Promising Practices in MCH Needs Assessment: A Guide Based on a National Study
December 2004
CHAPTER
I BACKGROUND AND INTRODUCTION
The Title V Needs
Assessment, a requirement of the Maternal and Child Health (MCH) Block
Grant, is a critical element of the MCH program planning process. Although
it is often completed by States primarily for the purpose of fulfilling
the Block Grant requirement, it can also serve a number of essential functions
for MCH programs. The assessment of needs and capacity can help to direct
State officials to the areas of greatest need and opportunities for intervention,
and the list of MCH priorities generated as a result of the assessment
can guide the planning of programs and allocation of resources.
Despite this potential,
States vary widely in the rigor, comprehensiveness, and clarity of their
needs assessments, as well as the extent to which they find the needs
assessment an effective tool for guiding future program planning and targeting
of resources to address the priority MCH needs. To gain a better understanding
of this variation and to identify promising approaches among the States,
the Maternal and Child Health Bureau (MCHB) conducted an analysis and
evaluation of the States' Title V needs assessment processes. This analysis
included several components:
- A review and abstraction
of selected States' 2000 needs assessments
- A review and abstraction
of these States' Block Grant applications and annual reports, to assess
the services currently provided by Title V programs and compare the
needs assessment findings and priorities to the services provided
- In-depth interviews
with State Title V officials on the process and implementation of the
2000 needs assessment, and new approaches they were planning for the
2005 needs assessment.
Based on these analyses,
we identified promising practices being used in 15 study States. This
guide is based on the findings of this study. These examples have been
drawn to provide planners with options and ideas for various aspects of
the needs assessment process.
In order to make the
needs assessment a more valuable tool, the following subjects are covered:
planning the needs assessment; assessing MCH needs (including information
on quantitative and qualitative analysis, capacity assessment, and priority-setting);
and putting findings into practice. All of these components can help make
the needs assessment a useful process and a comprehensive document that
can be effectively utilized to guide planning and policymaking.
CHAPTER
II PLANNING THE NEEDS ASSESSMENT PROCESS
The core elements
of a comprehensive needs assessment document are a strong substantive
analysis of needs and system capacity, and a clear linkage of priorities
to those needs. However, the key to a successful outcome that creates
support for MCH priorities is a well-defined process for carrying out
the needs assessment. In other words, the process is as important as the
product itself. By keeping this focus throughout, the resulting needs
assessment document will be succinct but comprehensive, and will likely
be accepted by all of the stakeholders involved. Proper planning will
assure that the document is well laid out and inclusive of all the appropriate
information, while also saving time and effort. Taking the time to include
the community and other organizations involved in MCH will result in a
document that is seen as legitimate by interested parties.
Through an analysis
of the needs assessment process in several States, a number of important
elements in that process have been identified. These process elements
can make needs assessment findings more comprehensive, applicable, and
acceptable to the families and communities that they will ultimately affect.
The following checklist describes these elements and offers examples of
how they have been implemented in the States in our study.
• Clear leadership,
responsibility, and oversight. The needs assessment should be guided
by a clear vision that encompasses the full scope of the needs assessment
process, including the identification of indicators, data collection and
analysis, and the application of findings. The leader or leadership team
should also possess the ability to command resources and to assemble data
from both public and private-sector resources. Examples of leadership
structures include:
- An MCH/Children
with Special Health Care Needs (CSHCN) Leadership Team
- The Management
Team of the Office of Family Health Services
- A Needs Assessment
Coordinator to manage the planning and coordination of the process,
and an Needs Assessment Planning Team comprising Bureau of Family and
Community Health and DPH Regional Office staff to refine the needs assessment
design, review and rework a needs assessment interview, and field-test
the interview.
• Expertise. The needs assessment should involve internal staff or external consultants
with appropriate expertise in data analysis and epidemiology. Examples
of sources of this expertise include:
- An MCH Information
Specialist
- A State Center
for Health Statistics
- An MCH Consortium
Data Work Group
- Outside consultants
• Community
involvement. The findings of a needs assessment are more likely to
be accepted by those it affects directly (such as consumers, providers,
and other stakeholders) if these constituents are involved in its development.
Major avenues for stakeholder involvement include focus groups and surveys,
task forces on emerging MCH issues, community/regional meetings, advisory
groups, and steering committees. Examples of this involvement include:
- A survey of advocates
on MCH priorities.
- Focus groups with
adolescents and the families of CSHCN.
- The establishment
of workgroups or task forces to address emerging issues.
- The use of listening
sessions, including representatives from State and Regional Health Departments,
WIC, grantees, coalitions, and other interested parties to identify
emerging needs and priorities and to collect information on potential
resources.
- The use of Advisory
Councils on health programs for women and children, for advice in selecting
measures, and determining priorities. Alaska, for example, formed an
18member Maternal, Child, and Family Health Advisory Committee, which
included both parents and professionals, to oversee the needs assessment.
Iowa's well-established MCH Advisory Council includes representatives
from medical and child care provider organizations, voluntary health
associations, consumers, as well as public officials, who meet quarterly
to reassess MCH priorities and evaluate progress on existing priorities.
• Creating
a local-level process to inform the State-level assessment. Since
much of the States' Title V and other MCH funds and many services are
administered at the local level, local health authorities and communities
are often best equipped with the information to assess local needs and
to plan local systems of care. Several avenues for local involvement include
MCH Consortia, local health departments, and Title V contractors. For
example:
- Title V contractors
can help lead a participatory and comprehensive local needs assessment
process. The contractors can partner with a variety of local stakeholders,
and as part of the assessment each locality can identify MCH-related
priorities.
- Local perinatal
consortia provide an opportunity to establish local-level coalitions.
The coalition can comprise consumers, providers, and other stakeholders
and can be responsible for developing local MCH leadership and systems
planning.
- Regional Councils
or Consortia can be used to conduct needs assessments to document the
demographics of the MCH population, service capacity, health risk and
outcome indicators, and community-level qualitative data.
- Data and technical
assistance in needs assessment (including a detailed guidance document,
such as those provided by Iowa and California) can be provided to the
State's local health jurisdictions.
