PROJECT NARRATIVE TABLE OF CONTENTS Section
Page
I.
Introduction .............................................................................................................................2
II.
Needs Assessment...................................................................................................................4
III.
Methodology .........................................................................................................................11 1. Improve Women’s Health ............................................................................................12 a. Outreach and enrollment in health coverage under the ACA ................................12 b. Coordination and facilitation of access to health care services .............................14 c. Support for prevention ...........................................................................................15 2. Promote Quality ...........................................................................................................17 a. Service coordination and systems integration, with medical home .......................17 b. Focus on prevention and health promotion ............................................................24 c. Core competencies for workforce ..........................................................................25 3. Strengthen Family Resilience ......................................................................................27 a. Address toxic stress and support delivery of trauma-informed care......................27 b. Support mental and behavioral health....................................................................29 c. Promote father involvement ...................................................................................31 d. Improve parenting ..................................................................................................34 4. Achieve Collective Impact ...........................................................................................34 a. Develop common agenda .......................................................................................34 b. Contribute to shared measurement system ............................................................36 c. Conduct mutually reinforcing activities.................................................................37 d. Provide continues communication .........................................................................38 e. Support backbone organization..............................................................................39 5. Increase Accountability ...............................................................................................40 a. Use quality improvement .......................................................................................40 b. Conduct performance measurement ......................................................................41 c. Conduct evaluation ................................................................................................43
IV. Work Plan .............................................................................................................................45 V.
Resolution of Challenges ......................................................................................................45
VI. Evaluation and Technical Support Capacity.........................................................................47 VII. Organizational Information...................................................................................................52
The Community Foundation for Greater New Haven
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I. INTRODUCTION The Community Foundation for Greater New Haven (The Foundation) requests funding from HRSA through the Eliminating Disparities in Perinatal Health program. The Foundation seeks to support the urban-focused New Haven Healthy Start (NHHS) under the Enhanced Services, Level 2 option. New Haven qualified for the funding because of an infant mortality rate of 12.1 deaths per 1,000 live births from 2007-2009 (76 deaths). In New Haven in 2006-2010, the fetal and infant death rate among babies of Black women was above 30 per 1,000 births, significantly higher than among the babies of White and Hispanic women. The chart below compares fetal and infant mortality by location and race/ethnicity, 2006-2010 across geographic areas for greater New Haven. The title of outer ring denotes suburban towns in the region and inner ring refers to suburban towns immediately adjacent (geographically) to New Haven.
Significant health disparities exist within concentrated geographic areas, particularly New Haven’s low-income neighborhoods. In fact, a deeper analysis of maternal and child data sets confirm that residents of these areas face higher rates of stress such as adverse childhood experiences. The map to the right depicts differences (averaged) in infant mortality by income level for New Haven neighborhoods. Community leaders and health partners hold a 20-year history of community-wide initiatives to improve maternal and child health outcomes—including a highly regarded Healthy Start model. New Haven’s Healthy Start (NHHS) initiative established effective public and private partnerships that produce significant, The Community Foundation for Greater New Haven
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positive results for over 1,000 participants annually. NHHS also increased community partner and participant engagement in the initiative, and incubated several important other communitywide initiatives that now set the stage for transitioning into a health reform landscape and an opportunity to focus on collective impact strategies that address social determinants of health. NHHS has accrued compelling results during its 15 years of building its Consortium and implementing strategies to reduce infant mortality while building neighborhood capacity:
Centralized Healthy Start outreach and recruitment workers at the New Haven Health Department (NHHD). Coordinated outreach activities across funding streams and used performance based objectives to monitor progress.
Developed a layered approach to intensive health education and professional development training for: a) Healthy Start participants; b) community-based organizations; and c) professionals and paraprofessionals integral to system change efforts.
Developed structured, standardized risk assessments that are completed by high-risk participants: a) at the time of entry into the pre-natal care system; and b) after delivery during the interconceptional period. The risk assessment process is integrated with local evaluation efforts (e.g., depression assessment).
Developed an improved method of assessing signs of depression, and the need for more bereavement services and support. The method has been integrated into the risk assessment.
Established a Perinatal Partnership that provides a forum for maternal and child health professionals to solve systemic issues.
Developed a care coordination protocol for high-risk women. This included securing funding to field test a care coordination / case management approach both for women who: a) enter the prenatal care system but are at risk to drop out of care; and b) deliver with no history of pre-natal healthcare. This level of coordination involves improving linkages with fathers and other significant male partners.
As a nationally recognized leader for its implementation of Healthy Start, NHHS has welcomed guests from Massachusetts and New York to share NHHS’ approach and success. Our Federal Project Officer referred representatives from Worcester, MA to view the NHHS database. The Brooklyn, NY Project Director, and Coordinator of Depression Services visited NHHS for technical assistance on depression service delivery. NHHS health system partners continue to improve access to medical homes and enhance care coordination because of healthcare reform. Yale Healthcare System acquired the second hospital in New Haven and now plays a leading role in developing a community-wide “health neighborhood,” a strategy set forth by the Connecticut Department of Social Services to increase the integration and coordination of community resources into patient care (and hospital discharge) plans. The two federally qualified community health centers continue to improve their capacity to offer robust medical homes to low-income patients. A long-standing integral partner, the New Haven Health Department (NHHD)—also the regional administrator for the HUSKY program and other state maternal and child health resources—serves as the designated, certified application counselor and official patient navigator for Connecticut’s acclaimed health insurance exchange, Access Health Connecticut.
