AMCHP 2005 ANNUAL CONFERENCE
DELIVERING RESULTS, IMPROVING PREGNANCY & BIRTH
February 19-23, 2005
RENA LARGE : Welcome to Skills Building Session C-4. This is System Capacity for Adolescent Health Public Health Improvement Tool. In your binders that you have--did everyone get a binder? In your binders, the first page behind the title page is the agenda and what we're going to go through today, and we'll adjust this based on the number of people that we have and how far we get and we'll be able to do a little more individualized discussion. The second tab is the PowerPoint presentation that we're about to begin, and the third tab is preparing to use the tool, which is where we'll get into some more individualized work followed by the six sections of the capacity tool, which we'll tell you a little more about.
So I will introduce myself, and then I'll let Kristin introduce herself when she comes up here. My name is Rena Large, and I am the senior program director for Adolescent and School Health at the Association of Maternal and Child Health Programs, and Kristin Teipel and I--and Kristin will introduce herself in a moment--we are going to present to you today an overview of the system capacity tool for adolescent health.
This is a joint project of the state adolescent health coordinators at work and the Association of Maternal Child Health Programs in collaboration with the Kanapa Institute for Best Practices and Adolescent Health at the University of Minnesota, which is where Kristin is from, and now that the tool is published on our website, Kristin and AMCHIP and some other partners from MCHB are going to devise a plan for technical assistance for the people that are interested in implementing it in their states. So let me tell you a little bit about the premise of the system capacity tool.
The underlying premise of this tool is that adolescent health is very complex. Addressing it is complex. It's not something that any one person should be responsible for, it should be the responsibility of a network of organizations, agencies and individuals, and it requires collaboration across public and private societal institutions across all sorts of agencies and institutions that touch the lives of adolescents.
Another underlying premise of this tool is that public health is critical to adolescent health. There are many places in public health where adolescent health is a priority. Healthy people 2010 within the objectives for the nation, there are objectives that relate to adolescents and young adults and within those, there are 21 that have been identified as critical objectives. State and territorial maternal and child health programs have negotiated measures and needs that they document and demonstrate in their MCHB Title V Block Grants, and many, many states have adolescent health related objectives and performance measures. The national initiative to improve adolescent health, which is a national initiative that’s built around Healthy People 2010 and the critical objectives, it's a joint partnership of the Maternal and Child Health Bureau Office of Adolescent Health, and we have guests from MCHB with us, and they may want to say a little more about that later.
It’s a partnership of MCHB and the CDC Division of Adolescent and School Health, and it's a network of national organizations and agencies all working towards improving adolescent health outcomes with many of the activities and resources being built around the critical objectives. This capacity tool that we are about to talk about today is one of the things that AMCHIP and the State Adolescent Health Coordinator's Network have done together under the umbrella of the national initiative, one of the many things that we have produced to reach that goal of improving adolescent health. And then there are the ten essential public health services, which is something that was a framework established by the Institute of Medicine , later taken and reframed for Maternal and Child Health specifically and, also, taken and reframed specifically for adolescent health.
So, there are many ways in which public health has already demonstrated adolescent health as a priority, and in that way, it's critical. If you're wondering why Maternal and Child Health is important in improving adolescent health, adolescent health is one of the critical developmental periods within life span development. It's a critical piece of family health, children become adolescents, adolescents become adults, and so it's all part of the life span, and so within Maternal and Child Health programs, they can provide a strong focal point for focusing on adolescents within that MCH framework within the Family Health framework, that insures that attention is being paid specifically to adolescents and their developmental needs and the needs of various age ranges and developmental stages that they go through. MCH programs can also insure that there is a strong infrastructure to effectively address adolescent health, because they are so intricately involved in the life span of populations in their states and territories from infants to women of reproductive age to improving birth outcomes.
So, insuring a strong infrastructure in general can also promote adolescent health efforts, and MCH programs can also forge partnerships with other agencies, institutions, as well as with youth and families. They have a long history of partnering with other providers and practitioners and families and networks and communities, experience in data and assessment, program planning, evaluation, and so they can play a really important role in forging the partnerships that are necessary to promote adolescent health. The system capacity tool is outlined around six areas of capacity. Now, one of the founding documents of the system capacity tool is the conceptual framework for adolescent health, which is also a project of AMCHIP and the State Adolescent Health Coordinator's Network with the input of most of the people in the room, and it documents some definitions of adolescence, healthy adolescence, youth development, terms that are important to adolescence and adolescent health.