• Coordination
with other systems. The Title V Block Grant cannot fund all of the
programs and services necessary to meet the needs of pregnant women, children,
and families. Therefore, it is critical that the Title V agency work closely
with other agencies and systems that serve these populations, such as
Medicaid and SCHIP, the education system, early intervention, juvenile
justice, and welfare and other family support services. Examples of interagency
collaboration on needs assessment include:
- In Rhode Island,
the director of the Title V agency participates in an executive-level
interagency body called the Children's Cabinet, which is composed of
directors of each State agency serving children and families and a representative
of the State's largest private children's advocacy organization.
- In Iowa, the MCH
needs assessment process is tied to the goals and action steps outlined
in Healthy Iowans 2010 and includes the range of agencies involved
in that plan.
- Virginia's Title
V agency works collaboratively in a State-level interagency planning
committee focused on MCH issues. Included in the committee are representatives
of the State Medicaid agency, the Title V agency, Social Services and
Mental Health.
Maintaining an open
and inclusive process for the needs assessment may seem arduous; indeed,
it requires consistent attention to the needs and interests of internal
and external stakeholders. However, this effort is vitally important to
assure that the assessment of needs and capacity fully reflects the knowledge
and opinions of those it most directly affects. It is also an effective
way to garner support for MCH goals and the priorities identified through
the needs assessment process.
CHAPTER
III COMPONENTS OF THE NEEDS ASSESSMENT
A thorough needs
assessment has two major components: an assessment of population needs,
and an analysis of the capacity of systems to meet these needs. This chapter
reviews the rationale for each of these components and offers tools and
examples to help State officials to conduct these assessments.
A. Assessing
MCH Needs
The first component
of a successful needs assessment is the collection and analysis of information
on the health status of MCH populations using data from a variety of sources.
The data should be drawn from a range of health indicators, and ideally
such indicators should include both quantitative and qualitative measures,
State-level data, and more targeted data that are based either on geographic
or demographic sub-populations. Several types of data analysis are useful
in needs assessment, including both point-in-time analysis (to provide
a snapshot of the current health status of MCH populations) and trend
analysis (to capture the progress and challenges of the public health
field over time).
1. Data Collection
The primary step in
needs assessment is the collection of data, both qualitative and quantitative.
Qualitative data are descriptive and are produced by instruments such
as interviews and focus groups, while quantitative data are numerical
in nature and are generated through surveys and questionnaires as well
as surveillance data, vital records, and program data. Both have advantages
and disadvantages, as described below.
Quantitative data
are an important component of any needs assessment. These data have a
number of qualities that are useful in needs assessment, including:
• In general,
quantitative data are most appropriate for describing the incidence and
prevalence of health conditions. For this reason, quantitative statistics
tend to carry credibility as a concrete and reliable source of information.
Most needs assessment readers will feel comfortable with this type of
data and will feel that they impart a scientific aspect to the work.
TABLE
1 – Sample Quantitative Indicators & Data Sources: Pregnant
Women and Infants |
INDICATOR |
POSSIBLE
SOURCES |
Demographic
Measures |
- Female population
by age and race/ethnicity
- Poverty
rate
|
|
|
|
|
|
- Insured
Rate
- Fertility
Rate
|
|
|
|
Health
Status Measures |
|
|
- Overweight/Obesity
- Alcohol,
tobacco, or drug use during pregnancy
- Domestic
violence before or during pregnancy
- Adequacy
of weight gain during pregnancy
- Breastfeeding
- Nutritional
Intake
|
|
- Rate of
Birth Defects (Especially neural tube defects)
|
- Birth Defects
Monitoring Systems
|
- Preventive
health screenings
|
|
|
|
Outcome
Measures |
- Infant mortality
rate, SIDS rate
- Maternal
mortality rate
- Perinatal
mortality rate
|
|
TABLE
2 – Sample Quantitative Indicators & Data Sources: Children |
INDICATOR |
POSSIBLE
SOURCES |
Demographic
Measures |
- Children by age group
- Poverty rate among children
|
|
- SCHIP eligibility
- Insured rate
|
|
|
|
Health
Status Measures |
- Alcohol, tobacco, and drug use among youth
|
- YRBS
- National Youth Tobacco Survey
|
- Prevalence of weapons and violence in schools
- Nutritional intake
- Use of dental care
- Overweight/obesity
|
|
- Hospitalizations (and related causes)
- Use of safety devices (such as seatbelts and helmets)
|
|
- Cases of vaccine-preventable illness
|
|
Outcome
Measures |
- Child and teen death rate
- Injury-related death rate
- Motor vehicle crash death rate
- Drowning death rate
- Adolescent
homicide rate
|
|
- Qualitative information
can reinforce quantitative data that have been collected. In this sense,
qualitative findings can provide examples or personal stories of situations
that have been identified through quantitative data, which can add to
the richness and thoroughness of a needs assessment.
- Qualitative data
can be used to fill in gaps where no quantitative data are available.
If there is an identified need but no quantitative studies to demonstrate
that need, then interviews or focus groups with people who are familiar
with the issue can be used to confirm its importance.
- Finally, one of
the most important ways in which qualitative data can be used is to
discover needs that weren't previously recognized. Because quantitative
data often have a time lag, emerging needs may not be recognized until
years after they have arisen. Qualitative data can be of use in this
instance because interviews or focus groups with people who are intensely
involved in MCH may reveal these issues sooner than quantitative analysis
alone.
TABLE 3 – Sample Quantitative Indicators
& Data Sources: CSHCN
|
INDICATOR |
POSSIBLE
SOURCES |
Demographic Measures |
|
|
Health
Status Measures |
- Severity/impact
of conditions
- Ability
to perform age-appropriate activities
|
|
- Children
born with birth defects or congenital anomalies
|
- Birth Defects
Monitoring Systems
|
|
|
Outcome
Measures |
- Asthma death
rate
- Infant mortality
rate due to birth defects
|
|
Table 4 shows some
of the indicators and qualitative methods used by States.