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NHHS health care partners will integrate the previous system building work which focused on outreach, case finding, case management, and care coordination. Medical home models, outreach to enroll individuals in the health insurance exchange, and new methods of financing associated with accountable care organizations will sustain these improvements. The initial years of this grant will allow these transitions to be completed, and for accountable care organizations and partners to identify and properly fund effective models that produce target maternal and child health outcomes. Equally important, NHHS will commit a higher level of intensity and resources to initiatives and to partners that address social determinants of health, create pathways for Healthy Start participants and their family members to thrive, while addressing specific issues such as adverse childhood experiences and a higher engagement by fathers. Within these capacity building and community development initiatives, NHHS partners will continue to deliver the full continuum of health education and health promotion activities that improve maternal and child health outcomes. NHHS will continue to develop its collective impact strategies and link these to other community- and region-wide data-driven initiatives such as the Community Index (see section II). The Foundation remains fully committed to serve as lead applicant and fiscal agent for this critical health initiative. II. NEEDS ASSESSMENT Target Community. Located in the south central region of Connecticut, New Haven is the state’s third largest city, with a total population of approximately 130,000. New Haven is 21 square miles in size, borders the Long Island Sound and lies at the fork of Interstates I-91 and I95, approximately 150 miles from Boston and 74 miles from New York City. New Haven consists of 20 different neighborhoods. Community Assessment. The Partnership for a Healthier New Haven, a multi-agency coalition, recently published the Community Index 2013. This Index includes a community health assessment designed to meet Yale-New Haven Hospital’s requirements in Form 990 Schedule H and Notice 2011-52 for creation of a Community Health Needs Assessment. The community health assessment also met the assessment requirements for the New Haven Health Department’s national accreditation process and requirement to develop a robust Community Health Improvement Plan consistent with the shift toward community problem solving approach that emphasizes primary prevention activities.
Map 1, City of New Haven and its neighborhoods
Yale-New Haven Hospital must complete a
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health needs assessment at least once every three years; thus Community Index health indicators and benchmarks will be updated accordingly and contribute to a broader community dialogue around community investments in health. According to the Community Index report (page 64), Hospitals will continue to partner with government, community, and public health leaders to identify needs, involve the community in planning, and distribute resources to areas of greatest need in an open and transparent way. For example, hospitals in Greater New Haven currently provide millions of dollars in benefits to their communities each year. Community benefits are unreimbursed resources that help address health needs, particularly of those who are underserved. The majority of these expenditures consist of health access initiatives like financial assistance for patients who have no insurance, linking patients to care facilities, contributions to the advancement of health care careers, health education programs, and donations to community organizations. Because of the nature of funding sources for hospital community benefit programs, at the national level, only about 5 percent of hospital community benefits are targeted specifically to community health improvements such as infrastructure change. This represents an area where community coalitions can work together to increase prevention funding and harness outside resources where possible. Therefore, as part of our efforts to move toward a collective impact approach, we offer summary data from the Community Index 2013 Report, augmented throughout the application with other specific maternal and child health-related data from Healthy Start partners or other community-wide initiatives. The following themes highlight major findings from the needs assessment, and are critical to understanding the factors that contribute to maternal and child health in the area and inform NHHS’ response: New Haven maintains an unacceptably high rate of infant mortality: 12.1 deaths per 1,000 live births from 2007-09. African Americans in New Haven are disproportionately impacted by infant death: New Haven’s black women have the highest rates of infant mortality and babies born at low birth weight, and black and Hispanic women in the city are less likely than white women to have adequate prenatal care. Domestic violence undermines the economic security and safety of many women and girls in New Haven: Between July 1, 2010 and June 30, 2011, one domestic violence agency in Greater New Haven received 2,291 calls to its 24-hour hotline and was involved with 5,788 court and 1,651 non-court cases. New Haven children are having children: In 2009, 73 children were born to young teens (1517), a rate of 31.2, compared to the state rate of 10.5. Poverty levels are high: The overall poverty rate (26.9%) is almost three times the statewide rate (9.5%). The Great Recession exacerbated New Haven’s poverty and inequality gap. Education levels are low: In New Haven, nearly 20% of individuals 25 years and older do not have a high school degree or equivalency. High perceptions of safety risks: In New Haven’s high-need neighborhoods, 7 in 10 residents feel unsafe to walk in their neighborhood at night; 3 in 10 feel unsafe to walk during the day. High levels of mental health needs: Self-reported by African-American and Latina pregnant and postpartum women; 73% of mothers in the MOMS Partnership reported needing help to cope with depression and stress.
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New Haven’s low-income neighborhoods contain significant disparities: NHHS target neighborhoods suffer from higher levels of crime and violent death, poorer educational outcomes, and poorer health outcomes including low birth weight and infant mortality.