It defines what the role of public health and Maternal and Child Health should be, and also provides some guiding principles for adolescent health. Now, the second piece of the conceptual framework is the implementation of that framework and those visions at the state level, and that's what the system capacity tool is designed to do. It takes the concepts, the definitions, the principles, the visions, the values from the conceptual framework, and it puts those things into a framework to look at how MCH can provide a focal point, how MCH can improve infrastructure, how MCH can forge partnerships, and so there are six areas that are outlined in the system capacity tool. The first being a commitment to adolescent health, now within the capacity area of showing a commitment to adolescent health there are things like having dedicated resources including someone who is designated as the adolescent health coordinator, providing opportunities for staff to increase their expertise if there is an adolescent health coordinator or if there is not an adolescent health coordinator so that the people that are touching those issues in the MCH program have the expertise or the opportunities to increase that expertise in adolescent health, and within a commitment to adolescent health, MCH programs can provide a focal point, which can be defined in a number of ways, but some sort of a visible commitment and priority to show that adolescent health in its own age range and developmental needs is a priority within the MCH framework.
The second capacity area in the tool is defined as partnerships, and this is partnerships in every sense, partnerships with other agencies, with other institutions, partnerships with youth and families, and the nature of those partnerships being combining, coordinating, integrating, doing better because we have more people in the room that are all working towards the same outcome, and part of that outcome being that efforts are coordinated with other efforts going on in the state and other opportunities for youth and families and partners to improve adolescent health. The third area outlined in the system capacity tool is defined as planning and evaluation, and this section of the tool talks about comprehensive coordinated planning. It includes needs assessment, strategic planning, prioritizing of issues for action. It includes things like having the capacity or building the capacity to plan developmentally and culturally appropriate programs for adolescents, the promotion and development of new policies, programs and services to fill gaps for adolescents, and the ability to evaluate and fine tune those efforts.
Those are all, those are some of the concepts within planning and evaluation. The fourth capacity area in the system capacity tool is defined as policy and advocacy. Policy and advocacy including a wide range of efforts, including state level policy development, maybe contributions to other types of policy development at the national level, advocating, promoting adolescent health needs--the developmental needs of adolescents, also educating partners on the needs of adolescents--developmental needs, work that's going on, data that has come out. So, while policy and advocacy for some means legislative lobbying, for us it means the things that you do to advocate for adolescents, to promote adolescents, to show and demonstrate why it's an important group and all of the policy and program efforts that might go along with that.
The fifth capacity area in the tool is defined as education and technical assistance, and this includes a wide range of concepts as well, including public education efforts, and also including education efforts for other professionals, health practitioners, other practitioners that come into contact with adolescents, teachers, social workers, any number of a range of professionals that come into contact with adolescents, and the last capacity area is defined as surveillance and data systems, and this includes concepts such as dedicating resources to put towards data and surveillance efforts that are specifically around adolescent health, having staff expertise if there’s not someone who is a dedicated data person on adolescent health, maybe there is someone who is the dedicated MCH person on data, but has some expertise and can speak to adolescent data sets. And then, also, again in surveillance and data having an adolescent health focal point so that pieces of data that are collected are not just pulled out of other things that are available, but there is a concentrated effort to create a complete data set around adolescent health and all the places where that overlaps with other information that’s available.
Now, those are just a few of the concepts within each of these capacity areas, and something that you will see once we start going through the tool and having a little more individualized conversation is that there is a lot of places where there is overlap, and what we've tried to do with the tool is to really streamline it so that the major concepts that fall best within any capacity area are in that capacity area, but may be mentioned throughout some of the others. So, we've really tried to increase the streamlining of this so that every piece of this that you might look at has something new and useful, and we're not reinventing the wheel and having the same conversations over and over again, and in that sense, the tool is really a process of building on your conversations until at the end, you have a complete picture of what adolescent health looks like, which then allows you to prioritize some areas where you think you might want to make some improvement or create some action steps to try to move towards improving or enhancing or creating whatever it is that you've prioritized. The tool itself, although it's useful in a lot of settings and we know that a lot of people are using it in a lot of ways, it's really designed to assist MCH Family Health Programs, and so the language in the tool is very much geared around MCH Family Health Programs, Maternal and Child Health frameworks. It's designed to help assess capacity to address adolescent health. Where are you currently in this process? Maybe you're nowhere and you're starting, maybe you're far along and you're looking at a way to prioritize the next year or five years. In that way, it gives you a framework for looking at where you want to go, so you have all of the pieces in front of you, and you can say these two areas are the places where we need to be most or where we haven’t addressed before or where we have the most capacity, and then it moves towards developing and implementing a plan of action to get where you want to go with those things that you've identified as important and a priority in your MCH program. So, it's a where are you, where do you want to go and how do you get there sort of tool.