Table
4 - Sample Qualitative Data Used in Title V Needs Assessment |
INDICATOR |
DATA COLLECTION METHOD |
- Factors
affecting poor pregnancy outcomes
- Medical
reasons for racial disparities in infant mortality
|
- Consumer
focus group
- Vital records,
fetal and infant mortality reviews
|
- Stability
of CSHCN health
- Overall
rating of the health status of CSHCN
|
|
|
- Key informant
interviews with state officials and advocates
|
- Health care
access, child care availability, dental access for children and
the increasing number of CSHCN
|
- Key informant
interviews with county health and tribal health center directors
or individual providers
- Focus groups
with families and providers
|
- Children’s
mental health care needs
|
- Focus groups
with families and providers
|
- Transition
services for youth with special health care needs
|
- Interviews
and focus groups
|
- Important
issues in the health of MCH populations in local communities
|
- District
and local MCH staff interviews
|
2. Data Analysis
Both quantitative
and qualitative data collection ultimately require data analysis. Although
most Title V agencies have access to State epidemiologists, there are
still a number of factors to consider during the data analysis phase of
needs assessment. These include identifying critical stratification variables,
utilizing trend analysis, and combining quantitative and qualitative analysis.
a. Identifying Critical
Stratification Variables
Analysis of needs
assessment data requires identifying which stratification variables are
of the greatest interest. Since each State is different, some of the more
traditional or common stratification variables won't be meaningful in
every State. For instance, in a State without much racial diversity in
the MCH population, analysis by race/ethnicity may not yield very interesting
or applicable results. However, if that same State had a large population
of single mothers, analysis by family type might produce meaningful results.
Following are some stratification variables to consider in analysis:
- Race/ethnicity
- Age group
- Residence (urban,
rural, suburban)
- Family type/living
situation
- Nativity (immigration)
status
- Language spoken
at home
- Income, education,
insurance type, or other measure of socioeconomic status
b. Trend Analysis
Although point-in-time
analyses are useful in needs assessment, trend analysis should not be
overlooked. The importance of trend analysis lies in its ability to describe
the change in an indicator over time. For instance, a point-in-time analysis
of teenage pregnancy may show high rates that may appear alarming to many
and would lead them to encourage a change in programming. Employing trend
analysis in this case might demonstrate that in fact the rate of teenage
pregnancy, although high, has been in decline for a number of years. This
would lead to a conclusion that current programming is working, and perhaps
should even be strengthened. Two different measures of the same indicator
lead to two different conclusions about the situation and the programming
addressing those needs.
A number of existing
survey instruments allow for the analysis of trends among MCH populations.
All that is required is a comparable measurement of the same indicator
over a number of years. Several data sources, such as Vital Records, the
Youth Risk Behavior Survey, and the Pregnancy Risk Assessment and Monitoring
System (PRAMS) provide State-level data on a regular basis to allow for
trend analysis. Others, such as the National Survey of CSHCN, have only
been conducted once but will be repeated to allow for analysis of trends.
c. Combining Qualitative
and Quantitative Data
Although qualitative
and quantitative data each have their own strengths, they are most compelling
when used together. Due to their respective strengths and weaknesses,
combining qualitative and quantitative data makes needs assessments more
comprehensive and coherent.
There are several
basic formats for combining the two:
- Using qualitative
to support quantitative. In this case, the main component of the
assessment is based on quantitative data, while the qualitative data
lend support and depth. The qualitative data are used to confirm the
quantitative findings or to provide personal stories that enrich the
assessment. For instance, an assessment can provide statistics about
a given indicator, such as teen pregnancy, then use quotes from key
informant surveys to reinforce the assertion and to provide a realistic
example of that need in the community. If the two different types
of data yield different results, it is important to explain why such
a difference might exist; possibilities include a lag in the quantitative
data or a difference between real and perceived needs.
- Using quantitative
to support qualitative. Some States choose qualitative data as
their primary needs assessment tool. Although not common, this approach
can be especially useful in States with significant emerging needs
or insufficient capacity to implement quantitative data collection.
In this situation, data can be presented in a fashion similar to the
one above; however, basic quantitative data are used to reinforce
rich descriptions of needs by primary stakeholders for each indicator.
As mentioned above, if the two data types indicate different needs
then it is important to explain the possible reasons for the discrepancy.
- Using qualitative
and quantitative separately. Whenever possible, the two approaches
above should be used. However, in many cases the type of data available
depends on the indicator, and both types of data may not be available
for every indicator. If the needs assessment is organized by population
(pregnant women and infants, children, and CSHCN) this allows for
similar indicators to be discussed together, regardless of data source.
However the various
data sources are used, the analysis of each MCH population's needs tells
only half of the needs assessment story. The remainder is provided by
the capacity assessment, as described in the following section.
B. Assessing
MCH Capacity
Capacity assessment
is the second major element of needs assessment and a necessary complement
to the process of assessing MCH needs described in Section A above. The
purpose of capacity assessment in public health is to evaluate the ability
of the existing system to provide and support needed health care and related
services. The capacity assessment must include services at every level
of the MCH pyramid and look beyond individual services to organizational
capacity and to actual and potential partnerships for MCH systems building.
The four steps of capacity assessment for MCH are:
- Assessment of the
capacity to provide direct and enabling services
- Assessment of the
capacity to provide population-based services
- Assessment of the
infrastructure-building capacity within the Title V agency to build
and support a quality MCH system
- Assessment of individual
and organizational assets available to support and improve the MCH system.
Within each of these
steps the assessment must not only inventory what resources are available,
but, more importantly, the capacity assessment should gather and evaluate
quantitative and qualitative indicators to assess the following three
major dimensions of service or system capacity:
• Accessibility. Access to services or resources may be assessed using indicators such
as:
the percent of a target
population in need who received the appropriate level of services; the
length of waiting lists for needed care; the geographic distribution of
available providers or services; and the availability of bilingual staff
or translators in public education programs and health care facilities
providing services to low-income women, children and families.
- Quality. Quality
of services may be assessed using both quantitative and qualitative
measures including those that assess the coordination of care, client
or caregiver satisfaction, and cultural competence. The quality of
assets can be assessed by determining the strength of each asset's
interest in MCH issues and the asset's potential to help build and
promote MCH systems of care. If data are available, the assessment
should also include information on how effective the services
are in producing the desired outcomes.
- Affordability. For the assessment of direct and enabling services, affordability
of services is a critical dimension to the capacity assessment. This
can be measured using indicators of the ability of the population
to pay for the services, such as noninsurance rates and the adequacy
of private insurance coverage for high-risk persons and those with
special needs, such as CSHCN. Another measure of affordability is
the extent to which public and private providers provide needed services
to the uninsured and underinsured.
