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California’s Home Visiting ProgramStatewide Needs Assessment for the

Affordable Care Act Maternal, Infant and Early Childhood Home Visiting Program

Presentation for MCAH Action

October 20, 2010

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Background

• The Supplemental Information Request for the statewide needs assessment (referred to as the first SIR) was released on August 19, 2010

• The statewide home visiting needs assessment was submitted on September 20, 2010

• California received confirmation that the statewide needs assessment was accepted

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Methods

• Extensive cross agency collaboration and coordination with key partners

– California Department of Social Services (CDSS)

– California Department of Alcohol and Drug Programs (CDADP)

– California Head Start State Collaboration Office of the California Department of Education (CHSSCO/CDE)

• Local Capacity Assessment Home Visiting Survey

• The Home Visiting Program Collaborative Workgroup

• The Home Visiting Program webpage

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Methods

• Input, data, evidence or reports were obtained from a number of other agencies to assist with this needs assessment

– California Department of Health Care Services, California Department of Developmental Services, California Emergency Management Agency, the Safe and Active Communities Branch, the STOP Violence Against Women regional coordinator for California, the California Partnership to End Domestic Violence, the Domestic Violence Assistance Program, First 5 California, the First 5 Association of California, multiple County First 5 Commissions, and MCAH Action

• Coordination with existing Title V, Child Abuse and Prevention Treatment Act (CAPTA), and Head Start needs assessments

• Conceptual frameworks

– Life Course Perspective

– Social Determinants of Health

– Socio-ecological Model

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Major Needs Assessment Components

To meet requirements for an approvable statewide home visiting needs assessment, state’s were required to:

1) Identify “at-risk” communities with concentrations of select risk factors

2) Describe the quality and capacity of existing early childhood home visitation programs in the State

3) Describe the State’s capacity for providing substance abuse treatment and counseling to those in need

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Major Needs Assessment Components

• CDPH/MCAH organized the needs assessment according to the six components required by the first Supplemental Information Request (SIR):

1) Statewide data report

2) Defining “community”

3) Data report for each identified at risk community

4) Description of the quality and capacity of existing home visiting programs

5) Description of the state’s capacity to provide substance abuse counseling and treatment services

6) Summary of the needs assessment results, including a discussion of how the state will address unmet needs

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Section 1. A Statewide Data Report

Summary

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Required Indicators

• The first SIR required that states report on the following required indicators:

Premature birth Domestic violence

Low birth weight infants School drop-outs

Infant mortality Substance abuse (x4)

Poverty Unemployment

Crime (x2) Child maltreatment

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Supplemental Indicators

• States were given the option to include “other indicators of at risk prenatal, maternal, newborn or child health”

• In consultation with its partner agencies, California chose to supplement the required indicators

• Selected based on one or more of the following criteria:– Identified as a priority by partner agencies– Can be altered through early childhood home visiting or reflect

target populations for home visiting– Are measurable at the state and county level

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Required Indicators

• The supplemental indicators include:

Prenatal care Breastfeeding

Prenatal substance use Children with special needs

Maternal depression Foster care

Short birth interval

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Appendix A

IndicatorTitle

VCAPTA

Head Start

SAMHSA Other Comments

Premature birth

-Percent: # live births before 37 weeks/total # live births

-- -- --

Low birth weight infants

-# resident live births less than 2500 grams/# resident live births

-- -- --

Infant mortality

-# infant deaths ages 0-1/1,000 live births

-- -- --

Poverty

-# residents below 100% FPL/total # residents

-- --

Crime

-# reported crimes/1000 residents

-# crime arrests ages 0-19/100,000 juveniles age 0-19

-- -- -- --

Domestic violence

-As determined by each State in conjunction with the State agencies administering the FVPSA

-- -- --

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Appendix A

IndicatorTitle

VCAPTA

Head Start

SAMHSA Other Comments

School Drop-out rates

-Percent high school drop-outs grades 9-12

-Other school drop-out rates as per State/local calculation method

-- -- --

Substance abuse

-Prevalence rate: Binge alcohol use in past month

-Prevalence rate: Marijuana use in past month

-Prevalence rate: Nonmedical use of prescription drugs in past month

-Prevalence rate: Use of illicit drugs, excluding marijuana in past month

-- --

Unemployment

-Percent: # unemployed and seeking work/total workforce

-- -- --

Child maltreatment

-Rate of reported substantiated maltreatment

-Rate of reported substantiated maltreatment by type

-- --

Other indicators of at risk prenatal, maternal, newborn, or child health

--

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Additional Analyses

• California developed a table and map to present county-level data to help inform the designation of at risk communities

