Momsfirst Local Evaluation 2019

MomsFirst Local Evaluation 2019 Frank G. Jackson, Mayor City of Cleveland Merle Gordon, Director Persis Sosiak, Commissioner of Health Lisa M. Matthews, MomsFirst Project Director Cleveland Department of Public Health Acknowledgement: Center on Urban Poverty and Community Development Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University 1 Table of Contents Description of MomsFirst 4 MomsFirst Collaborations and Collective Impacts 7 MomsFirst Local, Regional, and State Efforts 9 Root Causes, Social Determinants of Health, & Health Equity Overview 11 2019 MomsFirst Cohort 14 Healthy Start Benchmarks and Performance Measures 16 Improving Women’s Health 16 Improving Family Health and Wellness 17 Promoting Systems Change 19 Birth Outcomes and Infant Mortality 21 Impacts 26 Recommendations 27 Technical Notes/References 30 Data System 30 MomsFirst Goals and Data 30 Table and Figure Notes 30 References 32 2 Tables and Figures Tables Table 1 Regional Racial/Ethnic Demographics – Compared to MomsFirst Participants 15 Table 2 Profile of 2019 Births to MomsFirst Participants – Compared to Other Cleveland and Cuyahoga County Resident Births 16 Table 3 2019 Federal Benchmarks and Performance Measures – Improving Women’s Health 17 Table 4 2019 Federal Benchmarks and Performance Measures – Improving Family Health and Wellness 19 Table 5 2019 Federal Benchmarks and Performance Measures – Promoting Systems Change 20 Table 6 Infant Mortality Rate with Births and Deaths – among MomsFirst Participants 25 Figures Figure 1 Healthy Start Approach 5 Figure 2 Social Determinants of Health Tree 11 Figure 3 Social Determinants of Health – and their Contribution to Infant Mortality 13 Figure 4 Ecological Model – Life Course 14 Figure 5 Low Birth Weight 21 Figure 6 Very Low Birth Weight 22 Figure 7 2019 Infant Mortality Rates by Race – US, Ohio, and Three Largest Counties in Ohio 23 Figure 8 2019 Birth and Infant Death (<12 months) Shares by Race – Ohio and Three Largest Counties 24 Figure 9 Racial Disparity in Infant Mortality, Cleveland 2000-2019 25 3 Description of MomsFirst MomsFirst is a home visiting program, providing outreach, case management, interconceptual care and health education, designed to help mothers and families thrive during pregnancy and throughout their baby’s first 18 months of life. MomsFirst serves pregnant women and teens living in the City of Cleveland who are at high-risk for a poor birth outcome. Specific recruitment efforts seek to enroll pregnant women and teens who are incarcerated in the county jail, residing in homeless shelters, or receiving in-patient chemical dependency treatment. These women and their families experience complex circumstances that place them at increased risk for poor health, pregnancy and birth outcomes. The MomsFirst adolescent component works with pregnant high school students and their parents to ensure these young women have a healthy pregnancy, a healthy baby, and a plan for a successful future. All of these efforts are aimed at eliminating racial disparities in infant mortality by reducing the number of families of color who experience the death of a baby before their first birthday. In 2019, MomsFirst worked to achieve the following objectives for participating women and families: 1. an infant mortality rate below the Healthy People 2020 goal of 6.0 infant deaths per 1,000 live births; 2. fewer than 7.8% of all babies born at low birth weight (<2,500 grams); and 3. fewer than 1.4% of all babies born at very low birth weight births (<1,500 grams). MomsFirst was established in 1991 as the City of Cleveland’s Healthy Family/Healthy Start program. Healthy Start was enacted that same year by the Maternal and Child Health Bureau to address and reduce disparities in infant mortality experienced in communities across the United States at high-risk for poor birth outcomes. In its 28th year of existence, Healthy Start currently funds 101 programs in 36 states and the District of Columbia; MomsFirst is one of these programs. MomsFirst also receives funding from Cuyahoga County’s Office of Early Childhood: Invest In Children, Ohio Department of Medicaid, and the City of Cleveland General Fund. Healthy Start works to reduce infant mortality and adverse perinatal outcomes by focusing on four approaches (see Figure 1). These evidence-based approaches are linked to improving birth outcomes 4 Figure 1. Healthy Start Approach and reducing infant mortality. Healthy Start has identified 1. Improve Women’s 2. Improve Family 3. Promote Systems Health Health and Wellness Change Benchmarks (19 in total) for achieving each of the four 4. Assure Impact and Effectiveness approaches and through Workforce Development, Data Collection, Quality Improvement, corresponding Performance Monitoring