These dimensions of
capacity apply not only to the three major MCH target populations, but
also to subgroups, such as ethnic/racial minorities, non-English speaking
groups, and low-income women and families living in urban or rural communities.
Step One: Assessment
of Direct and Enabling Service Capacity
The assessment
of direct and enabling services necessarily begins with an inventory or
listing of existing resources that are available to serve the MCH population
and its needs. However, because this list could include hundreds of services
that directly and indirectly influence MCH, before embarking on an assessment
of direct and enabling services, the needs assessment team should determine
the specific range of health and related services that it will focus on
for its capacity assessment. This list should be broad enough to include
a range of key services that includes both health care and related human
or social services, but be focused on those services that are a part of
the Title V system of care as defined by the State.
While inventorying
available services and providers is an important first step, the goals
of capacity assessment cannot be achieved if the assessment only includes
a listing and description of the resources. The second essential—and
more time-consuming component of capacity assessment is the compilation
of data to evaluate the capacity of these resources.
Historically, many
State Title V agencies have limited the indicators of direct service capacity
in their needs assessment to annual program participation data or participation
trend data. However, though these figures may be easy to obtain, they
are not instructive for identifying specific strengths and weaknesses
or gaps in individual programs or the system as a whole, nor do they help
identify specific areas where change or improvement is needed. Capacity
of direct and enabling services can be reflected more completely using
a range of indicators to measure the accessibility, affordability and
quality of these key MCH resources.
The MCHB's National
Performance Measures (NPM) and Health Systems Capacity Indicators (HSCI) are a good starting point for a State's MCH capacity assessment because
all States have information on these measures easily available from either
National or State data sources. They also provide examples of model capacity
indicators that States can use to identify other capacity indicators.
Examples of NPMs and HSCIs that Title V agencies regularly monitor and
that can be an integral component of a State's capacity assessment include
the following.
MCHB Measures of Accessibility
(Percentage)
- VLBW infants delivered
at facilities for high-risk deliveries and neonates (NPM 17).
- Infants born to
women receiving prenatal care beginning in the first trimester (NPM
18)
- Newborns who are
screened and confirmed with metabolic conditions who receive appropriate
follow-up (NPM 1).
MCHB Measures of Affordability
(Percentage)
- Medicaid enrollees
under age 1 who received at least one initial periodic screen (HSCI
2).
- EPSDT eligible
children between the ages of 6 to 9 who have received any dental services
during the year (HSCI 7).
- Children without
health insurance (NPM 13).
- State SSI beneficiaries
under age 16 who received rehabilitative services from the State CSHCN
program (HSCI 8).
- CSHCN between the
ages of 0 and 18 whose families have adequate private or public insurance
to pay for the services they need data available from the National Survey
of CSCHN (NPM 4).
- MCHB Measures of
Quality (Percentage)
- Families of CSHCN
who receive coordinated, ongoing, comprehensive care within a medical
home (NPM 4) data available from the National Survey of CSHCN.
- CSHCN between the
ages of 0 to 18 whose families partner in decision making at all levels
and are satisfied with the services they receive (NPM 2) data available
from the National Survey of CSHCN.
- CSHCN between the
ages of 0 to 18 whose families report the community-based service systems
are organized so they can use them easily (NPM 5) data available from
the National Survey of CSHCN.
a. Key Assessment
Questions
The following are
the key questions that should drive the selection of indicators for evaluating
the capacity of direct and enabling services. They are divided along the
three dimensions of accessibility, affordability and quality.
Defining Accessibility
- Are there shortages
of providers or services in specific geographic areas or communities?
(Underserved geographic areas could be illustrated by a map.)
- Are safety net,
publicly subsidized services able to serve the underinsured or uninsured?
- Are there physical
barriers to accessibility and which geographic areas are most affected?
- Are there language
barriers and which demographic groups are most affected?
- Are the target
populations obtaining the services they need?
- Are consumers or
providers reporting unmet need for services or difficulty accessing
the services they need? How does this vary across demographic groups?
- What is the proportion
and location of sites serving low-income families not accessible by
regular public transportation that do not provide transportation assistance?
Defining Affordability
- What proportion
of women and children are uninsured and how does this vary across demographic
groups?
- What are the State
Medicaid and SCHIP eligibility guidelines for women, infants and children?
- What proportion
of eligible populations are enrolled in Medicaid, SCHIP or other State
insurance programs for women and children?
- What are barriers
to enrolling in Medicaid or SCHIP for the eligible population?
- What needed benefits
or services do Medicaid or SCHIP not cover?
- What percent of
private providers accept Medicaid or SCHIP coverage?
- Do out-of-pocket
costs pose a barrier to care for children?
- Do health plans
limit access to needed specialty providers or enabling services?
Defining Quality and
Effectiveness
- Is care coordinated?
- Is care for CSCHN
family-centered?
- Are the MCH providers
and service programs culturally competent?
- What do consumers
and caregivers say about the quality and effectiveness of services they
receive from MCH providers? (Indicators may include perceptions of provider
communication skills, waiting times, adequacy of time spent with provider,
respect for families, and expertise of provider)
- What do available
quality assurance or quality improvement documents say about the quality
of the services provided?
- What do evaluations
document regarding the effectiveness of the programs in achieving their
desired outcomes?
b. Organization of
the Assessment
Table 5, Table 6 and
Table 7 provide the structure for States to organize their indicators
of direct and enabling service capacity and include sample indicators
for each dimension. These examples are taken from our 15 study States.