MCH Client Characteristics: New Haven qualified for the funding opportunity as a result of a 2007-2009 infant mortality rate of 12.1 deaths per 1,000 live births from 2007-2009 (76 deaths). The tables below provide an additional breakdown of MCH data in New Haven. New Haven Demographic and Statistical Data Table Variable
White, nonHispanic 40,178 17%
Population by Racial Distribution Poverty Rates by Female Gender, New Haven, 2008–2010 Three year average for each of the following (2007-2009) # Live births 1,377 # Live births to teens NA % births with nonadequate prenatal care 8.8% Infant mortality rate (per 1,000) NA % Infants weighing 2500 grams or less 8.1% % born weighing 1500 grams or less 1.60% % born less than 37 weeks gestation 10.3% * Includes births with no race/ethnicity data
Black, nonHispanic 47,279 30%
Hispanic
33,817 43%
Other, nonHispanic 9,475 19%
2,225 NA 16.2% NA 14.1% 3.37% 15.4%
Total
130,749 100%
2,335 NA 15.7% NA 7.5% 1.41% 11.7%
362 NA 8.1% NA 8.6% 0.28% 10.8%
6,307* 840 13.9% 12.1 10.0% 2.08% 12.7%
New Haven Birth Data, 2007-09 (NHHS Evaluation Team) Variable # births % with early prenatal care % adequate or better prenatal care % low birth weight % teen mothers % unmarried mothers % who smoked during pregnancy
Mothers in HUSKY / Medicaid 3,904 68% 67% 10.8% 19% 81% 11%
All 6,315 75% 73% 10.2% 13% 63% 7%
Race and Ethnicity: There are 31% percent of residents in the New Haven project area who are white, 36% Black/African-American, 26% Hispanic, and 7% other identified races and ethnicities. These statistics represent a distinction from the racial and ethnic picture of the state, which is more than 70% white. Poverty: Poverty levels remain high in New Haven. In 2012, 36,210 families received SNAP (food stamps) and 89.7% of students in New Haven were eligible for free or reduced meals. New Haven households headed by single mothers have the lowest median annual income ($22,660) of all family household types, at 59% of the income of all households in the city and just 32% of the income of married couple households with children. Households headed by single mothers in
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New Haven also have the highest poverty rates among all family household types: 44% of households headed by single mothers in the city are poor.1 Children: A family’s socio-economic status is a leading predictor of children’s educational outcomes, reflected in the low academic performance levels of New Haven’s students. Educational outcomes, in turn contribute to a child’s ability to become a self-sufficient adult. Children who are born into poverty, in neighborhoods of high concentrations of poverty in New Haven, face immense challenges to breaking the cycles of generational poverty. In New Haven, children under the age of 18 accounted for 22.8% of the total population. New Haven Public Schools reports a total enrollment of 21,500 students including 1.2% Asian American, 11.1% white, 31.0% Hispanic, and 54.8% African American. An estimated 30.6% of New Haven students live in homes where English is not the primary language spoken (v. 21% statewide). Students lag behind the rest of the state on academic assessment scores (all subjects proficient), with 64% proficient in New Haven compared to 82% proficiency statewide. More New Haven Public School students are graduating high school in four years than ever before, but many are not academically prepared to succeed in college. While 64% of the Class of 2011 enrolled in a first year of college, only 49% enrolled in the second year. Unemployment: Adults seeking work in New Haven continue to face troubling times. From 2002-12, Greater New Haven community lost 7,000 jobs, although the City of New Haven did see a gain of 4,000, mostly in higher wage, professional opportunities. New Haven’s largest employers are its academic and health care institutions. The city is home to numerous institutions of higher education such as Albertus Magnus College, Quinnipiac College, Southern Connecticut State University, and Yale University. The dominant medical facility is Yale-New Haven Hospital, which in September 2012, took over the Hospital of Saint Raphael, a community-based teaching hospital, resulting in a loss of 200 jobs. The Saint Raphael campus remains open and is referred to as Yale-New Haven Hospital, Saint Raphael Campus. Women of Childbearing Age: The 2010 Census identifies 40,005 women of childbearing age (1550 years) in New Haven. Of women who gave birth within a 12-month period during the 2010 Census, 21% did not have a high school diploma or equivalency, 28% had graduated from high school, and 24% had some college; 31% were living at 100% below the poverty line and 15% were receiving some public entitlement. As recorded in the most recent Fetal Infant Mortality Review (FIMR), Yale-New Haven Hospital Women’s Center (providing perinatal care to 50%+ of the women in inner-city New Haven) indicated severe substance abuse in New Haven women of childbearing age. Between 1991 and 1994, 68% of 2,927 women tested positive for alcohol, tobacco, or other drugs. Of these, 35.5% reported that they smoked more than half of a pack of cigarettes per day during their pregnancy and 22.6% reported drinking more than one drink per occasion during their pregnancy. The use of these substances is closely associated with poor birth and infant health outcomes. Infant Mortality: New Haven’s infant mortality rate (IMR) is high compared with the entire state, at 9.5 vs. 5.2 for the state in 2010. In New Haven, significant disparities exist in infant 1
The Status of Women and Girls in New Haven, Connecticut, by Cynthia Hess, Ph.D., Rhiana Gunn-Wright, and Claudia Williams, IWPR #R355, July 2012.
