MCHB ALL GRANTEES MEETING

Response to Highlights of Critical MCH Issues Town Meeting with HRSA Deputy Administrator/ MCHB Associate Administrator

October 4-7, 2004

BONNIE: Thank you, thank you, Peter. Well, it’s very clear that both Dr. Williams and Dr. van Dyck listened carefully to the report-out. And now comes your turn. They want to hear from you on the issues that were brought out by the work groups, by the issues that they’ve summarized here, that they heard themselves, and now we want to hear more information from you. And I think if you will use the microphones that are in the center of the room on two sides and we’ll go from side to side, starting here.

MARK JUAREZ: Mark Juarez, the loan director in Oklahoma , and I wanted to talk about the issue of data collection and evaluation. We tend to focus, when we talk about evaluation, on collecting the outcome measures or specifically looking at the data collection, and there’s an equally important element in evaluation that a lot of times gets missed, and that is you really need some comparison to look at and it’s important that the design of the evaluation is there as well as the data collection system. So just collecting data will give some help, but for instance, if you start a new program requiring that there be some comparison group for evaluation, and I’ve been through too many processes with organizations, be it through the Academy of Pediatrics , where that element becomes an afterthought. So by the time you get to the point of wanting to really know if what you did made a difference, you really have nothing to compare it to because if you don’t do that up front it’s not done.

So I would really encourage when you think about the issues of evaluation, that you not just think of the data collection system and how you share data or what you’re going to collect as far as outcomes, but you also think about the recommendations for design. And I think that really requires the collaboration between people who are doing health services research and the programs, because it’s very hard to ask programs to do it. It’s something that’s different, it’s hard to think about, but it really will do a lot to provide an evidence base of the interventions that we try to really demonstrate that they’re working and that’s sort of a real critical issue.

DENNIS WILLIAMS: That’s a good comment, and I think we agree, very difficult to do but something that needs to be done.

BONNIE: Okay. Let’s go to this side.

KATE: It occurs to me that a mechanism that exists already that was used more and less well in the past to promote information exchange and collaboration among people in the regions and state by state, and that’s your regional offices. And I think that there are those of us who’ve been around for a little while who really are more in the change, I guess, in what the regional offices are now focusing on, and I guess I’d really encourage you to think about reinvesting those regional offices with the ability to bring us together, state by state, and within regions. And I guess I would say particularly state by state, because what I find is that the state systems are so different that transfer of information from one state to another within a region. I mean, I’ve gone to those meetings and taken away some really interesting stuff, but often I get back to my state and think well we can’t really, I’ve got sixty-seven counties here, not three. But, I guess the point I want to make is you’ve got a wonderful opportunity there. You’ve got an existing structure in those regional offices. I hope that you’ll let them be the facilitator of regional communication again.

PETER VAN DYCK: Well, it certainly was not our objective to prevent communication or hinder communication in any way. The regional offices are still there. We have refocused them, we’ve asked them to take on a different role than they traditionally had. I would ask you to give us a little bit of chance to see if our idea works. In the spirit of evidence-based, the proof of the pudding is in the eating to some extent, to a large extent. We have a vision about how the regional offices could help us achieve communication, better program management, focus on performance, in a positive sense, not in a negative sense, but focus on improving performance, working with grantees to improve that performance. This is a work in progress. We’ve just started. Our initial feedback, and I don’t know how many of you have been visited yet, but our initial feedback from the grantees who have been visited has been very positive, but we’re at the very beginning. I would ask you to give us a chance, but give us feedback.

If you don’t think it’s working, if you think you’re not getting the benefits out of that that you think you can, we’d like to hear from you about that. In that sense, feedback to us on a new process is very helpful so that we can over time make it the kind of system that benefits you as well as us. So the objective here is really one of improving performance, in feedback from you and your experience into the policy-making arena, and improving the overall quality of programs in the context in which those programs operate. That’s our vision. The key here is can we achieve it. We want to hear from you about that.

BONNIE: Peter, do you want to comment? Okay, Rich?