• Tables and maps were created for each indicator (i.e. both required and supplemental indicators)

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Example of an Indicator Table

• Lines indicate the state rate or percentage and state median

• State median was chosen due to the influence of large counties on the state rate

RANK ORDER COUNTY PERCENT

1 INYO 11.52 SISKIYOU 8.43 COLUSA 8.24 FRESNO 7.95 SAN FRANCISCO 7.35 LOS ANGELES 7.37 SAN BENITO 7.27 MARIN 7.27 SOLANO 7.210 SAN JOAQUIN 7.110 ALAMEDA 7.110 SAN BERNARDINO 7.110 KERN 7.114 IMPERIAL 6.814 LASSEN 6.8

CALIFORNIA PERCENT 6.816 YUBA 6.716 NAPA 6.718 RIVERSIDE 6.618 MERCED 6.618 SAN DIEGO 6.621 VENTURA 6.521 CONTRA COSTA 6.521 SACRAMENTO 6.521 SANTA CLARA 6.521 EL DORADO 6.526 STANISLAUS 6.426 DEL NORTE 6.426 TULARE 6.426 SAN LUIS OBISPO 6.426 KINGS 6.426 ORANGE 6.432 SUTTER 6.332 SANTA CRUZ 6.332 SAN MATEO 6.335 CALAVERAS 6.235 MENDOCINO 6.237 HUMBOLDT 6.137 MADERA 6.139 MONTEREY 5.839 SONOMA 5.839 SANTA BARBARA 5.839 PLACER 5.843 SHASTA 5.543 YOLO 5.545 LAKE 5.446 TUOLUMNE 5.346 BUTTE 5.348 TEHAMA 5.149 NEVADA 4.950 GLENN 4.2

ALPINE --AMADOR --MARIPOSA --MODOC --MONO --PLUMAS --SIERRA --TRINITY --

Table 3. Percentage of Low Birth Weight Infants Born to California Residents by County, 2008

State Median*

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Example of an Indicator Map

• The maps assign counties to quantiles based on their rate or percentage for that indicator

– Below the 50th percentile (i.e. below the state median)

– 50th-74th percentile

– 75th-89th percentile

– 90th-100th percentile

• Begins to identify counties most in need based on that indicator

Inyo

Kern

San Bernardino

Fresno

Riverside

Siskiyou

Tulare

Lassen

Modoc

Imperial

Shasta

Mono

Trinity

San Diego

Humboldt

Tehama

Monterey

Plumas

Los Angeles

Mendocino

Butte

MaderaMerced

Lake

Kings

Ventura

Tuolumne

Placer

Yolo

Glenn

San Luis Obispo

Sonoma

Santa Barbara

El Dorado

Colusa

Mariposa

Sierra

Stanislaus

Napa

Solano

Yuba

San Joaquin

Alpine

Santa Clara

Del Norte

Orange

CalaverasMarin

Alameda

Amador

Contra Costa

San Benito

Nevada

Sutter

Sacramento

San Mateo

Santa Cruz

Note(s): Excludes infants weighing less than 227 grams or greater than 8,165 gramsPrepared by: Maternal, Child and Adolescent Health Program, Center for Family Health, California Department of Public HealthSOURCE(S): 2008 Birth Statistical Master File*Due to rounding, categories may appear to overlap

Percent Low Birthweight Infants

0 to 49th Percentile

County Boundary

Too Few Events

Definition: Low birthweight infants weighing less than 2,500 grams

(4.2% to 6.4%)

50th to 74th Percentile (6.5% to 7.0%)

75th to 89th Percentile (7.1% to 7.3%*)

90th to 100th Percentile (7.3%* to 11.5%)

San Francisco

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Example of an Indicator Map by SAMHSA Region

• Data for some required indicators were only available by regions

• Regional rates were applied to each county for the purposes of this needs assessment

