Testimony, DOH Performance Oversight Hearing, FY 2017-2018

Testimony of Shana Bartley, Acting Executive Director

DC Action for Children

 

Agency Performance Oversight Hearing

Fiscal Year 2017-2018

Department of Health

 

Before the Committee on Health

Council of the District of Columbia

 

February 12, 2018

 

Good afternoon, Councilmember Gray and members of the Committee on Health. Thank you for the opportunity to address the Council as it reviews the Department of Health’s performance in the past year. My name is Shana Bartley, and I am Acting Executive Director at DC Action for Children (DC Action).

DC Action provides data analysis and policy leadership on critical issues facing DC children and youth. We envision a District of Columbia where all children, regardless of their race/ethnicity, family’s income or zip code, have the opportunity to reach their full potential. We are also the home of DC KIDS COUNT, an online resource that tracks key indicators of child well-being in the District.

DC Action for Children also serves on the Home Visiting Council with other advocates, community-based providers and agency leaders. This council works to strengthen home visiting in the District by building a cross-sector network of support for programs, advocating for resources and funding for their stability and growth and collaborating to address system-wide challenges to the implementation of home visiting services. We are grateful for the leadership and partnership of the Department of Health’s (DOH) staff on the Home Visiting Council and their commitment to promoting maternal, child and family health through evidence-based home visiting services.

This is an important time for DC’s young children, pregnant women and their families. DC is growing rapidly, and more and more young children are calling DC home: currently, 42,200 children under age five live in the District.[1] In 2014, the District saw 9,500 births across the city.[2] With such a large and growing population of children, it is crucial that DC is an excellent place to parent and a great place to be a kid. The research is clear that children reach significant developmental milestones between birth and age 5 and that those milestones are influenced dramatically by a family’s access to resources. In a city where almost 20% of children under 5 live below the poverty level, home visiting and other resources within a coordinated system of care and support are especially relevant to reducing disparities.[3]

My testimony today will focus on DOH’s efforts to support pregnant women, young children and their families, with particular attention to three key points:

  1. Women and children in the District must be supported by a strong maternal and child health system;
  2. Home visiting is an important strategy to support DC’s growing number of young children and their families, and it needs sustainable and secure local funding; and
  3. DC’s school health services program must be a child-centered, cross-sector collaboration.

Women and children in the District must be supported by a strong maternal and child health system

We know that what happens before, during, and after a pregnancy has a significant bearing on the health, wellness, economic stability and opportunity for growth of both moms and babies.[4] During this joyful and challenging period, when the transitions are many and the stakes are high, a system of care and support that includes access to quality healthcare, a range of programs and services designed to meet diverse community needs, family knowledge of available programs, and strong social supports is essential to ensuring that all DC mothers and babies receive the help they need to achieve positive birth and life course outcomes.

In 2015, DC’s infant mortality rate was the highest in the country at 8.6 deaths per 10,000 live births.[5] The District’s maternal mortality rate was also staggering, at more than 40 maternal deaths per 100,000 live births, according to the March of Dimes’ analysis of the CDC’s National Vital Statistics System.[6] In response to these and other concerning maternal and child health outcomes, the Department of Health has thoughtfully administered valuable and diverse maternal and child health programs, including home visiting programs, Healthy Start, place-based initiatives, school-based health centers, Help Me Grow and other supportive programs. These, alongside DC’s other public and private maternal and child health programs and health initiatives have resulted in a menu of invaluable supports that have the potential to improve outcomes for families. However, although a wide range of programs and providers exists, their full effectiveness is impeded by the lack of a true system of care for maternal and child health. This system would connect programs, providers, and other stakeholders to each other; connect families to the screenings, care providers, and programs they need; and identify gaps in care and services and the root causes of disparities.