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mortality rates among women from different race/ethnic groups. Between 2007 and 2010, the average infant mortality rates for blacks and Hispanics in New Haven were 17.7 and 9.1 per 1,000 live births respectively, while the IMR for whites in the city was 6.8 per 1,000 live births. African American infants were consistently at higher risk (1.5 to 2 times higher risk) for infant mortality than infants of white mothers. These findings reflect trends statewide, where African Americans had a higher prevalence for risk factors (i.e., birth rates among teens, lack of prenatal care, low birth weight). The Title V Needs Assessment reported that perinatal care could have a profound effect on lowering the incidence of infant mortality: the elimination of non-adequate care in Connecticut could reduce the incidence of infant mortality by 15%. Among African/Black American infants, where non-adequate care was more common, the elimination of non-adequate perinatal care could result in an estimated 24% infant mortality reduction.”2 Incidence of Infant and Fetal Mortality, CT Department of Public Health (CT DPH) 2010 GEOGRAPHIC AREA
No. Events
Denominator
Percent
INFANT MORTALITY (per 1,000 live births) Connecticut 196 37,713 5.2 New Haven 19 2,001 9.5
Significantly Different from Reference Group (p 4, then they may be clinically assessed and referred to treatment. The evaluation seeks to: 1. Describe the trajectory of clients' experiences with the NHHS mental health process: What percent of women are screened, clinically assessed, referred to treatment, and received treatment? What are the clients' reported experiences with this process? 2. Describe the challenges and barriers to the NHHS mental health process: What are care coordinators’ experiences? What are contracted providers’ experiences? Consultant Megan Smith (Yale University) will review NHHS database to document clients' trajectory through the mental health process; select a sample of NHHS clients referred to mental health services for a variety of conditions; review their records and conduct interviews with the clients, care coordinators, and providers.
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The findings are expected to: (a) increase NHHS staff, NHHS care coordination contractors, and Perinatal Partnership members understanding about the current maternal mental health process; and (b) spur reflection discussions and actions on how to improve the process. A brief, layfriendly document and accompanying power point may be distributed to stakeholders for facilitating reflective discussions and encouraging brainstorming of improvements. Findings may also be shared with the CT Behavioral Health Partnership and New Haven MOMS Project to spur discussions and actions on how to improve the New Haven and state's mental health system for low income women. The same brief described above may be distributed. Potential Obstacles. Although a detailed protocol for documenting care coordination services exists, the compliance for entering mental health data into the NHHS database has been low over the past couple of years. Currently, the NHHS Quality Manager is working with care coordinators to improve the quality of data tracking. Performance Monitoring. The MCH Bureau requires all Healthy Start grantees to report annually on performance indicators to assess progress and fidelity to the national model. Indicators include measures of mortality (infant, neonatal, post-neonatal); low birth weight; and core services (i.e., outreach contacts, enrollment, link to medical home, depression screening, and referrals made to male support services and mental health treatment). Care coordinator subcontractors are required to enter performance indicator data into the NHHS Database, as stipulated in the care coordination sub-contracts. The NHHS Quality Service Manager oversees care coordination and ensures compliances with protocols. NHHS contracts with Christine Langton and AOS - Advanced Office Systems for technical issues related to the NHHS database. NHHS staff handles all tracking and reporting of MCH Bureau performance measures. NHHS sub-contracts with four agencies to provide care coordination services: Yale New Haven Hospital, Yale New Haven Hospital, Saint Raphael Campus, Hill Health Center, and Fair Haven Community Health Center. NHHS also subcontracts with New Haven Health Department, New Haven Home Recovery and Housing Authority of New Haven for its outreach services. New subcontractors include New Haven Family Alliance and Community Action Agency. Although sub-contractors are required to provide core services, they may expand upon them. At the beginning of each program year, the NHHS Quality Service Manager works closely with subcontractors to set agreed upon unique goals and associated performance measures; these measures will be tracked through the NHHS Database. These changes have been codified in the revised sub-contracts. In fall 2011, NHHS introduced Performance Report Cards for each subcontractor based on agreed performance measures, with report cards shared during monthly meetings. These report cards are produced quarterly and shared with the Perinatal Partnership. NHHS staff will handle all tracking and reporting of sub-contractor performance measures. Outcomes and Impacts. In Phase I, the evaluation will focus on birth outcomes and the impact of participation on the Consortium. Comparison Analysis of Birth Outcomes. NHHS commissioned two previous evaluations examining NHHS birth outcomes. Early in the 2000’s an evaluation compared birth outcomes between NHHS clients and non-NHHS clients using birth certificate data. A more recent evaluation completed in 2010 by Dr. Colon and associates of Inter Alia Associates, examined
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trends in NHHS clients’ infant, neonatal, post-neonatal, and perinatal mortality rates and low birth weight from 2001-2010. No comparisons were made between non-NHHS clients. Findings indicated that all measures declined from 2001 to 2009, but increases were noted in 2010 for infant mortality and post-neonatal rates and low birth weight. NHHS will continue to examine trends using more recent data as well. Evaluators will compare birth outcomes between NHHS participants and similar, non-NHHS participants in New Haven overall and by racial/ethnic group from 2001-2009. To what extent have NHHS clients’ experienced better birth outcomes compared to similar, non-NHHS clients? Consultants Dr. Amanda Durante (New Haven Health Department, Southern CT State University) and Dr. Mary Alice Lee (CT Voices for Children) will utilize the following methods:
Conduct a retrospective comparative analysis of New Haven births and infant mortality outcomes for NHHS participants and similar, non NHHS participants from 2001-2009.
