NeighborhoodMinistries_Clarifications.pdf

Health Start Program Solicitation BPM002372 – Clarification

Neighborhood Ministries Inc.

Method of Approach

6.2.1.2.1. Submit examples of a prior project with activities similar to those as described in this solicitation, a description of the work performed, the approach used to complete the project, recommendations made to the clients and the project outcome. Other examples of similar projects need to be included;

Provide more information on how programs like Mom's Place and Parents College are similar to the Health Start Program.

Like the Arizona Health Start Program, Moms' Place is a community-based, evidence-informed parenting program that enrolls pregnant and postpartum women and families (particularly young, low-income, families of color). Services are provided in classroom setting, in office, and during scheduled home visits. Lay health workers support expectant mothers in establishing a medical home for consistent prenatal care. In an effort to improve maternal and child health, Moms' Place connects women to prenatal care providers and provides transportation to/from appointments. The program also provides prenatal and postpartum education, women’s health education, information and referral services, advocacy and emphasizes timely immunizations and developmental assessments for children. Much like Health Start, it also offers optional doula support services to provide short term support for program participants in labor and during birth. Also, like the Health Start Program, Moms' Place and Parent College provide family planning and birth spacing education aimed at preventing the cycle of repeat teen births.

Lastly, in direct alignment with the Health Start Program, Moms' Place began promoting male and family involvement in services and classes a few years ago. As such the Moms' Place name changed to Parenting por

Vida (Parenting for Life), and the Parent College programming was added. Neighborhood Ministries realizes that father and male engagement has a positive impact on pregnancy outcomes, breastfeeding success, and child development.

6.2.1.2.2 Identify a neighborhood/community, city or county targeted service area that would benefit from Health Start services per Arizona Revised Statue A.R.S. § 36-697. Offerors shall provide a map of the area and the zip codes of the area. The justification supporting the selection of the targeted service area shall be described in detail, including the demographic characteristics, health status data (low birth weight births, preterm births, infant mortality by maternal morbidity and mortality ethnicity) identifying a need for Health Start services. One (1) resource for these statistics is www.azdhs.gov/plan. Other supporting data that demonstrates need that shall be described include: poverty level, educational levels, unemployment, housing, crime rate and number of or lack of primary care and obstetrical care providers and other supporting health care and social/ behavioral health providers in the proposed targeted service area;

Provide the health status data (low birth weight births, preterm births, infant mortality by maternal morbidity and mortality ethnicity) for the proposed targeted service area. Need more clarification on how you plan on serving a very limited service area (one zip code) which is not serving enough geographic areas. Information is lacking regarding the description of obstetrical care and supporting health care and social/behavioral health providers in the one zip code. Provide more information on this.

Though the program will be housed in 85009 and will focus recruitment of families residing within this high-risk zip code, the program will not be strictly limited to families with an 85009 zip code. See section 6.2.1.2.3 below for further information.

In 2018 in Maricopa County, there were 51,701 births. Of those, 7.5% (3,881) were low birth weight births, and

274 infants died. Between 2012 and 2015, there were 141 maternal deaths. At 6.5%, 85009 is Arizona’s 3rd highest birthrate zip code. It has the second highest rate of teen births (17%) for women between 15 and 19 years of age. This high-risk zip code is located in First Things First’s Phoenix South Region. According the Phoenix

South Regional Council’s 2018 Needs and Assets Report, “A significant proportion of the births in the Phoenix

South Region are to mothers with characteristics that are associated with poverty, which has been shown to be correlated with various challenges.” It goes on to point out that 11.7% of births in the region were to teen mothers, and 7.7% of mothers giving birth in the region had fewer than five prenatal visits. Additionally, compared to

Arizona as a whole, births in this region are more likely to be preterm, involve low birthweight, and require newborn intensive care. See graph below.