RICH: I’ve really appreciated your comments as paradigms are changing within MCH, the interactivity between the levels in the system and putting that out and understanding how that works and that was the point that both of you made. That was something that our group was very concerned about. They didn’t want you to just tell them what to do, but rather they wanted to interact with you around what it is that they could do at this point and how they were going to develop that over time, with the expectation that everybody would get where they needed to go but it was a very interactive pattern rather than a top-down. So in hearing both of you saying that, I think Mike would feel much better.

BONNIE: Okay, over here?

NAP HOSANG: My name is Nap Hosang from UC Berkeley. In the context of marketing strategic communications and recruitment, one of the areas in which we could possibly influence more young minds on the recruitment end, and to market what is MCH to future leaders, not necessarily in the health sector alone, would be to allow us to develop curricula that would speak to many undergraduates all at the same time. And to some extent, I think in the current guidance, we are limited to not doing any kind of training at the undergraduate level, and I’m thinking that this is one opportunity to get to a wide audience of bright young people who will be leaders in the future. And it’s something that could be easily changed. I just wanted to put that on the table.

UNIDENTIFIED SPEAKER: Yeah. Good comment. Could people hear that? I think it’s important for everybody to hear that. Could you perhaps just go to that, everybody on this other side couldn’t quite hear you.

NAP HOSANG: Thank you. I’m Nap Hosang from UC Berkeley. In the context of marketing, strategic communication and effective recruitment to the MCH purpose, I think it is important for us to think about ways in which we could influence young people coming into the system, and not only necessarily coming into health but as leaders in other parts of our economy. And the area that I’m suggesting is that we open up training opportunities for courses in the undergraduate schools across the nation that speak to public health, and in particular speak to the Maternal Child Health component of public health. At the moment, the current federal guidance does not allow us to do any training development at the undergraduate level and this may be an opportunity that might be very productive in a cost-benefit way. Thank you.

UNIDENTIFIED SPEAKER: Thank you.

DAVID SHORE : David Shore , Ohio Department of Health. Much of the discussion I’ve been hearing over the last two or three days sounds familiar, and it’s because in Ohio we are grappling with many of the same issues. I want to hone in on one in particular and maybe get a few sparks here, and that is the concept of what’s been called marketing of MCH issues and ideas. We’ve actually had several of our leadership team meetings devoted to that concept, but it’s not Maternal and Child Health, it is indeed Public Health. And I wonder what your thoughts are about the benefits, disadvantages, pluses and minuses, in terms of looking at the field of Public Health and getting a greater awareness, understanding, collaboration... for Public Health, more broadly, as opposed to Maternal and Child Health. Are we part of the problem, in that at this meeting, in pushing we’re Maternal and Child Health and we’re number one, in a sense?

PETER VAN DYCK: I think that’s an interesting discussion and as some of us have talked about marketing before over the years, this issue does come up, and I think it’s neither one gets its due, Public Health or Maternal and Child Health, and I just can’t believe we can’t craft a message which serves both well. That would be my goal to try to do that.

DENNIS WILLIAMS:I would react to two things: Marketing is sometimes confused with lobbying. I thought the comment before the start of the session was well taken, although there are some legal issues here. But I don’t think that’s necessarily the sense that you meant this, although you need to keep that in mind. Is Maternal and Child Health a part of Public Health? Is it separate or different from it, and how should they work together? I think that is worth exploring. We have, inside the department obviously, we have other partners who are interested in this topic. The Centers for Disease Control and others, the National Institutes of Health, there are a number of organizations inside the department that have a broader perspective than just Maternal and Child Health, but it’s the broader public health perspective. I think there is opportunity here for collaboration, perhaps to the benefit of all, and exploring some of those opportunities maybe is worth doing. I think in the education and health professions training area, though, here the law is more restrictive, more directive, the resources available are more limited, and there’s a lot of differing points of view about what the priorities should be with respect to the health professions, and why is the federal government in the health professions training business at all? So those are issues we’re talking about, but they are also controversial and, you know, it takes dialog to often only clarify and help define issues and directions and that’s good.

PETER VAN DYCK: David, the other issue I think is important in this discussion is, can you do a marketing campaign generally around Maternal and Child Health or Public Health, or do we think about a marketing campaign around obesity or high blood pressure or immunization or smoking or teenage pregnancy, and how do these relate? And I think this is also a part of this discussion that needs to be considered when we talk about it.

BONNIE: Thank you for the question. We’ll go here and then to Jenny.