Now, the tool was created recognizing that every state and territory is different there is a range of capacity and ability. No two programs are the same. It is a series of questions, which you will see, that leads users through the process of thinking about what they have and where they want to go and what they can reasonably do within the environment that they're in. So, it can be tailored to every user's needs, and it also recognizes that there is a range of infrastructure characteristics that must be in place. So, it's not a comparison of your program to anyone else's program. It's not a comparison of your program to a set of five things that must be in place. It's really a process of reviewing what you have and figuring out what is best for you. So, it recognizes that some programs don't have adolescent health coordinators, some do, but they're not full-time, some do, but they focus specifically on one issue, like teen pregnancy. So, the point of the tool is not to say this is where you should be, it's to say where do you want to go and what can you realistically do? It's designed to compliment other efforts, other national and state tools, such as the Cast Five Capacity Assessment Tool for Title V Programs.
Cast Five is outlined based on the ten essential public health services, and while this tool is based on the ten essential public health services, it's not outlined like that, because we wanted to demonstrate that there are places where the emphasis should be different for adolescents. It's, also, designed to compliment, as I mentioned, the national initiative to improve adolescent health and young adult health by the year 2010, and a number of the partners involved in that effort are involved in the effort of developing this tool, and many of the elements of the surveillance and data section are based on the resources available and the idea of all moving towards implementing these critical objectives for adolescents within Healthy People 2010. It was developed over a two-year period with extensive literature reviews and expert input.
The six capacity areas were actually based on a literature review of capacity literature in the field in a variety of disciplines in business, in public health, in social work, in leadership development, in strategic planning, and so the six areas were boiled down from what is out there about what needs to be in place for anything to be successful, and that's how we came to these six categories. Multiple work groups of multiple people over a two-year process--about 70 different people around the country from MCH programs, federal agencies, national organizations contributed to the development of the content of the tool, and last May, we had the great fortune to pilot the tool in three MCH programs: once in Tennessee, once in Utah, and the third state being Wisconsin, and the process of doing that helped us to streamline the content to make the format really much more user friendly, to make the instructions much more clear, and we have a number of pieces that are scheduled to come out around the tool, how to facilitate within a larger group, how to use it for two days versus one day, how to tailor it to local level.
So, there is a number of things that now that we have refined the tool and the content, we are moving towards creating some other supplemental pieces, and there are a number of benefits--and if you don't have a list of those benefits already in your mind--there is a number of benefits for going through this process for assessing system capacity for adolescent health. One is that it's a way of documenting baseline capacity, whether you're establishing a new program or you are writing you Title V Block Grant, whether you are moving into a five-year needs assessment. It's a way of saying here is where we're starting so that if staff changes, if programs change, if funding, priority changes, you have a way of saying here is where we were so that we can see where we made progress or where we want to get back to when the priorities shift. So, it's a good way of documenting baseline capacity to go through this assessment process. It's also a really great way of identifying some best and promising strategies that have already taken place in your program.
While a lot of you probably have some of that documented internally or in reports or on your website, it's a way of having it all in one place so that the result of the assessment is not only where are we starting from, but what things have worked? What are the things that we have that say that worked--a data report, a program report--so that it's all in one place, and it's a great tool for internal and external partners to come in and give input into your process, to give input on how you can help them or how they can help you. It's also a way of identifying some gaps in programs, services, resources, a way to identify new partners that might need to be pulled into some sort of an adolescent health initiative, and for programs that are changing or just beginning an adolescent health effort, it's a way to think about how a MCH program is defined in terms of adolescent health. What's the role of the MCH program when there are so many other people and places and organizations and agencies doing this work--what is it that the MCH program can do, the adolescent health coordinator can do that builds and enhances that, not replaces it? And I will pause for a moment for questions, does anyone have any questions, and there’s lots of opportunities for questions later, but I’ll just throw that out there for a second. Any questions? Yes?