Analyze birth and death certificate data for New Haven births from 2001-2009. Potential comparison birth outcomes may include: Infant mortality; low birth weight; and very low birth weight. Birth weight is reported on birth certificate data.
The NHHD will be requested to create a database that contains birth outcomes, mother's age, mother's education, and racial/ethnic group from 2001-2009. The database will contain a variable indicating NHHS vs non-NHHS participant. NHHS participants will be identified by NHHS staff developing a list of all NHHS participants' names from 20012009. This list will be used to match mother's names on birth certificate data and followup death certificate data. Non-NHHS participants will most likely be identified by birth paid for by HUSKY, as an indicator of low-income women.
Depending upon the outcome of the results—positive or negative—the findings from this comparison study may be used in one of two ways: 1) Positive Findings: If findings indicate NHHS participants' birth outcomes are positive (better than) non-NHHS participants, results will be used to demonstrate the effectiveness of the model (i.e., evidence-based) in New Haven. Results will be widely shared internally with The Foundation, Consortium and Perinatal Partnership, and externally with the National Healthy Start Association, MCH Bureau, and research community. Products to be developed may include: 1) a lay person "brief" where information could be inserted in The Foundation newsletter, website, and other promotional venues; 2) press release to local media encouraging feature articles to be published about the NHHS; 3) peer-reviewed manuscripts; and 4) presentations at national meetings. 2) Negative Findings: If any of the results indicate NHHS participants and non-NHHS participants had similar outcomes or NHHS participants experienced worst outcomes, then results will also be used by NHHS staff to identify what's wrong and aggressively work to make changes. The findings will be shared with the Perinatal Partnership. A sub-committee will be established to investigate program elements and make recommendations for improvement with representation from Perinatal Partnership and NHHS staff. A consultant will be contracted to facilitate the review process. The product may be a brief report describing the review and recommendations for improvement.
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NHHS Consortium. Per MCHB mandate, Healthy Start grantees are required to convene a Consortium to provide overall leadership and direction for local programs. The Consortium membership must be comprised of at least 51% of current or former Healthy Start participants. The NHHS Consortium function and influence over the program has waxed and waned over the course of the project. NHHS Consortium Development Manager prioritized re-energizing the Consortium during 2012-14 program years, focusing on community partnership development. This focus on building the Consortium will continue. A consultant experienced with evaluating consumer consortiums and using qualitative methods will assess the influence of Consortium participation on the lives of NHHS clients and influence of the Consortium on direction of the NHHS program. To what extent and how have NHHS current or former lives changed by participating on the Consortium? To what extent and how has the Consortium influenced the direction of the program? The evaluator will observe Consortium meetings and review past meeting notes; administer surveys to Consortium members to describe their experiences with Consortium participation, functioning, and satisfaction; conduct in-person interviews with Consortium leadership and NHHS staff to describe their perspectives on the role the Consortium has played within the program and how it has influenced its direction; and conduct in-person interviews with Consortium NHHS client members and their care coordinators to describe the role the Consortium may have played in their lives. Depending upon the outcome of the results—positive or negative—the findings from this comparison study may be used in one of two ways: 1) Positive Findings: Positive results will be shared internally with The Foundation leadership and the Consortium, and externally with the MCH Bureau, National Healthy Start Association (the model shared at December 13 Leadership Institute), other initiatives using a similar consumer driven model, and others interested in a community-based participatory approach (i.e., Robert Wood Johnson Foundation). Products that may be developed include: 1) a lay-person brief that describes the Consortium model, how the model was implemented and results; 2) a peer reviewed publication; and 3) presentations at national meetings. 2) Negative Findings: he Consortium tools developed during 2012-2013 will be used annually. If the findings indicate no substantial effect on participants' lives or influence on the program, then results will be used to justify re-structuring the Consortium. A brief lay-person friendly report will be drafted and shared with Consortium members. A sub-committee will be established to investigate program elements and make recommendations for improvement with representation from Consortium members and NHHS staff. A skilled consultant will be contracted to facilitate the process. VII. ORGANIZATIONAL INFORMATION Applicant Lead and Fiscal Agent: The Community Foundation for Greater New Haven (The Foundation) will continue to serve as lead and fiscal agent for NHHS. The Foundation represents the largest charitable organization in South Central Connecticut, one of the oldest community foundations (established in 1928) and one of the top 50 largest (of more than 700) community foundations in the United States managing over $400 million in philanthropic assets. The The Community Foundation for Greater New Haven