MARIO DRUMMONDS: Yes, my name is Mario Drummonds. I’m with the Central Harlem Healthy Start Program, and I also was the Red Team Three leader. I wanted to amplify just a few of the thematics that we talked about in our group. Number one, I’m willing to question the marketing also. It seems to be a very big question that cuts across all of our groups, and to me I think we need to talk about building marketing capacity on the federal level, on the state level, as well as on a local level. Does HRSA have a chief marketing officer that’s somewhere within the line of march under Tommy Thompson? And then also, should MCHB develop a social marketing function within MCHB to do several things? Number one, we talked a lot today about branding MCHB, or my colleague just talked about maybe it shouldn’t be just MCHB, maybe we should be talking about branding public health in some form or fashion. And then, Peter, you just talked about, we really are selling health care when we talk about obesity, when we talk about immunizations, but I think there’s a poverty of theory and practice in terms of how do we do that from a private sector perspective, in terms of how we fight some of the tobacco companies and the soda companies?

We’re really outgunned in terms of the air war. We have a lot of the troops here in terms of on the ground, but in the area of message development, in the area of marketing delivery systems, in the area of segmentation, in the area of blind engagement in terms of a message from a public health perspective, I think there’s uneven development. There’s a need for Centers of Excellence, not only the University of South Florida , but we need to develop this capacity throughout the nation so we can actually fight the war that we’re waging around public health in this country. Could you respond?

DENNIS WILLIAMS: Yeah. Well, I will make one comment. It seems to me that in terms of marketing, part of the question is “marketing what?” And I think Peter’s comments were well taken here. The Secretary has been very aggressive and forceful about putting forth public health campaigns that, I mean, I would interpret as marketing. The focus on obesity, the focus on the steps to a healthier U.S. , the federal government has for the past ten years been fighting tobacco on various fronts, currently on the legal fronts. So that the federal government and its programs, its leaders, can and have been a force for focusing the public’s attention on key public health, not just Maternal and Child Health perhaps, but on public health including Maternal and Child Health issues. The Surgeon General’s also someone who has over the years, it’s been an office that has been used to highlight and market and bring to the attention of the American people these kinds of issues, and mobilize them around various strategies to try to address them. So I think, in fact, the federal government does a lot in this respect. Perhaps we could do more, but we certainly do a lot.

PETER VAN DYCK: Do you want to comment on whether HRSA has an office of marketing or communications?

DENNIS WILLIAMS: We certainly have an office of communications. We don’t have, I think, in the sense that you mean it, an office of marketing, but we are a participant in all of the initiatives I just talked about. From Peter’s offices, from other offices in HRSA, we are and have membership on these broader departmental groups focusing on prevention, steps to a healthier U.S. , obesity, all these things we are involved in, along with other components of the department.

MARIO DRUMMONDS: I’m not saying that you’re not involved in those things, it’s just that we’re not winning, and if we’re not winning, we have to make an assessment of how can we re-tool? How can we amplify our message a little bit better against the forces that are not pushing wellness? I’m not saying, all during these last several days, we’ve talked about several good initiatives, but the bottom line is, when you actually hear those messages, those public health messages are not resonating in a very deep way in the local communities around this country. It tells me that we need better-skilled people to do this work.

DENNIS WILLIAMS: I would never say there isn’t more that we couldn’t do.

PETER VAN DYCK: This is such an issue, and it has come up at previous meetings that this, I think, clearly is an area that we can get some further input from.

BONNIE: Thank you for the question. Jenny?

JENNY SHARPE: My name is Jenny Sharpe. I’m with the Center for Children with Special Needs in Seattle . But I’m putting on a hat I wore thirty years ago as a regional economist and getting to this cost-benefit idea? By my rough, back-of-the-envelope calculation, this meeting has cost somewhere between one and a half and two million bucks out of all of our aggregate grants. And I was glad to hear you respond to some of the priorities and goals and things and recommendations that came out of the committees, but I’d like to know how we’re going to be able to track the benefits of this meeting, and I was happy to hear Dr. van Dyck say that you’re going to prioritize the recommendations and form some work groups, but how are we going to know that this meeting made any difference?

PETER VAN DYCK: Would you like to volunteer to help us?

