HRSA/MCHB 2005 FEDERAL/STATE PARTNERSHIP MEETING

PUBLIC HEALTH ACROSS THE LIFESPAN

Partnering to Prevent Child Maltreatment: Lessons and Outcomes

LORETTA FUDDY: Thank you. And yes, I have a very large division in Hawaii. One difference between Hawaii and most other states is we do not have county and local Departments of Health. We're a centralized state, so everything is at the statewide level. I'm the point person for anything that deals with women, adolescents, children, vulnerable populations across the spectrum.

So pleased to be here with all of you here today. I, too, they didn't get my final version up. It's very close to what's in your handout. I tried to improve a little bit on the color scheme and there were a few typos I needed to correct.

So I always like to start off with a few data slides, because when you talk from a state, you never know how similar is Hawaii to your own state. So if I start with a few data points, you can say, well, we're very close or far off.

In Hawaii, our age distribution for children under the age of seven makes up about 10% of our population. Hawaii has a large military population. We are the central base in the Pacific. So they make up about 3.6% of our population, about 4%. And we work closely with our military community.

Our uninsured population is about 113,00, 14,000, and for children under the age of 18 they make up 24% of our uninsured. Now, that's changed a little bit. I'll talk about that in a minute. And our Med Quest population, they make up ‑‑ the bulk of it is children under the age of 18. You can see 50%. Med Quest is our Medicaid population.

The majority, our eight islands make up one state, and the majority of the people live on the island of Oahu and Honolulu, 70%. And just to give you a sense, we're very ethnically diverse. Looking at native Hawaiian population makes up about a third of our population that we have. We're getting more of an influx of Hispanic population as well.

In Hawaii, 30% of our population has households less than $40,000 income. That's at the 185% poverty level. If you looked at us comparing children under the age of 18 living in poverty, if you looked at the national rate, it's 15%. But Hawaii has a higher poverty level because of a high cost of living so it pushes it up closer to 20, 25%.

Compared to the rest of the nation, we have more than double of people who work in more than one job, because of our cost of living. So we have a lot of working parents and even those that work two and three jobs. About 14% of our homeless population are our children under the age of 18. Our infant mortality rate, if you looked at an average, it was 6.8 compared to the 2010 objective, 7.2. But this last year, 2004, we took a real dip, and so we actually got below 2010 at 5.4 per thousand live births. So we're really pleased with that effort. We're one of the infant mortality states so maybe that's why we put some focus on that.

Looking at child deaths, we had over the four‑year period 679 natural deaths, so to speak, child deaths. 79% were natural deaths. If you look at injury that made up about 13% of our deaths, child deaths. 3% homicide, 2% suicide, and 3% undetermined. And you can see the infants are at great risk for injury and homicide.

Child abuse in Hawaii, we have unduplicated counts in year 2003, 7,000 cases. Half of those, 51% are confirmed for child abuse and neglect. 45% of these are under the age of five. So again pointing out the vulnerability of the very young population. In looking at some of the circumstances around the child abuse, 85% of those families that are confirmed child abuse have substance use involvement. That's a real critical factor for that. Out of home place for a six‑month period, we had 3100 children.

We did a children's budget several years ago, and looking at how does our safety money spread out, and you can see 58% is for our child abuse and neglect prevention and treatment. 18% for youth violence prevention. 10% for substance use. 7% for legal services. 4% for domestic violence and injury prevention school safety 3%. So the majority is in that prevention and treatment arena, primarily treatment.

Just today we're supposed to be talking about collaboration and partnership. So I wanted to make a distinction here that why do we use two terms? I was trying to think shouldn't we be using one term. Because collaboration when you look at it is an act of working together to achieve something. But often what you see is it's more like parallel play. And if you look in the dictionary, collaboration is also akin to working with the enemy. And sometimes I think that's what we look at. We look at turf issues and we say we're all in this together, but we have slightly different view of it and sometimes we view the other side as not having a different culture than we do.

Whereas partnership is a relationship between the organizations with similar aims, working together towards a common goal. And basically we are equals in the decision making process. So there's a little different bent to partnership versus collaboration. To me it's like higher level. And I think we want to aim for that higher level.

So, again, I have mandated collaboration and partnership. I mean creating a common agenda, it's the right thing to do. For us in maternal and child health and family health, it is the standard way of operating. However, oftentimes what we find is that these partnerships or collaborations are defined for us. They're defined in our statutory base. They're part of our funding requirements. The Legislature in Hawaii is very active and they're always setting up tasks forces that force all the partners to the table or there's some kind of crisis in the community, a high profile child death and then people come around that.

So family health in Hawaii is the lead for child abuse prevention. The Department of Health has the statutory base for child abuse and neglect prevention, secondary prevention, primarily. We have the children's trust fund efforts, statutorily under us. The child death review and domestic violence prevention.