The indicators are organized according to the three MCH populations: (1)
pregnant women, mothers and infants; (2) children; and (3) children with
special health care needs (CSHCN). In this way, the results of the capacity
assessment can best be matched to the indicators of MCH need that are
also organized by population group.
c. Emerging Issues
that May Impact Direct and Enabling Service Capacity
In addition to gathering
information about the current capacity of direct and enabling services,
it is important to identify the impact of emerging issues on the State's
ability to provide or assure access to direct and enabling services. The
following is a checklist of categories of emerging issues to be considered
for inclusion based on their relevance to a State:
Changes in Medicaid
or SCHIP
Budgetary Issues
Public Health Emergencies (e.g., the impact of competing priorities
such as bioterrorism or vaccine shortages)
Changes in State Demographics (e.g., the growth and changing nature
of the immigrant populations)
New/Emerging State Policy Priorities or Mandate
Table
5. Sample Capacity Indicators for Pregnant Women and Infants |
ACCESSIBILITY |
AFFORDABILITY |
QUALITY/EFFECTIVENESS |
Percentage
of VLBW infants delivered at facilities for high-risk deliveries
and neonates
(MCHB NPM #17)
Percentage
of infants born to women receiving prenatal care beginning in first
trimester
(MCHB NPM #18)
Percentage
of women with a live birth scoring 80% or higher on the Kotelchuck Index for adequacy of prenatal care (MCHB HSCI #4)
Percentage
of women beginning prenatal care in third trimester
Perception
of importance of prenatal care by community members in areas with
poor pregnancy outcomes (qualitative data)
Number
and geographic distribution of perinatal providers in public and
private settings
Number
of mothers receiving case-management services as percentage of total
births to low-income and other high risk women
Percentage
of eligible pregnant women served
in WIC
Number
and geographic distribution of family planning providers/clinics
serving teens and low-income women
Number
of total infant child care slots available relative to need |
Percentage
of Medicaid enrollees under age one who received at least one initial
periodic screen (MCHB HSCI#2)
Percentage
of SCHIP enrollees under age one who received at least one periodic
screen
(MCHB HSCI #3)
Percentage
of poverty level for pregnant women's eligibility in the State's
Medicaid and SCHIP programs (MCHB HSCI #6)
State
eligibility guidelines for Medicaid coverage of family planning
services
Percentage
of women in need of subsidized family planning services who receive
them
Medicaid
coverage of mental health services for postpartum women
Percentage
of private maternity care providers willing to serve pregnant women
who are enrolled in Medicaid
Percentage
of Medicaid-eligible pregnant women enrolled in Medicaid
Percentage
of eligible infants covered by Medicaid or SCHIP |
Reasons
women of childbearing age cite for no regular source of medical
care
Percentage
of OB-GYNs reporting that they routinely
screen for domestic violence and provide referrals as appropriate
Perceptions
of discrimination by prenatal health care providers because of race/ethnicity
Barriers
to prenatal care experienced by low-income insured and uninsured
pregnant women.
Percentage
of prenatal clients offered HIV testing
Cultural
competency
of prenatal providers serving new immigrant populations and racial/ethnic
minority groups |
Table
6. Sample Capacity Indicators for Children |
ACCESSIBILITY |
AFFORDABILITY |
QUALITY |
Number
and location of medically underserved areas (MUAs)
and Health Professional Shortage Areas (HPSAs)
Number
of active primary care physicians serving children (available on
AAP Web site for States and local areas)
Ratio
of child population to number of clinically active pediatricians
(available on AAP Web site)
Number
and geographic distribution of public clinics available to serve
low-income and uninsured children and families.
Percentage
of caregivers reporting emergency rooms as usual source of sick
care for their children
Number
and location of Dental HPSAs
Number
and geographic distribution of primary care clinics providing dental
care to low-income or uninsured children
Percentage
of children who have not seen a dentist within the last 6 months/year
(parental report)
Percentage
of children aged 5 who have never had a dental check-up
Percentage
of children who needed and sought dental care in the last year and
weren't able to get it
The
percent of EPSDT eligible children aged six to nine who have received
any dental services during the year
(MCHB Health Services Capacity Indicator #7)
Number
and geographic distribution of mental health clinicians, day treatment
programs, residential counseling centers, residential treatment,
and psychiatric hospitalization services for children and youth.
Percentage
of eligible children served in WIC |
Percentage
of uninsured children
(MCHB NPM #13)
Percentage
of eligible children covered by Medicaid or SCHIP
Number
and geographic distribution of private pediatricians who accept
Medicaid and SCHIP coverage
Percentage
of potentially Medicaid-eligible children who have received a service
paid by the Medicaid Program. (MCHB National Performance Measure
#14)
Extent
of dental health coverage in SCHIP insurance benefits for children
Number
of dentists willing accept Medicaid or SCHIP coverage
Percentage
of children with dental insurance
Extent
of mental health coverage in SCHIP insurance benefits for children
Percentage
of low-income children under age 6 receiving child care that is
either fully or partially paid for with a subsidy |
Percentage
of pediatricians and pediatric clinics adhering to Bright Futures
Guidelines for preventive and primary care
Percentage
of parents reporting that their child's health professional did
not encourage preventive health steps for their child
Cultural
competency of child health providers serving new immigrant populations
and racial/ethnic minority groups |
Table
7. Sample Capacity Indicators for CSHCN |
ACCESSIBILITY |
AFFORDABILITY |
QUALITY |
- Percentage
of newborns who are screened and confirmed with metabolic conditions
who receive appropriate follow-up
(MCHB NPM #1)
- Percentage
of families of CSHCN reporting unmet need for health services
(Available from National Survey of CSHCN)
- Percentage
of families of CSCHN reporting problems obtaining referrals for
needed specialty care (Available from National Survey of CSHCN)
- Number of
pediatric specialists and subspecialists and their geographic distribution in a State
(Available on AAP Web site)
- Number and
geographic distribution of rehabilitative service providers for
children
- Percentage
of children screened and determined eligible for publicly financed
Early Intervention services who receive them; or number and geographic
distribution of children on waiting list for Early Intervention
follow-up services
|
- Percentage
of CSCHN whose families have adequate private and/or public insurance
to pay for the services they need (MCHB NPM #4)
- National
Survey of CSHCN (survey of caregivers) includes the following
indicators for this measure:
- adequacy
of benefits and covered services,
- extent
of out-of-pocket costs, and
- choice
permitted for child to see provider he/she needs to see.
