed materials and create efficiencies, lanyards with 8 gb. flash drives were created containing tools and resources such as best practice recommendations for screening, diagnostic, and early intervention services, published articles from the Joint Committee on Infant Hearing (JCIH), as well as brochures in English and Spanish. OCSHCN continues to partner with the EAR Foundation of Arizona and NBS to support ADHS' follow-up efforts. OCSHCN partners 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. ADHS' Bureau of Women and Children's Health home visiting programs continue to enhance their review of hearing screening. c. Plan for the Coming Year Programs serving children 0-5 will continue to provide 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. Efforts will be required to ensure that training is provided, reporting requirements are understood and followed, and ongoing technical assistance on policies, procedures and equipment issues is available. A comprehensive logic model is being developed in 2014 to be implemented next year that look at short and long term goals, activities, and outputs to better assess the direction of the program. Continuous quality improvement (CQI) projects are also being developed now and through 2015 to improve outcomes for babies who fail or miss the hearing screen. The education plan for 2015 will include projects targeting those families for whom a disparity exists; to inpatient or outpatient screens, subsequent outpatient screens, or diagnostic evaluations. 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. Effective April 1st, hearing screen is now required and hearing loss is included as part of the 29 core panel of NBS disorders. An effort for expanding outreach to hearing screening service providers is being developed and will include social media, web site, conference exhibit and presentation opportunities. ONBS is planning to make significant efforts in reaching Native American communities in 2015. Initial attempts to promote follow-up for Native American infants who've failed their initial hearing screening required additional cultural understanding. ONBS will expand its efforts to follow-up on infants who have failed their initial screening with the help of WIC offices targeting regions with high LTFU to ensure families are aware of the resources available. An eventual goal of the project will be to place notifications in files of children enrolled in WIC. Community Health Nurses and Health Start Community Health Workers and Community Health Nurses will continue to review hearing screening results with parents and provide resources. Home Visitors, OCSHCN and ONBS 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. Community Partnerships 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 146 Consumers, Hands & Voices and others. E. Health Status Indicators Health Status Indicators 04B: The rate per 100,000 of nonfatal injuries due to motor vehicle crashes among children aged 14 years and younger. Health Status Indicators Forms for HSI 04B - Multi-Year Data Annual Objective and Performance 2009 2010 2011 2012 Data Annual Indicator 38.6 36.6 30.2 24.6 Numerator 554 497 413 334 Denominator 1434985 1358059 1368206 1358070 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 - 2013 This number includes data only on hospitalizations; it does not include emergency room 2013 20.8 284 1364423 Final visits. The count includes both traffic crashes and non-traffic crashes. The rate per 100,000 of nonfatal injuries due to motor vehicle crashes among children aged 14 years and younger decreased significantly (by 15.4%) from 2012 to 2013 (p<0.02). Narrative: This indicator has been decreasing every year for the last five years, from 38.6 in 2009 to 20.8 in 2013. This decrease is likely multifactorial. Booster seats have been mandatory for children under age 8 since August of 2012. When the new law went into effect there was a great deal of social media and education around the importance of child safety restraint. Building capacity, Title V funds have been used to purchase and distribute car seats to families in need for the last few years. In 2013, the Arizona Mexico Border Commission Health Committee identified the difficulties for families in Sonora to purchase car seats due to cost. ADHS Office of Injury Prevention, in collaboration with the Border Commission launched a new program to collect gently used car seats. Through a partnership with local fire departments, these seats are collected at drop off sites and redistributed in Sonora, Mexico. Beyond building capacity in Sonora, this program reinforces the importance of the use of car seats for all children on both sides of the border. The OIP also established a new website called A Safe Ride Home (http://www.azdhs.gov/phs/owch/ipcfr/a-safe-ride-home/index.php) which promotes car seat safety in Arizona. 147 F. Other Program Activities Arizona Telemedicine Program OCSHCN is part of the Arizona Telemedicine Program and has an established CSHCN telemedicine network at four regional sites throughout the state. Telemedicine has increased access to care for CSHCN in remote areas of the state and allowed for more efficient utilization of rare pediatric subspecialty providers in the areas of neurology and orthopedics. OCSHCN is developing a more extensive CSHCN telemedicine network to include an Indian Reservation based health center and outreach clinic sites. The expansion will also increase the types of specialty care offered through telemedicine visits to include hearing screening, cardiology, metabolic nutrition and genetic testing follow up at multiple sites throughout the state, especially in areas without or with limited access to pediatric specialty providers. /2013/ /2013/Pediatric orthopedics, neurology, neurosurgery and metabolic services are in place. There is no current telemedicine for hearing screening. //2013 // Family Violence Prevention & Services Grant The Family Violence Prevention and Services Act provides funding to prevent family violence and to provide immediate shelter and related assistance for victims of family violence and their dependents. In Arizona, funds are provided to safe homes in rural areas, known as the Rural Safe Home Network. Between October 1, 2008 and September 30, 2009 the Rural Safe Home Network provided 14,567 shelter nights to 466 women, 515 children and 3 men. /2013/ Between October 1, 2010 September, 2011 the Rural Safe Home Network provided 23,565 shelter nights to 313 women, 305 children, and 1 man and non-residential domestic violence services to an additional 3,741 women, 264 men, and 1635 children.