UNIDENTIFIED SPEAKER : How did this states that the, that were piloted, how were they chosen, and why were they chosen?
RENA LARGE: That's an excellent question. How were the three states that were chosen for pilot selected? And I actually believe that both of you--your states applied for the process, as well. The process of selecting the states was that we put out an announcement saying that we had this opportunity, acknowledging that we had limited funds for travel and resources. We had a certain time line in which we needed to be able do the pilot, and what we did is we looked at the whole range of programs that applied. We had 15 states and three territories that applied for the opportunity, and what we did is we sort of grouped them into who has low capacity, who has medium capacity and who has high capacity, so that we could be sure that the three states that we selected were diverse, not only in their own needs, but also, across the country diverse in the kind of staffing that they already had, the kind of capacity that they already had, and we narrowed it down from there.
We looked at that range of states from low to high capacity, and also, some based on timing. If a state had something going on that would prohibit them from participating in the time that we had. So, it was a really hard decision to make knowing that we would only be able to select three, but the process of doing that really helped us to narrow the focus of what we were doing and what the purpose of this is and what the content was. All along, recognizing that we wanted to be able to assist everyone else that applied, and so now what we're doing is we're outlining a technical assistance plan very strategically that involves not only AMCHP, but the Maternal and Child Health Bureau, the Kanapa Institute for Best Practices and Adolescent Health. So, that's the process that we went through. We had a review committee that helped us to narrow down the states, and we also looked at other ways that we were already assisting some of the states. So, if there were programs where we already had something going on and we wanted to be able to finish out what we were doing, that sort of thing, then we factored that into where we went. Any other questions, no?
UNIDENTIFIED SPEAKER: [Inaudible]
RENA LARGE: Okay. As you can see, this is very relaxed. Feel free to speak up if you want to. Kristin and I--this is the first time that we've presented this in a training sort of a way since we finished the pilot, so we're just going to wing part of this.
First, let's tell you a little bit about the tool that's in your packet. I did tell you a little bit about this when we started, but we'll go through it a little bit more. As I mentioned there are multiple pieces of the system capacity tool. If you look in the first tab where your PowerPoint presentation is--right behind the PowerPoint, there is an overview of the tool, and this is sort of the promotional piece--the overview piece that talks about what this is, what it's based on, how it came to be developed and recognition of the many people and groups that contributed and where you can find the information on our website. If you flip to the next index tab, there is a piece called Preparing to Use the Tool, and that's what we're going to work on a little bit more in a moment with you is thinking about how to use the tool and why and who is involved and what you want to get out of the process. So, let me tell you about that and then we'll flip through the other pages, and then we'll start some of our smaller discussions.
Basically, the process of using the tool is to sit down and think about the planning of it. What is your purpose for conducting it? You may have a wide variety of reasons. It may be to plan a new program, to refine an old one. It may be to hire an adolescent health coordinator or to rewrite a job description to determine training needs. Whatever the reasons are, part of the process of planning to use this tool is documenting the reasons why, so that when you get to the end, you can come back and say, here’s what the outcome of my assessment is, here’s what I said I wanted to do with it. It also helps to share the information with other people that are participating. It helps orient stakeholders and partners that might be involved in the process.
The next step is identifying what exactly it is you're assessing. Now, we said before that we had designed this tool for MCH programs to look at adolescent health capacity, but within that there's a lot of things that can be assessed. It could be specifically the MCH program that is being assessed. It could be an existing adolescent component of the MCH program. It might be the entire health department efforts that you want to assess from a MCH point of view around adolescent health. It could be how the MCH program is assisting other partners in promoting adolescent health. So, there is any number of things that could be assessed, and in the pilot states, which we have some samples from the states, and this is just an internal--internal summaries that we created for each of the states that went through the process, but in each of the states where we piloted it, it was very different.
In one state, the staff from the MCH program met only the staff from the MCH program. It included the women's health person, the children with special healthcare needs. It included the medical director, injury prevention, which had just been moved into MCH, it included MCH data people, and so in one state they used it specifically to talk about their capacity internally, although they did invite one representative from a very large local health department to give them some feedback on how the state level MCH capacity was trickling down to the local level.