- Percentage
of State SSI beneficiaries under age 16 receiving rehab. services
from the State CSHCN program (MCHB HSCI #8)
- Degree to
which the State CSHCN Program provides or finances specialty and
subspecialty care, not otherwise accessible or affordable to its
clients.
|
- Percentage
of CSHCN who receive coordinated, ongoing, comprehensive care
within a medical home (MCHB NPM#3)
- National
Survey of CSHCN includes the following indicators for this measure:
- child
has unmet need for care coordination
- child
has a personal doctor or nurse
- child
has a usual source of sick care
- Percentage
of families of CSHCN reporting receiving family-centered care
- National
Survey of CSHCN includes the following indicators for this measure:
- provider
spends enough time with family
- provider
listens carefully to parents
- provider
makes parent feel like a partner in child's care
- provider
is sensitive to family's values and customs
- provider
gives the specific information that family needs
- Percentage
of families of CSCHN who are satisfied with the services they
receive
- Sample Indicators
from State surveys:
- family
concern with skill of their child's physician
- family
concern with provider respect for parent
- waiting
times for appointments, adequacy of time spent with child
- Cultural
competency of providers serving CSCHN in new immigrant communities
and other racial/ethnic minority groups
|
Table
8. Sources of Information (Quantitative & Qualitative) on MCH
System Capacity |
INFORMATION
SOURCES |
ACCESSIBILITY |
AFFORDABILITY |
QUALITY
OR EFFECTIVENESS |
Program
Data |
MCH
Program |
• |
|
• |
CSHCN
Programs |
• |
|
• |
Medicaid/SCHIP |
• |
• |
• |
Newborn
Screening Program |
• |
|
|
Early
Intervention Program |
• |
|
|
School
Health |
• |
|
|
Family
Planning |
• |
|
|
WIC |
• |
|
|
Lead
Screening |
• |
|
|
Public
and Private MCH-Focused Outreach/Public Awareness Programs |
• |
• |
|
Care
Coordination/Family Support Programs |
• |
|
• |
Child
Care |
• |
• |
• |
Survey
and Surveillance Data |
National
Survey of CSHCN |
• |
• |
• |
Health
Access/ Information Surveys |
• |
• |
• |
PRAMS |
• |
• |
• |
Vital
Statistics |
• |
|
|
Fetal-Infant
and Pregnancy-Associated Mortality Reviews (FIMR and PAMR) |
• |
|
• |
Special
Topic Surveys, e.g., Oral Health, Mental Health |
• |
• |
• |
- Consumer/Family
Satisfaction Surveys
|
• |
• |
• |
Provider
Surveys and Clinic Staff Surveys |
• |
• |
• |
School-based
surveys of parents, children and/or teachers |
• |
• |
• |
Health
Professions Associations |
American
Academy of Pediatrics |
• |
• |
|
State
Medical Societies |
• |
• |
|
State
Primary Care Associations |
• |
• |
|
Qualitative
Data |
Focus
Groups |
|
• |
• |
Key
Informant/Stakeholder Interviews |
|
• |
• |
Other
Local, Regional or Topical Needs Assessments |
• |
• |
• |
Program
Evaluation Research |
• |
• |
• |
Table 8 provides examples
of many of the data sources Title V agencies have drawn from for the conduct
of their assessment of direct and enabling services. Program data, for
example, have a large amount of potentially useful indicators, including
numbers of participants in relation to numbers in need or eligible, program
income-eligibility criteria, size of waiting lists, data on program staffing
and hours, and information from quality assurance or quality improvement
reviews. Several national surveys, State surveys and State surveillance
systems are also rich sources of capacity information. Other important
data sources include associations of health professionals that maintain
current information on provider distribution, shortages and training needs.
Local or regional health needs assessments and topic-specific needs assessments
conducted within the State also provide critical information for the State
Title V capacity assessment. Finally, as discussed in the section above
on assessing population needs, focus groups, and key informant interviews
are excellent tools for MCH needs assessment. With regard to assessing
system capacity,
these data collection methods can provide information not otherwise available
on clients' views of the quality of services and on factors promoting
or impeding the accessibility or affordability of services.
Step Two: Assessment
of Population-Based Service Capacity
The purpose and
organization of the capacity assessment of population-based MCH services
are similar to that for direct and enabling services, with one exception.
At this level of the MCH Pyramid, affordability is not likely a factor
affecting capacity. The following key questions can guide States in their
selection of indicators to measure population-based service capacity.
Examples of indicators that have been used by Title V agencies are included
where relevant.
Accessibility
- What proportion
of the population receive the service? (Sample indicators: percentage
of newborns receiving screening, percentage of children who receive
appropriate vision and hearing screenings, percentage of third graders
who have received protective sealants on at least one molar, and the
length of waiting lists for Early Intervention screening and services.)
- Are the services
accessible to all geographic areas and to all demographic groups in
the State? (Sample indicator: percentage of children under age 6 living
in high-risk areas screened for lead poisoning.)
- Are there physical
barriers to accessibility and which geographic areas are most affected?
(Sample indicator: qualitative information about access barriers to
community screening programs.)
- Are there language
barriers and which demographic groups are most affected? (Sample indicator:
the extent of outreach and services provided in other languages in communities
with concentrations of non-English speaking groups.)
Quality
- Are the services
culturally competent?
- What do the target
groups say about the quality of services?
- How effective are
the services in achieving their desired outcomes for the general target
population and specific high-risk groups?
Step Three: Assessment
of Infrastructure-Building Service Capacity
States must assess
not only the capacity of the services that are being delivered to the
target populations, but also the State agency's internal program capacity,
through an analysis of its MCH infrastructure-building services. Title
V program capacity includes delivery systems, workforce, policies and
support systems (e.g., training, research, and information systems) and
other infrastructure needed to maintain MCH service delivery and policy
making activities. The program capacity will define the core capacity
of Title V to reach its mission as State Title agencies continue to evolve
from providers of direct services to a focus on promoting, monitoring
and assuring quality of comprehensive systems of care for the MCH population.
In recent years, The
Women's and Children's Health Policy Center of Johns Hopkins Bloomberg
School of Public Health and The Association of Maternal & Child Health
Programs, in partnership with MCHB, have developed a set of model assessment
and planning tools titled Capacity Assessment for State Title V (CAST-5) for State agencies to use to assess their internal agency
capacity, with a focus on infrastructure-building services. CAST-5 is
designed as a group assessment process limited to internal Title V agency
staff, though it could include staff from other agencies or departments
within the State Department of Health who collaborate closely with Title
V on infrastructure-building services, such as school health or injury
prevention programs. Title V representatives interviewed suggested that
for this process to be most effective and prevent internal agency bias,
it should be facilitated by someone who is not directly involved in administering
or delivering Title V services, or who does not have a special interest
in a particular MCH issue or population.
CAST-5 divides
infrastructure-building resources into the following categories:
- Structural Resources. These include the physical structure of the agency, its computer hardware,
other material resources, and financial and human resources.