Inyo

Kern

San Bernardino

Fresno

Riverside

Siskiyou

Tulare

Lassen

Modoc

Imperial

Shasta

Mono

Trinity

San Diego

Humboldt

Tehama

Monterey

Plumas

Los Angeles

Mendocino

Butte

MaderaMerced

Lake

Kings

Ventura

Tuolumne

Placer

Yolo

Glenn

San Luis Obispo

Sonoma

Santa Barbara

El Dorado

Colusa

Mariposa

Sierra

Stanislaus

Napa

Solano

Yuba

San Joaquin

Alpine

Santa Clara

Del Norte

Orange

CalaverasMarin

Alameda

Amador

Contra Costa

San Benito

NevadaSutter

Sacramento

San Mateo

Santa Cruz

San Francisco

Region 1

Region 12

Region 8

Region 9

Region 2

Region 3

Region 15

Region 13

Region 7

Region 10Region 11

Region 6

Region 14

Region 4 Region 5

Note(s): The National Survey on Drug Use and Health (NSDUH) is an annual survey of population aged 12 or olderPrepared by: Maternal, Child and Adolescent Health Division, Center for Family Health, California Department of Public HealthSOURCE(S): Substance Abuse and Mental Health Services Administration. (2010). Substate Estimates fromthe 2006-2008 National Surveys on Drug Use and Health (Office of Applied Studies). Rockville, MD.*Due to rounding, categories may appear to overlap

Binge Alcohol Use in Past Month

0 to 49th Percentile

County Boundary

Too Few Events

Definition: Binge alcohol use is defined as drinking five or more drinks on the same occasion(i.e., at the same time or within a couple hours of each other) on at least 1 day in the 30 days prior to the survey

(19.8% to 21.0%*)

5oth to 74th Percentile (21.0%* to 22.6%)

75th to 89th Percentile (22.7% to 24.3%)

90th to 100th Percentile (24.4% to 25.3%)

Regional Boundary

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Section 2. Community Unit Selection

Summary

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Consideration of Several Units for Defining “Community”

• The first SIR’s guideline in defining “community” stated that “Each state should describe its understanding of the term “community” in accordance with the unique structure and make-up of the State.”

• California considered several possible units for defining “community.”

• California chose to define “community” as county for this needs assessment.

– California may refine this definition in response to the future SIR on the Updated State Plan.

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Identifying At Risk Communities

• The first SIR provided a definition of “at risk community” whereby an ‘at risk community’ is a community for which indicators, in comparison to statewide indicators, demonstrate that the community is at a greater risk than the State as a whole.

• For this needs assessment, at risk communities in California were defined as those counties with a rate or percentage worse off than the statewide median for any one or more of the indicators.

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At Risk Communities in California

• Every county has at least two indicators worse off than the statewide median.

• Based on California’s definition of at risk communities for this needs assessment, all 58 counties were designated as at risk.

• 54 of 58 counties, or 93%, had rates or percentages worse off than the statewide median for six or more indicators.

COUNTYPOPULATION

SIZENUMBER OF LIVE BIRTHS

NUMBER OF INDICATORS > MEDIAN

CALIFORNIA 38,648,090 551,567LOS ANGELES 10,441,080 147,684 8SAN DIEGO 3,224,432 46,742 10ORANGE 3,166,461 42,456 2RIVERSIDE 2,139,535 32,866 13SAN BERNARDINO 2,073,149 33,788 11SANTA CLARA 1,880,876 26,730 2ALAMEDA 1,574,857 20,972 4SACRAMENTO 1,445,327 21,389 14CONTRA COSTA 1,073,055 13,136 8FRESNO 953,761 16,760 12SAN FRANCISCO 856,095 9,104 9VENTURA 844,713 12,076 9KERN 839,587 15,315 16SAN MATEO 754,285 9,765 3SAN JOAQUIN 694,293 11,030 14STANISLAUS 530,584 8,549 14SONOMA 493,285 5,761 9TULARE 447,814 8,533 12MONTEREY 435,878 7,434 7SANTA BARBARA 434,481 6,319 9SOLANO 427,837 5,607 14PLACER 347,102 4,035 8SAN LUIS OBISPO 273,231 2,737 8SANTA CRUZ 272,201 3,538 7MARIN 260,651 2,716 6MERCED 258,495 4,423 16BUTTE 221,768 2,518 13YOLO 202,953 2,669 12SHASTA 184,247 2,186 16IMPERIAL 183,029 3,221 15EL DORADO 182,019 1,814 12KINGS 156,289 2,710 10MADERA 153,655 2,535 9NAPA 138,917 1,671 10HUMBOLDT 133,400 1,601 11SUTTER 99,154 1,468 14NEVADA 98,680 871 10MENDOCINO 90,289 1,168 14YUBA 73,380 1,264 16LAKE 64,053 705 16TEHAMA 63,100 790 12SAN BENITO 58,388 816 8TUOLUMNE 56,086 486 13SISKIYOU 46,010 498 14CALAVERAS 45,870 373 10AMADOR 38,022 288 6LASSEN 35,889 323 12DEL NORTE 29,673 312 14GLENN 29,434 472 12COLUSA 22,206 367 13PLUMAS 20,428 175 12MARIPOSA 18,192 147 8INYO 18,110 226 6TRINITY 13,898 126 13MONO 13,617 175 6MODOC 9,777 92 8SIERRA 3,303 22 6ALPINE 1,189 13 7