While the national average of physicians per 100,000 residents is 210, there are only 201 physicians per 100,000 people in 85009, meaning residents of this zip code have reduced access is to healthcare. Expecting mothers residing in 85009 typically seek obstetrical care through the following providers:

• Wesley Community & Health Centers’ Golden Gate Campus (85009)

• Nueva Esperanza Women’s Center (85014)

• Mountain Park Health Center’s campuses (85008, 85042 and 85033) – Federally Qualified Health Centers

• St. Joseph’s Hospital and Medical Center (85013)

• Valleywise Health (85007, 85008, 85031, 85041)

• Adelante Healthcare’s campuses (85395, 85374) – Federally Qualified Health Centers

• St. Joseph's Maternity Outreach Mobile Unit (MOMobile)

Chicanos Por La Causa, Valle del Sol, Friendly House, Valleywise Behavioral Health Center, and Jewish Family and Children Services are agencies that provide social and mental/behavioral health services to the families

Neighborhood Ministries serves. Also noteworthy is Phoenix Urban League, which offers Navigator Services and is a predominant WIC site in the 85009 zip code area.

6.2.1.2.3 Include the projection of the number of proposed prenatal and postpartum clients and children to be enrolled in the program that must live within the targeted service area, as well as the number of total enrollments, proposed prenatal and family follow-up visits, multiple child visits provided, and proposed trainings attended for the first (1st) year. Offeror may provide number pregnancy test visit services, prenatal visit – birth doula support and classes for clients and community health education classes as an option;

The projection numbers are too high for the area (85009). Specifically, the classes, enrollments and the Social Work/LPC Consultation. Provide additional information on how this will be accomplished with a limited geographic area.

The program will be housed at Neighborhood Ministries, which is located in zip code 85009, and given the high number of births in 85009, we will focus our efforts on this zip code. However, we understand the population to be served is often transient and, given that families often access Neighborhood Ministries’ services after hearing about them from friends or family members, clients from other zip codes will naturally migrate to this program.

Walk-in clients and those referred to the program will not be turned away unless they are already participating in another home visitation program. Therefore, enrollment in this program will not be limited strictly to participants with an 85009 zip code.

Under the guidance and direction of Dr. Elizabeth Reifsnider from Arizona State University’s College of Nursing and Health Innovation, a nurse will conduct multiple home visits with each family enrolled. According to best practices identified by the Nurse/Family Partnership established by David Odel and Harriet Kitzman of the

University of Rochester, vulnerable, at-risk families experience better outcomes when they have return nurse visits. Visits from Social Workers will be equally important. Through this program, Social Workers will help families resolve economic, housing, domestic violence and substance abuse issues. The Community Health

Worker (CHW) will work under the nurse. A part time, public health nurse position will be available to support and guide the CHW in establishing class agendas as well as goals and outcomes for follow up home visits.

6.2.1.2.4. Describe the strategies that will be utilized to conduct outreach and to recruit new prenatal and postpartum clients on an ongoing basis;

What providers/programs will be used to conduct outreach and to recruit new prenatal and postpartum clients?

In addition to the outreach events and recruitment strategies outlined in the original submission, program staff will distribute collateral materials at local businesses potential clients frequent. This includes grocery stores, corner markets, hair and nail salons, neighborhood restaurants and bakeries, coffee shops, and laundromats. Staff will also host a booth at local flea markets to recruit participants, and local health providers (doctors, behavioral health practitioners, and dentists) will be educated on the program and encouraged to refer eligible patients.

Lastly, the staff members of Neighborhood Ministries’ various programs will refer eligible families to this program.

6.2.1.2.5. Describe the resources available to enroll clients from the identified neighborhood/community selected as the targeted service area. Identify gaps in health care and social/behavioral health services that exist in the targeted service area. Briefly explain the relationships the Offeror has established with community resources;

Provide additional Information on the resources that are available for enrolling clients.

What FQHC is in the area and what will be the birthing hospital?

St. Joseph's Maternity Outreach Mobile Unit (MOMobile) is a great resource available for enrolling clients, as are the FQHCs in the area. These include Mountain Park Health Center’s campuses (85008, 85042 and 85033) and Adelante Healthcare’s campuses (85395, 85374). The birthing hospitals selected by families in our service area are typically Valleywise Health Medical Center (85008) and St. Joseph’s Hospital and Medical Center

(85013).

6.2.1.2.6. Describe how the Health Start Program Coordinator will be selected and how the CHW and any other staff and consultants will be hired, trained and supervised. Delineate how many Health

Start Program Coordinators, CHWs and any other staff positions and how may Full-Time

Equivalents (FTEs) per staff identified that will service the identified targeted service area through home/office visits and optional group education and outreach training classes or workshops. Provide an organizational chart of proposed program staffing and organization;

Provide more information on how the RN, the Licensed Social Worker or the CHWs will be hired or how the FTEs will be trained.