JENNY SHARPE: Well, I was going to suggest that maybe the D.C. office of your Office of Performance Review might be able to set up a report card based on the recommendations that came out of the committees as you’ve prioritized them and, you know, every six months post to your website. Let us know how you’re doing.

PETER VAN DYCK: I think that’d be wonderful to try to get some ideas on how we can do this and keep people—

JENNY SHARPE: I’d be happy to help.

PETER VAN DYCK: That’d be great. And if other people would like to help, talk to the chairs up here before you leave and we’ll take that seriously.

BONNIE: You’re signed up, Jenny. Over here.

TAMMY WOOD-LIVELY: Hi! My name is Tammy Wood-Lively, and I’m with the Hemophilia program that represents nineteen hemophilia treatment centers in Ohio , Michigan and Indiana . The issue I wanted to raise has to do with coordination of services. We have nineteen treatment centers and we’re finding, not only in our states, but across the country, increasingly through the state Title V programs, who are often working with their Medicaid programs, that we aren’t being included, necessarily, in the contracts for service-provision—

PETER VAN DYCK: Are or are not?

TAMMY WOOD-LIVELY: Are not. And we also have pharmacy programs, too, so with the pharmacy benefits programs that we-they’re entering single-source contracts that exclude other MCH grantees. So I’m just wondering, is there any way, whether through the grants process or any, I mean, any way that we could somehow coordinate and make sure that MCH-funded programs like Title V aren’t excluding other MCH-funded programs when we have shared goals and priorities?

PETER VAN DYCK: I mean, that’s a wonderful comment. We have something like what, a hundred and twenty hemophilia treatment centers across the United States, and we have a lot of other grantees, and yes, there should be a way and we hope that this meeting would create some of those partnerships or at least start to create some of those partnerships that would allow that to happen. This is an excellent suggestion. Financing is extremely important, and I hope it’s in the, I mean I didn’t hear it specifically in the comments, but I wouldn’t be surprised if it isn’t written down. If it isn’t, send us a note so we don’t forget it, and we’ll include it.

TAMMY WOOD-LIVELY: I will.

BONNIE: Thank you.

PETER VAN DYCK: There is, in the Title V law, and for those of you who were here Sunday I did highlight it, that says that the Title V state agency must have a written agreement with the Title XIX agency, and that would be the ideal place to have the outline that says how Medicaid is going to be billed by the different MCH services and that there’s commonality or sameness in some of those. So I encourage you all to know who your Title V state director is for issues such as this, where there is a responsibility for them to coordinate, facilitate this activity.

TAMMY WOOD-LIVELY: Thank you.

DENNIS WILLIAMS: And that might be useful more broadly also. Medicaid reform, my guess is over the next year or two, will come back up for discussion. It’s not clear, I think, whether it will be successful, but nevertheless, there would be probably further public discussion about the future direction of Medicaid, understanding how the Medicaid issues that you see from your perspective would help us, I think, as we try to influence, or at least engage in that discussion in a meaningful way that would help you and help our other grantees as they do the work that you’re—

TAMMY WOOD-LIVELY: My question, I guess, just a follow-up: Is there any way through the actual Title V block grant that that can become one of the requirements of those grantees, that that be part of the contract between Title V-Title XIX?

PETER VAN DYCK: It certainly can be encouraged, and you know the folks that write the guidance for the block grant are here and are hearing what you say, so I think it’s important. I might add that it’s not only the one-way, from Title V to you. You have negotiated agreements with Medicaid too around 340b or the drug pricing related to the purchase of factors and all that which could benefit perhaps the Title V program as well, some of those arrangements. So it works both ways.

BONNIE: We’re going to take the questions, or the comments, from the four individuals who are still standing, and then we’ll close the session, so let’s start over here.

KEN JAROS: Hi! Ken Jaros from the Graduate School of Public Health at University of Pittsburg . I want to clarify a little bit the Blue Team’s communication back to the group regarding health communication. We’ve talked a bit this morning about marketing, but our group actually was fairly uncomfortable with the term marketing, feeling it was a bit too narrow. We don’t want to only market Maternal and Child Health. We want to develop capacity to communicate the public health message, to develop constituencies, to organize communities at the local level, at the state level and at the regional level. So we really think that the term marketing is a bit too narrow, and we want to think more about communicating the public health message. And that includes some marketing but it also includes major health communication issues as well.