Population Size, Number of Live Births and Frequency of Indicators Worse-Off Than the State Median, by County and Population Size

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Section 3. Data Report for Each At Risk Community in the State

Summary

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Sample of a Data Report for Each At Risk Community

• California completed a data report, using the required Appendix A matrix, for each of the designated at risk communities, defined previously as all 58 counties. Below is a sample, the full data report includes all 14 required and 7 supplemental indicators as well as detailed comments.

Alameda County Data Tables: Summary of Indicators

Indicator Title V CAPTAHead Start

SAMHSA Other Comments

Premature birth

-Percent: #live births before 37 weeks/total # live births

-- -- -- -- 9.5

Low birth weight infants

-# resident live births less than 2500 grams/# resident live births

-- -- -- -- 7.1

Infant mortality

-# infant deaths ages 0-1/1,000 live births

4.2 -- -- -- --

Poverty

-# residents below 100% FPL/total # residents

-- -- -- -- 10.4

Crime

-# reported crimes/1000 residents

-# crime arrests ages 0-19/100,000 juveniles age 0-19

-- -- -- --4663.4

3940.7

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Section 4. Information on the Quality and Capacity of Existing Programs/Initiatives for Early Childhood Home Visitation in At Risk

California Communities

Summary

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Process to Assess Existing Home Visiting Programs/Initiatives

• Contacted state partners about their current home visitation efforts

• Obtained and reviewed existing local home visiting capacity surveys

• Contacted national/state representatives of evidence-based home visiting programs

• Developed and disseminated a Capacity Assessment Home Visiting Survey

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Assessment of Home Visitation Programs at the Local Level

• Counties have at least one home visitation program and the majority have multiple programs

• Counties report use of a variety and, often, multiple funding streams, yet still report inadequate funding

• Counties report multiple gaps and unmet needs

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Sample of the Survey Results for Each At Risk Community

• California completed a survey results report, for each of the designated at risk communities with survey data (n=54). Below is a sample, the full data report includes a narrative component.

Name of the

Program

Model or approach

Specific service

provided

Intended recipients/

Target population

Targeted goals/

outcomes

Demographic Characteristics

Number of

families served

Waiting list for

services

Funding Source

-- HFA --

Low income, Pregnant Women,

Teens, Hx of DV, Hx of Substance Abuse, Low

student achievement

/Dropouts

-- -- 150 Other

--PAT --

Low Income, Pregnant

Women etc.-- -- 84 HS/EHS

Contra Costa County Survey Results

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Section 5. Narrative Description of California’s Capacity for Providing Substance Abuse Treatment and Counseling Services to Individuals/Families in

Need of these Services Who Reside in At Risk Communities

Summary

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Substance Abuse Treatment Capacity in California

• Information for this section provided by CDADP

• Alcohol and Other Drug (AOD) treatment capacity in California is estimated to be 110,623

– This includes 38,000 pregnant and parenting women served by 300 publicly funded alcohol and drug treatment and recovery programs

• An estimated 3.3 million Californians need but are not receiving AOD treatment

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Section 6. Narrative Summary of Needs Assessment Results

Summary

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Summary of Needs Assessment Findings

• CDPH/MCAH worked in close collaboration with it’s partners to develop the home visiting application and needs assessment

• Input from other state agencies and local stakeholders and partners, including the Home Visiting Workgroup, was also obtained

• California defined “community” as County and designated all 58 counties as “at-risk”

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Summary of Needs Assessment Findings

• Extensive local expertise exists for the provision of home visiting programs but current resources are inadequate

• CDADP estimates AOD treatment capacity to be 110,623 with 3.3 million Californians in need but not receiving AOD treatment

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Conclusion and Next Steps

• California is waiting for the federal guidance for the Updated State Plan

• The Updated State Plan will provide an opportunity to refine the needs and resources assessment– To include additional indicators and data– To refine the definition of “community” (e.g., census

tracts and/or MMSA’s)– To refine the designation of “at risk” communities

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Questions?

• For additional questions or information on the Home Visiting Program, including a copy of California’s Home Visiting Needs Assessment, please visit the webpage:

– http://www.cdph.ca.gov.programs.mcah/Pages/HVP-HomePage.aspx

Thank you!