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Foundation plays a unique role as a neutral convener and community catalyst to create positive sustainable change by raising money for the community's needs, making grants to local nonprofits, managing organization endowments, and assessing the extent to which community assets and resources positively impact the quality of life. In 2012, The Foundation’s funds distributed over $21 million in grants to local nonprofit agencies as a result of the generosity of donors and The Foundation’s sound investment performance. Competitive grants are awarded based on demonstrate leadership, sustainability and evaluation in addressing an issue. The Foundation provides a platform for NHHS to operate more effectively as a convener and catalyst for collective impact, to align with other critical community-wide initiatives, and to integrate maternal and child health indicators into the conversation around community indicators (e.g., Community Index 2013). The Foundation supports programs that build healthy families and communities, and serves as “home” to several successful family support initiatives including NHHS. NHHS grew out of a community concern during the 1980s over an unacceptably high infant mortality rate in New Haven. The Foundation, on behalf of the New Haven community, secured the first federal Healthy Start grant in 1997. Today The Foundation remains home to the only model in which a major community foundation serves as lead and fiscal agency, and a pioneer in moving Healthy Start projects into an era of collective impact (see section III.4). Project Leadership: The Foundation maintains the same organizational and leadership team as under the current, successful federal Healthy Start grant, and prides itself on meeting or exceeding all federal project management and reporting requirements (program performance, fiscal). NHHS maintains the same project leadership team and management team comprised of implementation partners as under the current, successful, federal Healthy Start grant. Foundation Staff. The Foundation will apply the same management principles and leadership philosophies to continue producing exemplary performance with respect to project administration and to project outcomes. The NHHS leadership team (described below) receives the full support of The Foundation’s full administrative structure. Specifically: a) William Ginsberg, President & CEO (in kind contribution) assists with statewide, regional, and community strategy, policy, and leadership issues as well as fundraising; b) A.F. Drew Alden, Senior Vice President of Finance, Investments and Administration provides strategic direction related to operations and budgeting and serves as liaison to the Foundation Executive leadership; c) Penny Canny, Senior Vice President of Grant Making and Strategy provides the direct link between Healthy Start and The Foundation’s knowledge and evaluation center; d) Sarah Fabish, Director of Scholarships and grants facilitates programmatic linkages such as with her role as a member of the New Haven Early Childhood Council; and e) Marcie Monaco, Manager of Finance, will manage all financial transactions and complete financial reporting requirements. Leon Bailey, Senior Vice President of Organizational Effectiveness provides direct support NHHS. All of these positions represent matching funds. NHHS Project Staff. The organizational structure will remain the same, with the exception of replacing the Program Assistant with Cynthia Chan. Michael Rebimbas continues as the Quality Services Manager. Natasha Ray continues as the Consortium Development Coordinator. Kenn Harris continues as the NHHS Project Director, manages the day-to-day operations of the project, and reports directly to the Foundation’s Senior Vice President of Organizational
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Effectiveness. See Section VI for information about the evaluation team. See attachments for position descriptions and brief biographies of key personnel. Healthy Start will continue to support a Consortium (see Section III) that represents partners, participants, other stakeholders, and will support various workgroups such as the Perinatal Partnership, the Outreach Group, the Men’s Consortium, the Teen Group, and the Evaluation Team. Partners lead the Consortium and other working groups, with support provided by NHHS Staff. For example, a Robert Wood Johnson Foundation Clinical Scholars Program at the Yale School of Medicine co-chairs the Consortium with a Healthy Start participant. The organizational chart (Attachment 6) shows the structure in the context of the Consortium and the subcontract partners of NHHS. NHHS staff will enter into subcontracts with healthcare system partners (e.g., Yale New Haven Hospital, New Haven Health Department, Hill Health Center); community-based organizations related to strengthening family resiliency (e.g., New Haven Housing Authority, Christian Community Action, New Haven Home Recovery); and other critical initiatives (e.g., New Haven Family Alliance – Male Involvement Network; Yale School of Medicine (e.g., evaluation team, MOMS Partnership). See budget narrative for additional information. Management: The Foundation’s administrative and financial management apparatus supports $21 million in annual grant making and manages relationships with representatives from over 700 charitable funds. The Foundation maintains superior internal financial controls for managing federal funds. A Foundation accountant assigned to NHHS, with the assistance of a bookkeeper: a) process bi-weekly payments to Healthy Start vendors and/or sub-grantees; b) produce monthly financial reports on each of the Healthy Start program models; c) meet monthly with the NHHS Project Director to review the validity and implications of the financial reports as well as to receive authorization to process payments; and d) submit quarterly to the federal government form PSC 272 (cumulative expenditure reports). Higher level financial oversight and auditing fall under the domain of A. F. Drew Alden, The Foundation’s Senior Vice President of Finance, Investment, and Administration. Mr. Alden manages, in the context of a Board Audit Committee, The Foundation’s independent audit process. Two months after the close of The Foundation’s fiscal year, an external accounting firm audits the compliance of the Foundation with the types of compliance requirements described in the U.S. Office of Management and Budget Circular A133 Compliance Supplement as well as the Government Auditing Standards. The most recent independent audit confirmed the non-existence of any material weaknesses, reportable conditions, or noncompliance in financial statements associated with Healthy Start. NHHS staff will develop, via constructive dialogue with subcontractors, parameters for performance benchmarks and payment schedules. Foundation staff will assist in preparing these performance-based contracts and in preparing to meeting federal reporting requirements. The NHHS Project Director and the Quality Services Manager will play integral roles in managing implementation. These two staff members will be monitoring participant volume and flow as well as increasing the capacity of NHHS partners to measure and report quality of service delivery (including outcomes). NHHS will continue to implement a customized database that operates on an Access software platform. NHHS partners can access the secured database via the VPN, and ideally, soon via the web. The lean staffing model, the focus on performance and accountability, and the production of monthly (in some instances weekly) reports create