VAN DYCK: Thanks for the comment.

BONNIE: Thanks for the question, comment.

JONATHON MEIER: Yes. My name is Jonathon Meier and I work with the Healthy Start program along the border in Texas , in Laredo . And several of the groups touched on the observation that there needs to be a paradigm shift for HRSA and MCH, and several individuals in this meeting mentioned it again from a medical perspective, changing from medical model to a health model, and I would just like to add a little more meat to that, and then ask number one, do you feel such a paradigm shift is necessary? And number two, if you do, what steps would actually be taken for that to occur? I think the paradigm that needs to be taken on is a strength-based perspective, which involves looking at families. It’s an alternate way of looking and thinking about families, instead of looking at their deficits. It looks at personal narratives as a way to help detect exceptions to their problems. It identifies strengths rather than digs for vulnerabilities, thereby forcing us to look at families in a different way.

It causes practitioners to embrace building authentic relationships. It begins a change process where families are and works within their world of experience. It believes that all children and families and communities have the ability to bounce back from hardship. It’s committed to cultural competence. It sees labeling as destructive. It helps people empower themselves. Each person is viewed as a victor and not a victim, and it makes resources available and it removes barriers. And this strengths perspective and approach really is one that I doubt few would argue with, however I really see that HRSA and MCH is more problem-focused than solution-focused. So my two questions are: Do you feel really that that is a necessary paradigm shift, and what steps could be taken to accomplish such a dramatic change?

PETER VAN DYCK: Well, we’re certainly familiar with the strength-based or the asset-based approach to thinking about things. There are states and programs that use this, and I think it’s something, it’s worth discussing, and I’m not sure it’s that big a shift. I think we incorporate many of those concepts in our programmatic aspects and in our strategic planning. But it probably is time to think about the strength-based or asset-based approach, at least in our discussions of how we present our face to the world.

BONNIE: Thank you for that question.

BURRIS DUNCAN : My name is Burris Duncan, I’m from the University of Arizona in Tucson , and I’m really, first time here and I’m really privileged to be among such a large group of people interested in public health. I have one observation and one suggestion. The observation is that as we look at the critical issues in front of the Maternal and Child Health population, it seems to me that there’s one document that really has not been addressed or to my knowledge has not been referred to in all of these discussions, and that’s a document, “The Conventional Rights of the Child.” As I can remind this audience, you probably know that the United States is only one of two countries in this world to have not signed on to that convention: The United States and Somalia . I think it’s a shame that that has not happened, that we have not as the United States signed on to such an important document. My suggestion is, I wondered if as leadership of the bureau looks at its goals, if it might not use that document to assist it in developing its goals and its policies? Thank you.

PETER VAN DYCK: I don’t have any comment. I mean, that’s a good comment.

BONNIE: Take it under consideration. Thanks for the question, it was a very good observation. And our final comment?

ELLEN AMORE: Hi, I’m Ellen Amore from Rhode Island . I’ve been very pleased to hear the focus throughout the meeting on data and evidence base and performance measures, and I just wanted to congratulate the Maternal Child Health Genetic Services Division on really being a leader in this area in promoting feed integration, and I would encourage continued support of these activities because through our grant we’re now starting to really use this data and be able to document the real advantages of doing it. We’re also documenting what we do in Maternal and Child Health, and that really ties in nicely with the other focus of marketing what we do, and this data and the integrated data in particular is letting us tell a story about what we do and the successes that we’re seeing. It’s also positioned us nicely, and I know that there’s other grantees who also find themselves in this position, to participate in other federal initiatives like around ARC and electronic medical records and those sorts of communications for the benefit of individuals in public health. So, I think it’s great to promote the data integration keys

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PETER VAN DYCK: Thank you.

BONNIE: Thank you very, very much. Thank you, Dr. Williams, Dr. van Dyck. It’s been a really stimulating interaction and discussion. I know I’ve taken some notes. I know you have. I’ve watched both of you. So, thanks to all of you. Hang around for the summary and closing remarks, and join me in giving Dr. Williams and Dr. van Dyck a big hand.