//2013// Sexual Violence Prevention & Education Grant Arizona's Sexual Violence Prevention and Education Program is funded through Centers for Disease Control and Prevention. Between November 1, 2009 and October 31, 2010, the program reached 15,722 unduplicated Arizonans with multi-session workshops of primary prevention of sexual violence and education. In 2009 BWCH expanded its scope beyond primary prevention of sexual violence and was awarded a Department of Justice grant for direct services of survivors of sexual assault. These funds are unique with respect to providing services to those collaterally affected by the victimization, including but not limited to, friends, coworkers, and classmates. /2012/ In 2011, in line with the state plan on Primary Prevention of Sexual Violence, BWCH expanded training on Bystander Intervention Skills ("Bar Campaign') to include staff at alcohol serving establishments in three key areas of the state. The outcome is to increase staff's knowledge of sexual violence primary prevention issues, strategies, policies and enhance their skills in being an active bystander in an alcohol-related environment. //2012// /2013/ Between November 1, 2010 and October 31, 2011, the program reached 24,063 unduplicated Arizonans with multi-session workshops of primary prevention of sexual violence and education.//2013// Toll-Free Hotlines BWCH operates three toll-free hotlines: the Children's Information Center (CIC), the Pregnancy and Breastfeeding Hotline, and the WIC Hotline. The CIC is a statewide, bilingual/bicultural tollfree number that provides information, referral, support, education and advocacy to family care 148 givers and health care professionals throughout Arizona. The Pregnancy and Breastfeeding Hotline facilitates entry of pregnant women into prenatal care services and provides breastfeeding support. The Hotline serves as the state's Baby Arizona Hotline, in partnership with Arizona's Medicaid agency, AHCCCS. Baby Arizona is a presumptive eligibility process which enables pregnant women to access prenatal care before Medicaid eligibility is determined. The Hotline is staffed by two bilingual Certified Lactation Consultants. An International Board Certified Lactation Counselor is available to answer all breastfeeding questions after normal business hours and to answer technical questions 24 hours a day, seven days a week. /2012/ BWCH operates six toll-free hotlines: the Children's Information Center (CIC), the Pregnancy and Breastfeeding Hotline, and the WIC Hotline, the WIC Complaint Hotline, the Folic Acid Hotline, and 311 BABY. The WIC Complaint Hotline takes complaints from consumers about stores that may not carry WIC approved foods or won't honor certain WIC approved foods. They also take complaints from stores about possible fraud. 311 BABY is a national hotline that connects callers with a local number regarding topics related to prenatal health. //2012// EMPOWER In 2010, ADHS implemented s new program known as the Empower Program. The program promotes 10 standards on nutrition, physical activity and tobacco prevention designed to create a healthy environment for children in child care settings. Child care providers that adopt the standards receive a reduction in licensing fees, training and technical assistance, and a logo that identifies them as an "Empower Center." ADHS blended three funding streams, including Title V, to help off-set the licensing fees for providers that participate in the program. The development of Empower helped to facilitate proposed changes in licensing requirements that support the standards. HRSA's State Early Childhood Comprehensive Systems Grant (SECCS) Arizona's SECCS grant is administered by and integrated into the work of Arizona's Early Childhood Development and Education Board, known as First Things First. BWCH receives some funding from the grant to enhance integration of early childhood at ADHS and among other state agencies. BWCH convenes an ADHS bimonthly 0-5 workgroup to foster coordination of maternal and child health services within ADHS. HRSA's Emergency Medical Services for Children (EMSC) The EMSC program utilized its Pediatric Advisory Committee for Emergency Services, along with additional stakeholders, to begin working on establishing a voluntary pediatric designation system for hospital emergency departments. This system will identify minimum training and equipment a hospital should have to care for a pediatric patient, and is scheduled to begin in fall of 2010. /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 149 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. 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. 