- Data and Information
Systems. These include technological resources for state-of-the
art information management and data retrieval, analysis and reporting.
- Organizational
Relationships. These include formal partnerships or communication
channels with other types of public and private organizations.
- Staff Competencies. These include staff knowledge, skills and abilities and those of other
individuals who work with the Title V program (including consultants).
To assess the MCH
system's capacity in each of these areas, CAST-5 utilizes a four-part
analysis often referred to in strategic planning literature as a SWOT
analysis. A SWOT analysis involves the identification of: (1) organizational strengths, (2) organizational weaknesses or gaps, (3) internal
and external factors that provide opportunities or that can facilitate
improving and expanding the infrastructure resources, and (4) internal
or external threats or barriers to improving or expanding these
resources. The information from this group assessment is then brought
together for the staff to prioritize where efforts may be most effectively
spent to improve MCH system infrastructure in the short and long term.
CAST-5 is a
user-friendly, practical guide for States that uses a defined set of process
indicators and a set of assessment guidelines, tools, and exercises. States
interviewed suggested that CAST-5 may be followed in whole or part,
depending on States' needs and the level of resources available for the
capacity assessment.
Step Four: Assessment
of Assets for MCH Systems-Building
Key resources
that are often overlooked in public health needs assessments, but are
essential for building MCH systems at the State and the community level,
are the individual and organizational assets that are available
to build partnerships or collaborations. The public health and related
community development literature suggest that needs assessment should
be re-oriented away from its emphasis on negative needs, toward a positive
approach that builds on existing partnerships and collaborations at the
State and community levels.1 The formal or informal connections
that State MCH leaders make with other important assets at the State and
community level can contribute greatly to the understanding of and support
for MCH goals by the public as well as to the effectiveness of the system
of care.
For MCH, this approach
involves inventorying the assets that exist in the State and at the community
level in the form of individuals, formal and informal associations, and
institutions such as libraries or faith-based groups, and determining
how these people and groups can be organized to more effectively address
MCH concerns and build systems of care for women, children and families.
Worksheet 1 serves
as a form for inventorying and evaluating existing and potential assets.
1The model
of assets-focused capacity assessment presented here is drawn from the
community development literature and particularly from publications by
the Asset-Based Community Development Institute at The Institute for Policy
Research at Northwestern University and their joint work with the American
Academy of Pediatrics.
As assets are identified
they can be listed and categorized into the groups listed in the left-hand
column of Worksheet 1. The worksheet is structured to collect information
on the strengths of each asset, their potential for building and partnering
in MCH systems, and the specific tasks needed to mobilize each of these
assets. Completing this form may require some research, but most of the
assets will be identifiable from the personal/professional experience
of the State and local agency staff as well as from members of the needs
assessment advisory or planning group. One option is for this part of
the capacity assessment to be completed as part of a group exercise; this
could be integrated with the infrastructure-building exercises recommended
in CAST-5. Alternatively, this worksheet can be copied and distributed
to members of the needs assessment team for them to complete individually
and bring back to the group for discussion and integration into a collaborative
assessment of MCH assets.
Upon completion of
a capacity assessment the Title V agency will be able determine whether
the resources are present, accessible and effective to deal with the identified
health needs in your target populations. This information is key for matching
capacity strengths and weaknesses to your identified needs, to prioritizing
among the many identified needs, and then finally for determining what
must be done differently to develop and maintain the necessary resources
and systems of care to meet the State's MCH population's needs.
C. Matching Needs
to Capacity
The next step
is to begin to compile all of the information gathered through the needs
and capacity assessments. For this information to be most meaningful,
health needs and system capacity to meet those needs must be analyzed
together.
The first step in
this process is to assess the key strengths and weaknesses in the capacity
of the system to meet the identified needs. Examples of capacity strengths
and weaknesses include geographic areas where services are particularly
accessible or absent, populations that are well- or underserved, or issues
that are thoroughly addressed or neglected. The types of needs and the
focus of the strengths and weaknesses identified will vary across the
levels of the MCH Pyramid.
Worksheet
1: Assessment of Current & Potential Assets for MCH Systems Building |
POPULATION |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Worksheet 2 presents a template for arraying the findings
of the needs and capacity assessments. For clarity, State officials may
want to complete separate worksheets for each of the MCH priority populations.
Worksheet
2. Analysis of MCH System Capacity to Address MCH Needs |
POPULATION |
Service
Category |
Needs |
Capacity |
Strengths |
Weaknesses/Gaps |
Direct
Services |
|
|
|
Enabling
Services |
|
|
|
Population-Based
Services |
|
|
|
Infrastructure |
|
|
|
System-Building/Collaboration |
|
|
|
The next step in the
analysis is to evaluate the relative importance of the identified needs.
Worksheet 3 can be used to divide the identified needs into four categories
or levels of relative need and capacity, as described below.
- High Need/High
Capacity. These are issues that are ripe for intervention, as
resources exist to address the needs.
- Low Need/High
Capacity. These may include issues that have traditionally received
large amounts of resources but which have declined in importance,
or geographic areas with substantial medical resources but low levels
of need in the immediate area.
- High Need/Low
Capacity. These are priority issues to which resources are not currently
being devoted.
- Low Need/Low
Capacity. These are low-priority issues.
Worksheet
3 |
NEED |
CAPACITY |
High |
Low |
High |
Intervention |
Need
to reallocate resources to address these needs |
Low |
Excess
capacity—
Can move resources to other needs |
Not
a priority |
Those that fall in
the first category of high need/high capacity are likely to be those that
are most in need of and susceptible to intervention.
Based on this analysis,
State MCH officials can develop a master list of priority MCH needs from
which ten high-priority issues can be selected. The process of selecting
these ten priorities is discussed in the next section.
D. Setting
Priorities
The final step
in the needs assessment process is the selection of ten (or more) priority
areas for program planning and resource allocation. This requires first
that the findings of the needs assessment be framed as priorities, and
then that the priority issues that are most critical be selected for inclusion
on Form 14 of the Block Grant Application.
In order to track
progress toward the priority goals, priorities must be linked to concrete
measures. Therefore, Section IV.B. of the Block Grant Application asks
States to link their priorities with National and State Performance Measures.