In another state, the people who participated in the assessment process included not only a large selection of the MCH program, but it also included representatives from other agencies who had been convening together as an MCH advisory group around adolescent health, and so it included representatives from alcohol and drugs, community services, tobacco prevention, WIC, nutrition services, policy and planning. So, it included a number of people within the health department in that process.
And then in the third state where we went, they actually had a very large diverse group of people who participated in the process, not only people at the state level, inside the MCH program, inside other programs in the health department, people from the state education agency, but it also included community level people, community level people working with pregnant mothers, teens who are pregnant, working with HIV prevention among teens in the community, and some of those people were not familiar with MCH prior to this assessment taking place. So, in that state they used the process to pull in some new partners, to get some feedback, it’s a state where they just established the adolescent health coordinator position a few years ago and are having trouble defining what the role of that person is in the state, and so they used that process to invite in other partners to get some feedback on what it is that MCH could be doing to compliment all of these other efforts.
So, in each place it was distinctly different who was involved in the process and what exactly was being assessed, and then another part of the planning process is to think about what you want to get out of the process. Now, maybe the purpose of the assessment leads you to what it is you want to get out of it, but there maybe other things that come out at the end, so maybe your purpose is to action plan around some priority issues at the state level around adolescent health, but maybe a product of that is a fact sheet for policy makers or a report for the health commissioner or some sort of a planning document for the people that are planning the budgets for The Title V Block Grant, and so the kinds of products that come out of it can also help you think a little bit about what you’re assessing and who to be involves with and I think that it’s safe to say that these are all intertwined in each other and none of them are static on their own, each one of the questions has to really be considered to think a little bit more about where you want to go at the end of this process.
So, the tool itself offers some pros and cons of who to invite, who to include, what the level of involvement is from the management to the program level, whether or not it includes external partners or internal partners. There are definitely more pros and cons than the ones that we have listed, but these are some of the pros and cons that came out of the pilot states, and if you flip that page, the next page includes some pros and cons on the process for using the tool. So, in each of the states where we went, because of the timing and the funding, we spent two days, two full days with the folks from the health department and their invited partners. That’s not necessarily the way that it works best in every place, it maybe something that can be done via email or one big meeting or two days of a meeting or pieces of a meeting or smaller work groups, and so this outlines some of the pros and cons that we have thought a little bit about, and we have had people express to us what the benefits of one versus the other is to help think a little bit about how this works best in any, and whatever the program is that’s being assessed.
And we’ve also thrown in some information about how long we think the process takes based on our own experience, this obviously might be different in any place and depending on how many people are involved and what kind of process is used, it could take longer or shorter than the times that we have outlined here, but we wanted to give people a sense of how long it took us to develop the process, to get through it with the states, to finalize the summaries, and so we’ve kind of laid out what some of those sample tasks were depending on what it might look like for a face to face meeting versus email versus conference calls. And while the timeline shouldn’t be the most important component of this process, certainly if you were planning for the five year needs assessment or some other thing that had a very specific timeline, you would want to think about how what you want to get out of this fits into the timeline you have and how best to accomplish that.
And then if you flip to the next tab in your binders, this is the nitty gritty of the tool, these are the six capacity areas and right now we have these laid out on our website in separate pieces so the overview, the planning, the tool, the action planning guidance, they’re all laid out separately just for ease of downloading, but ultimately they’ll all be in one document. So, for now they’re all laid out separately for you, and this section includes instructions on how to use the tool, steps for rating the capacity areas, and then each section goes into detail with how that capacity area is defined and then each capacity area just for streamlining and ease of use, is divided into three, what we are calling elements, and basically they’re a way of categorizing concepts into headings so that it’s easy to use, the conversations build on to each other and at the end of each element, there’s a place to rate that element which builds into a larger rating for a capacity which, if you use all six of the capacity areas, builds into a larger rating overall. So, there’s a lot of ways the tools can be used, it’s meant to be tailored to whoever’s using it, some people might use one piece, some people might use all of them, and we’ve tried to lay out what the best combination of those pieces are. So, each of the tool sections, each of the capacity sections begin with some discussion of how the user’s might want to consider using this, and so it’s very much intended to be tailored to whoever’s using it.