150 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 2013 Budgeted Expended 6941708 6271583 FY 2014 Budgeted Expended 6468652 FY 2015 Budgeted Expended 7016019 1420000 352441 985000 982000 7693086 6466495 7693086 7980789 0 0 0 0 7472018 5899341 7472018 7422018 0 0 0 0 23526812 18989860 22618756 23400826 61382212 52968813 55357356 60017948 84909024 71958673 77976112 83418774 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 2013 Budgeted Expended FY 2014 Budgeted Expended FY 2015 Budgeted Expended 3632356 2900071 3619625 3653229 5523094 4512567 5512859 5562547 9573184 7882324 9304919 9827022 3306713 2014711 2689641 2916687 151 Special Healthcare Needs e. Others 1163887 1503764 1166341 1147044 f. Administration 327578 176423 325371 294297 g. SUBTOTAL 23526812 18989860 22618756 23400826 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 91045 c. CISS 0 0 0 d. Abstinence 1302706 1217627 1216238 Education e. Healthy Start 0 0 0 f. EMSC 130000 110000 130000 g. WIC 42599706 40360259 42214457 h. AIDS 0 0 0 i. CDC 0 0 0 j. Education 0 0 0 k. Home Visiting 12045184 9430000 12158152 k. Other EMSC DEMO 199915 199869 PROJ FAMILY 1813619 1694140 1873805 VIOLENCE PREP 1103821 1044259 1039023 RAPE PREV ED 624000 665799 552216 SEXUAL 198555 298736 306522 ASSAULT SVCS STATE INJURY 180621 180621 180621 SURVEIL SUDDEN UNEXP 56000 56000 INFANT ORAL HEALTH 384000 WORKFORC PROJECT 900000 LAUNCH Form 5, State Title V Program Budget and Expenditures by Types of Services (II) I. Direct Health Care Services II. Enabling Services III. PopulationBased Services IV. Infrastructure Building Services V. Federal-State Title V Block Grant Partnership Total FY 2013 Budgeted Expended 4355595 3875783 FY 2014 Budgeted Expended 4289355 FY 2015 Budgeted Expended 4288146 3459392 3095509 3312148 3471370 10657349 8771121 10666511 10951719 5054476 3247447 4350742 4689591 23526812 18989860 22618756 23400826 152 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// /2015/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. //2015// B. Budget The estimated Title V allocation for Arizona, FFY2011, is $7,090,511. For FFY 2011, 33.12% ($2,348,502) of the Title V Block grant will be allocated for preventative and primary care needs for children and adolescents; 30.71% ($2,117,202) will be allocated to children with special health care needs; 29.75% ($2,009,389) will be allocated for women, mothers, and infants and 6.42% ($455,418) will be budgeted for administrative costs. It is projected that there will be $612,223 unobligated funds from our FY2010 block grant. The Office for Children with Special Health Care Needs expends their funds on a state fiscal year (7/1 - 6/30) and does not begin using the funds awarded 10/1 until 7/1 the following year. For FFY 2011, the state's match and maintenance of effort includes State General, Lottery, Dental Sealant, and donation funds. The $30,903,383 in State General funds include High Risk Perinatal Services, Children's Rehabilitation Services (CRS), Child Fatality Review Program, and operating funds allocated to the Public Health Prevention Division and, supports some of the personnel located in the Bureau of the Women's and Children Health, and the Office of Oral Health. The $5,222,260 in Lottery funds includes the Teen Pregnancy Prevention and Prenatal Outreach (Health Start) Programs. The $101,968 in donation funds are for the Children's Rehabilitation Services Program and $250,000 is from fees 153 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 Women's and Children's Health (Part A & B): $1,209,640 will support the Department's birth 154 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 Breastfeeding Hotline, Breastfeeding Consultation, Immunizations, Early Childhood, Oral Health 155 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 156 providing community education. 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// /2015/ The estimated Title V allocation for Arizona, FFY2015, is $7,016,019. For FFY 2015, 35.86% ($2,515,650) of the Title V Block grant will be allocated for preventative and primary care needs for children and adolescents; 31.82% ($2,232,487) will be allocated to children with special health care needs; 28.13% ($1,973,585) will be allocated for women, mothers, and infants and 4.19% ($294,297) will be budgeted for administrative costs. It is projected that there will be $982,000 unobligated funds from our FFY2014 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 2015, the state's match and maintenance of effort includes State General, Lottery, and Dental Sealant funds. The $9,810,809 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 $5,391,998 in Lottery funds includes the Teen Pregnancy Prevention and Prenatal Outreach (Health Start) Programs. $200,000 is from fees generated by the Dental Sealant Program. Arizona's FFY2015 match and overmatch of $15,402,807 continues to exceed the maintenance of effort amount of FFY1989'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 - $2,619,389: Bureau of Women's and Children's Health (Part A & B): $1,399,897 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 of Children with Special Health Care Needs (Part C): $1,219,492 will support administrative initiatives, education, training, support services, advocacy and outreach. Two Health Advocacy for Children, Youth and Families contracts were issued to community based organizations focused on inclusion of CYSHCN in nutrition, physical activity and injury prevention. 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 Opening The Doors: How to Prepare You Practice for People with Special Needs' Primary Care Physician Conference. Population-Based Services: $1,014,497 is budgeted for initiatives that include the Sensory 157 Program, Pregnancy and Breastfeeding Hotline, Breastfeeding Consultation, Immunizations, Early Childhood, Oral Health services for children, injury prevention and preconception health, including raising public awareness and providing community education. Enabling and Non-Health Support: $1,343,090 will support the Medical Home Project and the Pregnancy, Breastfeeding Hotline and Children with Special Health Care Needs ($812,995), which includes respite and palliative care services. Direct Health Care Service: $1,744,746 will support hospital, physician, transport, community nursing services for high-risk infants, and Reproductive Health services for women. Indirect Administrative Costs: $294,297//2015// 158 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. 159