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opportunities for the NHHS staff to hold management meetings internally and with subcontractors and partners. The NHHS Project Director communicates regularly financial/programmatic information to the Consortium and the Perinatal Partnership. The NHHS Consortium Coordinator holds primary responsibility for recruitment, orientation, and retention of Consortium Members, and provides staff support to the Consortium’s working committees. The nature of the Consortium building work requires close connections with the outreach and health education service components. The NHHS Quality Services Manager meets regularly with the Consortium Development Coordinator to coordinate work flows, share information, plan health education and outreach events, and advance project outcomes. [See section III.5 for details.] The NHHS Project Director meets regularly with the evaluators to assess performance (objective v. actual); to guide additional analyses that inform mid-course adjustments; and to use the data in reflection sessions with the Consortium as well as other venues (e.g., Perinatal partnership meetings; meetings with subcontractors) [see section VII, Evaluation]. Contractors will receive performance report cards, and community indicator data will be available through a web dashboard and updates to the Community Index. Sustainability: Healthy Start sustainability activities occur at three levels of the project. First, the Consortium operates a Sustainability Committee. NHHS recognizes that federal funds fill “gaps” in the community’s MCH system. NHHS leadership together with The Foundation has convened representatives from key stakeholder and subcontractor organizations to design longer term strategies to sustain core elements of the NHHS program such as the Consortium or the Care Coordination model. Each of the primary NHHS partner organizations works in concert with Foundation staff to build endowment funds (to provide support for non-reimbursable and core social supports necessary to sustain a well-functioning perinatal healthcare delivery system). Third party reimbursement and government funding for certain healthcare services play a role in building a strong healthcare delivery system. The ACA and changes in the healthcare landscape (i.e., the local hospital establishing accountable care organization) will tighten care coordination and increase the effectiveness of investments in prevention. These resources alone rarely address all of the challenges faced by women of childbearing age, and NHHS and its partners will continue to pursue a collective impact strategy that addresses social determinants of health. At an operational level, the NHHS Perinatal Partnership examines how to improve access to and maintenance in the healthcare system, particularly for high-risk populations. Discussions relate to improving the responsiveness of the system (e.g., cultural diversity, friendly environment), the efficiency of the system (i.e., data collection systems, training), and examining the impact of healthcare policy and financing considerations as it relates to the populations most at risk for adverse maternal and child health outcomes. Each of these areas of focus relate to project sustainability as opportunities exist to change the service delivery system for the express purpose of improving health outcomes. The Foundation maintains a high level of institutional commitment to supporting communitydriven approaches that achieve positive maternal and child health outcomes. This institutional commitment resulted in The Foundation’s support of the Commission on Infant and Child Health (during the 1980s-mid-1990s) and continued from 1997 to the present with multiple, continuous federally funded Healthy Start grant awards. The present Healthy Start application will support a
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shift in the model to collective impact and to addressing more strongly social determinants of health and strengthening family resilience. The Foundation’s objective of Ensuring Health and Wellness25 supports the notion that promoting well-being and increasing individuals’ and communities’ access to health care and supportive services will improve health outcomes for all. The Foundation supports organizations focusing on health and wellness across all grant types with the most significant investment through the responsive grant process, which accounts for nearly half of the total investments in this area. In 2012, The Foundation invested over $1.8 million through 339 grants to organizations and programs focusing on health and wellness above and beyond $900,000 of federal Healthy Start funds. Grants to Ensure Health and Wellness account for about 16% of all Foundation grant-making and nearly 30% of responsive grantmaking. Together, Health and Education represented half of all the discretionary grant-making in 2012. Twenty percent of all discretionary grant-making is in the area of Health. This is driven by the fact that Health is the area of grant-making with the most preference funds available (45 of the 99 preference funds have a health preference). The majority of these grantees represent NHHS partners and/or partners in other community-wide initiatives related to maternal and child health. In 2014, the Foundation will, under the guidance of the Male Involvement Network and New Haven Healthy Start, begin distrusting small grants from a fund established specifically to support fatherhood initiatives. Organizational Capacity Supports Community Readiness: Sections III.1.a.