This requirement can be seen as limiting, as some important MCH issues,
such as substance abuse, mental health, and obesity, are not reflected
in the National Performance Measures. However, State-specific measures
can be crafted to assure that progress toward these goals can be assessed
and monitored. Also, because the Block Grant application is organized
around the Performance Measures, it can be easier to assure that programs
and resources are directed to each priority if they can be tied to the
measures as well.
1. Framing Priorities
In selecting and framing
priorities, State officials face several choices:
- Broad or narrow? A priority framed broadly, like “ improve access to comprehensive
prenatal care” can encompass a wide range of programs, so it
can be clearly shown that resources are being devoted to the issue.
On the other hand, broad priorities can be difficult to measure. A
more specific goal, like “reduce overweight, addressing physical
activity and nutritional habits,” is measurable but would require
that resources be allocated to a specific (possibly new) program.
- New issues
or existing programs? Some States choose to focus their priorities
on issues that have not traditionally received MCH funding, such as
oral health, mental health, and nutrition, in the hope that identifying
them as priorities will raise their visibility and justify the allocation
of resources to these issues. Others include in their priority lists
at least a few traditional MCH concerns.
- How many to
choose? While Form 14 has space for 10 priorities, States may
select more (or fewer). Some State officials felt that even 10 was
too many to track consistently, while others added one or two additional
priorities because they were unable to limit their list to 10.
2. The Priority-Setting
Process
Often the needs assessment
process produces far more than 10 potential priorities. States need an
inclusive, representative process for selecting among this priority list.
The steps in this process include:
- Convening
a body of stakeholders. Convening a Steering Committee or other
body of stakeholders on both the State and local levels can provide
a forum for an open discussion of potential priorities and the use
of a method for selecting among them. These committees may include
agency representatives as well as outside stakeholders, including
providers, family advocates, local health departments, and universities.
States may hold these discussions on a regional level around the State
or convene one group for a discussion of Statewide priorities.
- Choosing priorities
through consensus methods. A number of methods exist to help a
group to come to agreement on a list of priorities. These generally
involve asking each participant to rate each issue according to a
list of criteria, whether quantitative (such as prevalence) or qualitative
(such as the degree of political support for
addressing the issue). All of the participants' rankings are then
combined to create a ranked list of priority issues.
- Selecting
criteria. Whatever the process or forum used to select priorities,
participants will need criteria with which to select ten priorities
from a longer list. States reported using a number of different criteria,
including some reflecting the impact of a health issue; the issue's
susceptibility to intervention; and practical concerns about monitoring
and addressing the need. Criteria may be selected from the checklist
below; of course, data must be available for each priority on the
criteria that are chosen.
Impact Criteria
- Prevalence of the
problem (rates and absolute numbers)
- Seriousness of
the issue (morbidity and mortality rates)
- Economic impact
of the problem
- Whether the issue
affects subsequent (downstream ) issues
- Degree of demographic
disparity
Intervention Criteria
- Whether the issue
can be addressed with known interventions
- Whether the number
of risk factors is small and identifiable
- Amount of resources
(from Title V and other sources) available for the problem
Practical Criteria
- Degree to which
other agencies identify the issue as a priority need
- Whether the issue
can be tracked and measured
The priorities can
be scored and ranked based on the criteria selected, and the top ten selected
for inclusion in the Block Grant application.
CHAPTER
IV PUTTING NEEDS ASSESSMENT FINDINGS INTO PRACTICE
A needs assessment,
if it is to be truly useful, does not end when the document is submitted
to MCHB. Rather, the needs identified and priorities selected must be
used to design programs and allocate resources. In many States, however,
this is not easily done; the forces of political pressure and bureaucratic
inertia often work against even the best-intentioned efforts toward change.
In the real world, MCH agencies cannot completely revamp their budgets
each year, or every five years, regardless of the data and reasoning behind
their stated priorities. Existing positions and programs are generally
continued unless there is a pressing reason to terminate them, and funding
for new positions and programs can be difficult to find. In addition,
a substantial proportion of MCH funds are often passed on to local health
jurisdictions, whose decisions about allocating these funds may or may
not be linked to the State's priorities.
Nonetheless, several
States offered useful examples of how priorities and needs assessment
findings can be applied to planning efforts on the State and local levels.
These include:
- Use measurable
priorities. Data that demonstrates a clear need is the most effective
tool for getting funding for programs that are based on MCH priorities.
Moreover, linking the priorities
to performance measures—especially those on which MCH agencies
are required to report—helps to assure that resources will be
devoted to these issues.
- Marshal empirical
evidence. Likewise, if it can be shown that a program is effective
or, better yet, cost-effective, it is more likely to receive political
support.
- Take advantage
of open slots. When positions become open due to attrition or
retirement, take advantage of the opportunity to redirect them toward
issues on the MCH priority list.
- Partner with
other agencies. Numerous agencies outside of MCH, and in some
cases outside of health departments, address MCH issues in their work,
such as Departments of Education, WIC programs, and mental health
and substance abuse programs. Interagency planning and program development
can help to leverage new sources of funding, minimize duplication,
and improve coordination.
- Use priorities
to guide contracts with local agencies. Several of the study States
required their local health jurisdictions to incorporate the MCH priorities
into their annual work plans. In general, these States allow local
agencies to select three to five priorities and require them to develop
action plans to achieve measurable targets in these areas.
Actually using the
needs assessment findings and the identified priorities to guide funding
decisions can be challenging. Tying the priorities to measurable indicators
of performance, either State-based or National, will help to draw resources
to these issues. On the other hand, States should not feel limited to
the issues covered by the National performance measures in selecting their
priorities, as many of the most pressing MCH issues, such as obesity,
asthma, and access to dental care, are not covered by these measures.
Therefore, the development of State-level measures, with associated sources
of data, may be critical to assuring that the priorities selected are
used to guide programming decisions.
The Title V needs
assessment, while sometimes an arduous process, can be a rewarding one
as well. A thorough and comprehensive assessment can provide an MCH agency
with clear, evidence-based guidance on the allocation of its own resources
and strong arguments for the development of new sources of support. This
requires attention to the inclusiveness of the needs assessment process,
the rigor of data collection and analysis, and integration of findings
into a coherent document. With a focus on each of the critical elements
of needs and capacity assessment, this process can form the basis for
planning and improving systems of care for children and families.