As was mentioned in my introduction, we are the lead for Title V Part C, but also for early intervention and the early childhood development program as well.

The Maternal and Child Health efforts include, we have our Healthy Start program, not to be confused with the infant mortality prevention, our child abuse prevention program which is statewide. We developed a baby safe program, substance abuse free environment to work with pregnant moms who are substance abusing. We have Domestic Violence Advisory Council, Child Death Review, Hawaii Children's Trust Fund and then a safety collaboration. And then I'll focus on the last three.

But we also support other efforts going on in the community. Hawaii is very much into group meetings and being partners. I sit on the Blue (inaudible) for change traffic force which is a child welfare reform program that developed a program for neighborhood places for child abuse prevention for at risk families. We're center‑based rather than home‑based. The Department of Human Services, like most other states, had a review and as a result had to submit a program improvement plan. I've been on that task force as well.

We're very much interested in not only looking at mothers which has been the primary focus for our home visitation program, but how do we include the fathers. So within the last two years Legislature set up a father hood commission. I sit on that commission.

Working with volunteer Legal Services of Hawaii; they have the (inaudible) law center, which does home visitation, not home visitation, foster care visitation activities. Injury Prevention Coalition. Good Beginnings Alliances is zero to eight. Young population looking at the full spectrum of children.

Then our Early Childhood Coordinating Systems Grant, Good Beginnings Alliance. When we developed the Early Childhood Coordinating systems grant, we decided to have uniformity in the state. If you want to push the agenda, let's push the same goal. So Good Beginnings Alliance goal is all children will be healthy, safe and ready to succeed. We've adopted the same goal for our Early Childhood Coordinating System and the emphasis on safe today is what we'll be looking at.

Other legislative task forces we've set up a fetal alcohol spectrum disorder to look at that. Children of incarcerated parents. Substance abuse prevention. We have a huge ice problem in Hawaii, methamphetamine. This is run by the task force is chaired by our Lieutenant Governor. Much of what we have done in our home visitation prevention program, they say now the children that are known to child welfare should also participate in this effort. So we've had a legislative task force that says how can the Department of Health and Department of Human Services work more closely together? And that's spun off some new initiatives for us.

And then the Kaiki Caucus is actually run by the Legislature and every year we put together a champions for children and we walk around the Legislature with all child agencies and talk about specific issues. And so we do that uniformly in the state.

So basically collaboration and partnership is essential to everything that we do here in Hawaii.

Just to give you a broad breadth of what we do. Child death review covers Department of Health, Human Services, Department of Education, Medical Examiners Office, Attorney General, fire police, emergency medical, physicians, the military as well. And this was an unfunded mandate for us. We passed the legislation about ten years ago. There was no dollars given to it. We formulated all of this without dollars. Once we hit the road running, this is a joint funded effort. We received funds from the Department of Human Services, the CAPTA grant, to fund a nurse position. And we received money from our preventive health Block Grant to fund a data position. So that's how we use our partnerships to leverage the dollars to get the work done.

Interesting, we've completed our child death review for a series of years, and an interesting finding I wanted to share with you is regardless of the cause of death, most involved a history of domestic violence, drug abuse, CPS involvement, by a member of the child's family. So most of us don't think about that. But when you look at someone who has died because of suicide, unintentional injury, a natural cause, you know, most of us think homicide, there's the CPS involvement, there's the substance use involvement. But there's obviously at risk families that puts them at greater risk for even automobile injuries. So this was a finding for us that we said this is something we can rally around that we're all interested in the overall safety of children and these risk factors seem to permeate through all systems.

Our Children's Trust Fund was developed 12 years ago. Again, with no funding. We seem to have a pension in Hawaii to have things that are statutorily based with no funding forcing us to the table and saying make it work and then we need to go find the funding for that. But you can see it includes many partners. We rely upon the child abuse prevention preventive health grant to fund most of our grant making in the community. But our goal was to raise $10 million in endowment funds, and we have achieved that.

That is vested with Hawaii Community Foundation.

One of the pieces we're doing with Children's Trust Fund, for the past 12 years it's really been focused on grant making to the community, to look at new initiatives, new ideas that are creative. Now we feel like it's time to focus on the policy piece. And we kind of hampered because this is a collaborative effort between the Legislature and our planning group. So it's a private/public partnership but we didn't have a 501(c)(3). We just set that up so we can be much more proactive in the area of public awareness, education and advocacy.

And we're just getting funding for that. The Hawaii Children's Trust Fund we put out $4 million in community grants over the past ten years. We have an annual grant making of 500,000 to the community. We sponsor an annual child abuse prevention conference. It's the primary sponsor for our children in youth month activities. It really is a forum for our child abuse issues. It also provides technical assistance and support for our grant making agencies. And then it really focuses on public awareness, the positive parenting messages. We've put out a calendar that had children's art with some of the key messages. And we're looking forward to doing more activity. We passed legislation finally for a tax check off so that will continue to fund our area and that will be implemented in January of this year.