and Evaluation Performance Measures that identify service activities and strategies for meeting each Benchmark. The 2019 data highlighting MomsFirst’s progress toward each Benchmark are presented in the Healthy Start Benchmarks and Performance Measures Section to follow. MomsFirst has used a braided funding approach to ensure that all home visiting services delivered, regardless of which particular funding source is used to cover operating expenses, employ the core elements of Healthy Start. This financial model ensures a seamless approach to prenatal home visiting in the city and strengthens the MomsFirst brand. Nevertheless, the largest portion of MomsFirst funding has come from its Healthy Start award, at $1.8 million each year over the past five years. In responding to the Competing Continuation application in December 2018, MomsFirst carefully put together a plan that could be made operational under a more than 50% funding cut at the Federal level. The plan included issuing a Request For Proposals to select subcontractors who could meet a more robust set of service delivery and data reporting expectations, within a diminished budget. During the first quarter of 2019, MomsFirst was actively planning for a streamlined program to address the anticipated Federal funding reduction. The MomsFirst plan for the next five-year grant cycle (April 2019-March 2024) was to reduce direct service providers to five, focusing on quality vs. quantity of services, enhancing infrastructure, increasing staff development, and implementing curriculums and practices to fidelity. It is notable that the project has continually considered the issue of sustainability and transition and developed a “toolkit” of approaches, which was shared in a panel presentation by the MomsFirst Project Director in early 2019 via a Healthy Start EPIC Center Webinar. 5 To begin, MomsFirst Project administrators analyzed early 2019 participant data and assessed partner programs that may have served some subsets of current and future enrollees and met to plan the transition of over 130 families with children approaching 18 months of age to the Bright Beginnings program by March 31, 2019. MomsFirst Project administrators also met with a local collaborator, the Nurse Family Partnership, to begin transferring very high-risk families early in pregnancy (less than 28 weeks), to their program. The Nurse Family Partnership program arranges home visits from registered nurses to low-income, first-time mothers. The visits begin during pregnancy and continue for two years following birth. Communications regarding potential changes to MomsFirst began with letters sent to participants regarding program changes and transition to new providers. One-on-one meetings with staff members were held to discuss the reduction in funding. Key stakeholders, subcontractors and partners attended meetings to discuss changes in the program. An emphasis was placed on the renewed focus on effective services and the requirements for high quality, standardized service delivery. The home visiting landscape has changed dramatically over the past five years with the advent of additional Ohio Medicaid funding and programming in the community further increasing the saturation of home visiting programs. Additionally, over the past year, MomsFirst direct service staff has been challenged with meeting enrollment thresholds and maintaining contractual compliance, often leading to failed compliance reports and financial penalties. This impacted two subcontractors that decided to withdraw from service delivery (St. Martin de Porres, effective 7/3/18 and Harvard Community Services Center, effective 12/31/18). Scaling the program to fit within the reduced funding level was welcomed and allows the program the opportunity to be strategic with its resources. Given the program changes ushered in with the beginning of the April 1, 2019-March 31, 2024 Federal funding cycle, in early April, a “re-launch” of MomsFirst was initiated. The theme was “Fostering and Nurturing a Culture of Quality,” which focused on the foundational elements of staff empowerment, teamwork and collaboration, leadership commitment, customer focus, and continuous quality improvement. Many components designed to enhance those foundational elements were added in 2019, including new fatherhood and child development binders, universal paper case files, Case Manager Workshops, Community Health Worker Drop-Ins, Ages & Stages Questionnaire kits, Baby Basics training, and Nurturing Parenting training. 6 MomsFirst Collaborations and Collective Impacts To prevent infant mortality and eliminate the racial disparity between Black and White infant deaths in the City of Cleveland, MomsFirst has actively cultivated strong

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