-b. explain how NHHS partners already integrated outreach and enrollment protocols for the ACA via Access Health CT, the state’s health insurance exchange. Section III.2.a. describes how NHHS partners will coordinate services and integrate systems to provide a medical home for every family. Section III outlines the projects links to the existing perinatal system of care that enhances the community’s perinatal health programs already in operation in the target area. Sections III.2 and III.3 explain efforts to more effectively address health prevention and health promotion, and to strengthen family resiliency in targeted geographic areas of highly concentrated health disparities through approaches that address social determinants of health. NHHS partnered with and supported the Connecticut state and local Title V MCH block grant agency in their 5-year needs assessment and their recent assessment of home visitation programs. The NHHS Project Director meets regularly with Ms. Rosa Biaggi, Director and appropriate staff at the CT Department of Public Health, Family Health Division to align our work and discuss ways to collaborate and coordinate our efforts. The CT Department of Public Health, New Haven Department of Health and NHHS secured a Partnership to Eliminate Disparities in Infant Mortality grant (through the W.K. Kellogg Foundation) from AMCHP, National Healthy Start Association and CityMatCH to conduct an Action Learning Collaborative focused on looking at the Impact of Racism on Birth Outcomes. Our partnership with the local health department, Maternal, Child and Family Health Division Director remains vibrant. NHHS continues to work closely with our local New Haven Health Department Epidemiologist, Dr. Amanda Durante, who also is part of the NHHS Evaluation Team and with researchers from UConn to complete focus groups and produce reports that inform statewide and local maternal and child health strategies. The most recent federal Healthy Start report for New Haven (grant number H49MC00095) provides detailed information about project accomplishments. 25
For a complete description, visit: http://www.cfgnh.org/Learn/EnsureHealthWellness/tabid/535/Default.aspx
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Section III.4. as well as the information above describes how The Foundation, in partnership with the NHHS management team, holds capacity, expertise, and past experience to carry out, coordinate, and lead a complex, integrated community-driven approach to the proposed activities within the proposed target area directed at the proposed target population. An impressive, diverse array of local and state leaders—from neighborhood residents to chief elected officials to the chief executive officers of major healthcare institutions and institutions of higher education support NHHS as a mission-critical maternal and child health collective impact initiative that connects to many other initiatives associated with school readiness, social development, and public health initiatives that now more than ever address social determinants of public health in an effort to reduce health disparities. See Section III.b.1 for a description of the robust partnerships that anchor several cross-purpose teams (e.g., perinatal partnership). The linkages to other prominent public-private community partnerships such as Yale’s Community Alliance for Research and Engagement (CARE) and the MOMS Partnership further reinforce to local and state leaders the importance of New Haven Healthy Start. For example, NHHS Project Director Kenn Harris serves on the MOMS Partnership guide team with leaders from Clifford Beers Guidance Clinic, The Diaper Bank, All Our Kin, the Housing Authority of New Haven, Connecticut Department of Children and Families, Connecticut Department of Social Services, and Yale School of Medicine. To close the circle, The Foundation, provides grant funding to support this mental health initiative. NHHS project staff and partners have and will continue to serve as a resource, trainer, mentor, and consultant to other Healthy Start grantees and perinatal projects. NHHS and its partners provide technical assistance to the federally funded Healthy Start project in Hartford as well as other Healthy Start (state or locally funded) projects, and maintain a strong working relationship with the Connecticut Department of Public Health and the Connecticut Department of Social Services. New Haven Healthy Start will continue to work closely with the Yale School of Medicine Robert Wood Johnson Foundation Clinical Scholars program. This year, the CDC has engaged a Robert Wood Johnson Clinical Scholar who has committed to serving as the Consortium’s Co-Chair alongside one of the New Haven community residents. Every two years, a new scholar will serve as a Co-Chair of the NHHS Consortium. New Haven Healthy Start project director Kenn Harris co-delivered a January 13, 2014 webinar to national Healthy Start sites titled, “Male Involvement / Fatherhood: Core Adaptive Model (CAM) for NHSA. Personnel from over 60 national Healthy Start sites participated in the webinar. The health chapter of the Community Index 2013 offers statements by Paul Cleary, PhD, Dean of the Yale University School of Public Health; and Marna P. Borgstrum, Chief Executive Officer of the Yale Healthcare System. Dr. Cleary states (Community Index 2013, page 47): … there are unacceptable disparities by income and area of residence, which for many is related to socioeconomic status. One of the greatest opportunities for improving health in the region is to build bridges to the community, and translate cutting edge scientific findings into programs and actionable information for our most vulnerable neighbors. The Yale School of Public Health’s Community Alliance for Research and Engagement (CARE), is a fitting example. CARE members have formed key public, private and neighborhood
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partnerships and are working actively to improve many of the conditions highlighted in this chapter, especially in the areas of the City with the highest prevalence of health problems. A complex challenge to achieving optimal health lies in fostering an interdisciplinary approach…For example, health is inextricably linked to economic opportunity, jobs, housing and civic engagement. This report is a comprehensive tool which can stimulate us all to think creatively and collaboratively about how to improve the health and overall quality of life of all those in the Greater New Haven Region, so that soon we can have an even better story to tell about all residents, not just the more fortunate among us. The Foundation, via its New Haven Healthy Start team and partners, stand ready to pioneer Healthy Start into the area of collective impact, and to move the model more deeply into solutions that address social determinants of health.
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