And then for each of the elements, there’s a place, as discussions take place around a concept, there’s a place where you can document strengths, weaknesses, opportunities, threats, and we have provided that in each of the elements so that no matter what is being discussed the high lights can be documented, so that at the end it’s easier to think a little bit about why did I say this was a priority, why did I say that we don’t have capacity here, or that we do have capacity here, and that is all part of the process of documenting, the baseline capacity is using the swat analysis form as the conversations take place, which at the end allows, yes?
UNIDENTIFIED SPEAKER: Could you tell me what swat stands for?
RENA LARGE: Oh, strengths, weaknesses, opportunities and threats. And there’s some discussion in the binder in each of the sections about what falls into those things. They may mean something different to everybody, but we’ve kind of laid out just for consistency, the kinds of things that we think are useful to think about in strengths, in opportunities, in weaknesses and threats. And then the whole process of this brings a user, hopefully, to the point where whether they’ve used one piece of this or all pieces or some combination, they’ve come to the point where they’ve looked at what they have, they’ve documented the reasons why they said that, they’ve rated that area, they’ve come up with an overall rating or rating for each capacity area that they can look at and say, okay, I’ve rated low here, I would like to do this or I’ve rated high here, but we would still like to do this.
So, it’s a process of leading people to the end were they have some full documentation of what they’re doing, where they would like to be, what they can reasonably do to allow them to think a little bit more about prioritizing where they want to put some efforts, and the priorities that come out at the end are not always the things that rate the lowest, for example, in some of the, if you look at the back page of each of the state examples that we gave you, there’s a list of what they prioritize or what the discussions were in there. And in some of those places the things that rated the lowest may not have been the things that rate that turned to be priority actions, for example, in one state technical assistance, that being the way that they promote adolescents health to the public, to professionals, that rated really low in capacity, but it didn’t rate high in the action planning because they didn’t think it was something they could address right now, there were other things like surveillance and data systems that also rated low, which they thought they were poised to act on, so sometimes the action planning and the prioritizing doesn’t necessarily come from the things that you have the lowest capacity in, sometimes it’s something that you think you can do good in and you have other things going on that can help support your efforts.
And then whatever, whatever it is that you want to get out of the process, if it’s a product, if it’s a report, a fact sheet, a data summary, whatever the product is that comes out of this, that may be an action plan working on specific things, that’s what comes at the end of this, that’s what the tool is for, to lead people to a place where they are in a position to take action because they know what is important, what rated lowest, what rated highest, what their capacity is, what their opportunities are, what their weaknesses might be, and the process of doing that over time, allows you to go back and reassess what you have done previously. So, documenting efforts right now, will allow you over the next two, three, five, ten years, to have a process of continual quality improvement, to come back and look at what you said, what you did as a result, what the outcomes were and whether or not those efforts need to be assessed.
So, it’s really intended to be a very long term planning tool, a long term quality improvement tool, and then of course, once the process is complete or whatever the first steps of it are, then everyone should celebrate because you have created something that will live on for new staff, new programs for new programs, for new managers, for new priorities, new grant opportunities, funding opportunities, and it’s something that’s going to live long into the future once that information is documented. There are a number of things on the website right now and what we’re going to do today is we’re going to go through some of these pieces of the tool, but when you get back to your offices, if you want to check out the system capacity section of the AMCHIP website, there are other pieces that are up on the website, including an overview of how this is linked to the ten essential public health services, there will eventually be a comparison of someone who has used cast five and what they think the difference is between the two tools. We’re putting some evaluation guidance up on the website, some sample agendas, so there’s going to be a lot of supplemental pieces coming out but for now we wanted to get this out so that people can start using it. And as I mentioned, Kristin and I and MCHB and multiple other partners are devising a plan of how to best provide technical assistance around this because like the premise of the tool, we believe that it’s not the responsibility of any one of us to be the one implementing this, that we all have a role to play and we should be partnering where resources and capacity and opportunity enable us to work towards implementing the system capacity tool everywhere. Any questions, or comments, lots of opportunities for that, since we have such a small group.
UNIDENTIFIED SPEAKER: (INAUDIBLE)
RENA LARGE: Yeah, I think now we’re going to have some individual discussions, so.