The events of the past year highlight the need for a coordinated system of care. In 2017, two of DC’s seven hospital maternity wards closed, accompanying a shift in Medicaid managed care contracts that has altered the landscape and affected some women’s ability to receive care from their preferred providers. These incidents were isolated, and we are still working to understand the impact of these changes. However, what is clear based on our work with community-based organizations, DC agencies, health care providers and other stakeholders is that much of the confusion caused by these changes could have been avoided in a coordinated system of care, where important functions and responsibilities were clearly defined. Given already high maternal and infant mortality rates in DC, we are concerned that incidents such as this, the lack of options for care for women with high-risk pregnancies in our communities with the highest birth rates and the lack of a birthing hospital in these communities will result in undue burden on pregnant women with the highest risk for negative birth outcomes and their babies.[7]

No one agency or entity, including the Department of Health, can or should be responsible for developing a system of care. I highlight the need for this system today because, as the public health agency, we hope that the Department of Health joins efforts to create a shared vision for maternal and child health and ensure that a system of care is in place for moms and babies in DC. We applaud the care and rigor with which DOH develops and administers programs for maternal and child health and well-being. We look forward to working with our partners at DOH, other DC agencies and community partners to conceptualize and put into place a maternal and child health system that will ensure quality care for DC families.

A final and critical note: In developing this system of care, equity must be a top priority. According to the CDC, black women are 243% more likely to die from pregnancy or childbirth-related causes than white women, an inequality that is likely reflected or exceeded in DC, where infant deaths are more 2.5 times more likely to occur to black mothers than to white mothers.[8],[9] Research finds that these disparities are not solely the result of factors associated with differences in income or education, as is often suggested. For example, New York City’s maternal morbidity report from 2016 finds that black, college-educated mothers who gave birth in local hospitals were more likely to suffer severe complications of pregnancy or childbirth than white women who never graduated from high school.[10] The data is clear: racial inequity drives disparities in health outcomes for women of color and we must ensure that DC is a place where all women have access to the healthy pregnancies and positive birth outcomes that every resident deserves.[11],[12],[13]

Home visiting is an important strategy to support DC’s growing number of young children and their families.

One key strategy for supporting pregnant women and the families of young children is maternal and early childhood home visiting. As a family support strategy, early childhood home visiting provides education, parenting techniques and resources to pregnant women and families with young children ages 0 to 5. In these evidence-based programs, trained home visitors work collaboratively with families who are expecting or who already have young children to achieve improved outcomes in school readiness, child welfare, and/or child health and development. Importantly in our current landscape, where a coordinated maternal and child health system is absent, these programs are a source of much-needed social support and serve to connect participants to other families, as well as to community resources that promote positive health, developmental and well-being outcomes for children and families. Additionally, these programs are especially valuable in facilitating engagement with expectant women and families who are traditionally difficult to reach and establish strong rapport with, as these families are often at the greatest risk for negative outcomes.

However, tenuous federal dollars are DC’s primary source of funding for home visiting.

Through a combination of federal and local dollars, the Department of Health is the largest funder of home visiting programs in the District. DOH’s programs are evidence-based, rigorously implemented, and are a fixture amongst DC’s early childhood programs and services. However, nearly all of DOH funding for home visiting comes from the federal Health Resources and Services Administration (HRSA) through the Maternal and Infant Early Childhood Home Visiting (MIECHV) program, which supports evidence-based early childhood home visiting programs and promising new approaches nation-wide. DOH began receiving MIECHV funding in fiscal year 2010 and is currently receiving a grant award of $1,624,146 to provide program funding over two and a half years through September 2018.

Historically, DC’s MIECHV funding has fluctuated subject to changes in federal programs and funding availability, highlighting the need for increased funding stability for home visiting programs and the families that benefit from them. In 2016, national discontinuation of the MIECHV development grant resulted in a loss of funding to some DC providers, who were forced to reduce their program caseloads and scramble for private funding as a result. This year, we were once again reminded of the tenuousness of federal funding sources: federal MIECHV authorization expired in September 2017 and was not renewed until late last week, despite concentrated advocacy on the part of federal and state partners and promises of reauthorization by Congressional staff.[14] Although MIECHV was ultimately reauthorized, the length of time between its expiration and its renewal, as well as the uncertainty about whether it would be reauthorized at all is a reminder that nearly all publicly funded home visiting in the District is subject to Congress and HRSA. DC families with young children rely on home visiting programs to achieve positive outcomes and we owe it to these families and to the programs that support them to ensure that funding is secure. Therefore, I emphasize today that a local commitment of funding for home visiting is necessary to ensure that DC families can receive these important programs. We believe that a commitment of $2 million dollars would support sustainable implementation of home visiting programs as well as the strengthening of the home visiting system in DC.