(Inaudible) for change is a child welfare reform. It looks at public awareness, child welfare issues. More focus from that side, input from Department of Human Services on their program improvement plan, training and education and then, as I said, they developed a family centered community driven neighborhood place sort of one stop shop in the community. The membership of that is not as broad as we do in the Department of Health. We seem to, for family health, bring everybody to the table. This really is a partnership between Department of Human Services, Department of Health and the agencies that have the neighborhood places. So not quite as broad as what we have.

We did pass a resolution to improve coordination and collaboration between our Healthy Start program and child welfare. There really has been a lot of movement between the two. What we found was that if Healthy Start was involved, oftentimes child welfare said you're doing fine we will not get involved. But these families have become more and more crisis ‑‑ more domestic violence, higher rates of substance use, and we felt we really needed that higher level of response.

So this has called us to the table. Now we've developed a differential response. Also Healthy Start identifies children at the age, at the time of birth. And that window closes within a three‑month period. With now our review what we said we'll accept anyone that we missed through our screening at the hospital or did not, because it's a voluntary program, did not decide to choose home visitation but show up at child welfare. It's not a child protective case but it is at risk and we will accept that family back into Healthy Start now for up to age one.

We put together a common list of indicators to track these children across two systems and to look at whether our system indicators are working. So are we making a change in how we respond to policies? So we have a formal memorandum of understanding. As (inaudible) says, get it down on paper. And now we are working to integrate, as you heard, the CAPTA says now any child known to child welfare must come through our early intervention program.

So, again, we had all children that were identified with a delay in the child welfare system come into early intervention, but this means everyone, regardless of whether they have a delay or not. And that we will need to provide screening and assessment for all of these children.

As you can see, we have many agencies in Hawaii focusing on child abuse prevention. This is something that we've tried to do within family health is to say we have so many and we're all kind of pulling in different areas, can we come together as one safety collaborative, Blueprint for Change, Department of Health, Good Beginnings Alliance, Department of Human Services, Children's Trust Fund, Judiciary, Child Abuse Prevention ‑ Hawaii, the Kaike Injury Prevention, and can we come up with a common agenda, can we come up with an agenda that will give this higher visibility in our community and move towards that. So this is a new effort for us to say let's bring all the partners together. Let's settle on one or two things that we can hope to drive. So it's like putting everything in one basket and can we get more bang for our buck. And we'll let you know how that goes. And, again, it's this kind of joint child safety agenda, joint advocacy, joint messaging, assuring a statewide system of prevention and intervention strategies that, again, agreeing that we have a full spectrum of services. How can we improve that coordination and service integration? And then we have it linked to our early childhood coordinating systems grant, this is going to be our safe piece in our early childhood coordinating systems grant. So the safety collaborative will help drive that particular component of our early childhood systems grant.

So challenges to partnering is basically turfs and schisms often occur as we try to pull people together it's like that parallel play and some say we need to focus more on treatment. Some say we need to focus more on prevention and then oftentimes it's who is the lead and is there recognition for the lead? You know is it really ‑‑ is it Department of Human Services? Is it Department of Health? You know you've got opposing cultures. You've got opposing priorities. And then when you look at it from a private public sector, the public sector has a different culture than the private. So, again, we do things differently. We have to try and learn to work together. It does take time to build that trust and credibility. Oftentimes it's very time‑consuming. It's process‑oriented to build that trust, takes a lot of working issues out, and some people get frustrated with that and they say we're not moving fast enough and they leave. So that's some of the challenges. As I mentioned, it's often unfunded or just very little funding and they say make it happen. And that's frustrating to many people. But the rewards are great. We can come up with one unified voice, leveraging of resources. As I said we fund our child death review through multiple streams, children's trust fund, multiple funding streams. We've leveraged all of our prevention dollars to increase grant‑making in the community. It is creative problem solving. It is much more customer ‑‑ consumer‑oriented. Oftentimes it's through these task forces that the consumers are the only ‑‑ that's how they come to the table. If we don't have a task force oftentimes we don't hear from the consumers. It's much more policy and outcomes oriented than if we operate by our own. And it's really creating that buy‑in at the various levels, the community level, the agency level and the political level for us.

Again, we can address a broader array of goals by having this partnership. We have increased in communication. Here's one of my typos that you can tell this is not my final. It's not shred commitment it's shared commitment.

That's how I knew this was not my final. We can reduce the duplication and have better integration of services, increase credibility, especially when you're advocating particular action and you go to the Legislature and if you're unified, you have greater potential of getting your point across and increasing the funding, and again increased availability and array of services. And so that's basically it. I went through it quickly because I knew time.