DC’s school health services program must be a child-centric, cross-sector collaboration

For my final comments, I shift to the Department’s work to improve children’s health outcomes through school-based health services. In 2015, DC Action for Children conducted the School Health Needs Assessment (SHNA) that found that students attending DC Public Schools and public charter schools experience both chronic conditions and common childhood ailments that can affect their ability to achieve their full potential in the classroom, and that the model for school health implemented at the time was not successfully addressing students’ needs.[15] We know there have been significant actions by the DC Council and DOH to ensure that students in our schools have access to quality health services in the nurse’s suite. However, there were two recommendations within our report that we think could serve to strengthen school health services that extend beyond nursing coverage.

First, we learned that school health services must be guided by a clearly articulated, shared vision carried out through cross-sector collaboration. The SHNA revealed that numerous barriers to cross-sector collaboration exist in the present system, including the lack of well-defined roles and responsibilities, limited collaboration, and resultant silos within the system. This responsibility does not solely rest on DOH; rather, development of the shared vision requires the leadership and expertise of a multi-sector set of stakeholders. The vision must be child-centered and focused on outcomes and shared performance goals that emphasize the deep relationship between children’s health, development and learning.

Second, the SHNA report recommends establishing a school health advisory body that would facilitate increased collaboration across District agencies, school health providers, and school leaders. This body would also support essential data sharing and troubleshooting as well as promote accountability to focus on outcomes. In short, coordinating the school health services program is no one agency’s issue; partners at all levels must come together to determine what a child-centered school health services program that prioritizes quality services and improved health and education outcomes looks like and how it can be achieved in the District.

­­We are grateful to see the Department of Health’s consistent dedication to reducing disparities and improving the health and quality of life of all DC residents, including pregnant women, children and their families. Thank you again for the opportunity to testify. I am happy to answer any questions you may have.

 

[3] Population Reference Bureau, analysis of data from the U.S. Census Bureau, Census 2000 Supplementary Survey, 2001 Supplementary Survey, 2002 through 2016 American Community Survey. Retrieved from http://datacenter.kidscount.org/data/tables/5650-children-in-poverty-by-age-group?loc=10&loct=3#detailed/3/any/false/870,573,86…

[4] Huizink, A. C., Robles de Medina, P. G., Mulder, E. J., Visser, G. H., & Buitelaar, J. K. (2003). Stress during pregnancy is associated with developmental outcome in infancy. Journal of Child Psychology and Psychiatry, 44(6), 810-818.

[5] Centers for Disease Control and Prevention, National Center for Health Statistics. Retrieved from http://datacenter.kidscount.org/data/tables/6051-infant-mortality?loc=10&loct=3#detailed/3/10/false/573,869,36,868,867/any/1271…

[6] National Center for Health Statistics, final mortality data; National Center for Health Statistics, final natality data.

Retrieved December 19, 2017, from www.marchofdimes.org/peristats.

[9] DC Department of Health, 2014 Infant Mortality Report; Retrieved from: https://doh.dc.gov/sites/default/files/dc/sites/doh/publication/attachments/IMR_2014_Edits_6.19.17.pdf

[11] Tucker MJ, Berg CJ, Callaghan WM, et al. The black-white disparity in pregnancy-related mortality from 5 conditions: Differences in prevalence and case-fatality rates. Am J Public Health. 2007 February 1;97(2):247–51

[12] Williams DR, Collins C. US Socioeconomic and racial differences in health: Patterns and explanations. Ann Rev Soc. 1995;21:349–86.

[13] Williams DR. Racial/Ethnic Variations in Women’s Health: The Social Embeddedness of Health. Am J Public Health. 2002 April;92(4):588–97.

[14] FY16 CHA Oversight Responses

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