Dr. Elizabeth Reifsnider (PhD, RN, WHNP, PHCNS-BC, FAAN) will serve as the program’s Nurse Consultant.

Dr. Reifsnider is the associate dean for research and Nancy Melvin Professor of Pediatric Nursing in the College of Nursing and Health Innovation at Arizona State University. As a tenured professor, she conducts research on health disparities, health equity, pediatric obesity, and breastfeeding. She is board certified as a Women’s Health

Nurse Practitioner as well as a Public Health Nurse Clinical Specialist. She has conducted multiple federally funded research studies that use a community-based participatory research approach and includes patients and families in research development, intervention application, and evaluation. She is known for her use of conducting intervention research with community partners through an ecological lens that considers the patient, family, organizations, and larger community as partners in care, striving to improve health equity. Dr. Peifsnider is an active clinician, was a public health nurse supervisor for four Oklahoma counties, and a consultant for the

Oklahoma Health Department in community/maternity nursing. Dr. Reifsnider. She has provided consultation and educational sessions to Neighborhood Ministries, serves on the Community Health Worker Leadership

Council (sponsored by ADHS), and is a volunteer at Desert Mission Food Bank in the North Valley.

As for the staff recruitment process, available positions will be posted through various hiring outlets, such as

Linkedin and Indeed, and on Neighborhood Ministries’ website. Dr. Reifsnider will assist executive staff in reviewing applications and resumes. During the interview process, candidates will be expected to demonstrate that they have community health experience; have experience working with diverse pregnant women, young women, and children; are comfortable entering communities foreign to them; are culturally-competent; and are comfortable offering services in clients’ homes.

As part of the the hiring process, new hires will be referred for background checks and finger printing. They will participate in Neighborhood Ministries’ New Hire Orientation, which includes all equal opportunity employer policies and procedures, and will attend mandatory training as specified by ADHS. All Community Health

Workers (CHWs) and Social Workers will be held to the best practice standards.

6.2.1.2.7. Describe how the required four (4) or more hours of consultation from a Registered Nurse and a

Licensed Social Worker or Licensed Counselor per month will be provided by whom and how

Community Health Workers (CHW) will participate in the consultation meetings;

The information that was provided was unclear regarding the consultation hours. Provide more information about how they are going to arrange for these services and on what they are going to do in these meetings. Provide more detail on how the required four or more hours of consultation will be provided.

A minimum of four hours per month of consultation will be provided. Nurse consultation will be provided by Dr.

Elizabeth Reifsnider, and a Licensed Social Worker will be contracted to provide consultation. Consultation will include staffing cases with CHWs and helping them navigate new or challenging situations.

6.2.1.2.8. If another similar home visiting program exists in the neighborhood/community selected as the targeted service area that serves the same population, document the efforts of the proposed

Health Start program and the other programs in the community, and how all activities will be coordinated to avoid duplication of services and staff;

Identify the other home visiting programs in 85009. And, provide more information on how they will avoid duplication of services and staff.

To avoid duplication of services, this program will only enroll families not already receiving services through a home visiting program. Other home visiting programs in in 85009 include the following:

• Healthy Families – Southwest Human Development

• Arizona Children’s Association

• Parents as Teachers

• Early Head Start – Urban Strategies

• Early Head Start – Chicanos Por La Causa

Experience and Expertise

6.2.1.3.3. Resumes or curriculum vitae for key/essential personnel, who are responsible for delivery of services, as defined in the Special Terms and Conditions. Provide resumes for existing staff that will be part of the project and job descriptions for all project positions and those to be filled.

Resumes shall include name, title, key responsibilities and previous experiences that are relative to that field. Include all professional licensure, certifications, experience, educational preparation, professional awards and publications. Describe staff accountabilities and expertise.

List how much time each person will spend on the project. Do not include personal information such as address, telephone number or email address as the resume will be posted in APP at

Contract award;

The CHW job description was provided, but not for the other positions being hired.

Provide the job description on these other positions.

Community Public Health Nurse

Are you a dynamic, detailed oriented, organized and autonomous caring nurse who wants to make a difference in the lives of infants and their families? Come join our home-visiting team, and assist pregnant women, newborns and families with young children. As a Community Health Nurse, you will work in collaboration with

Social Workers, Community Health Workers, and other community providers in completing developmental screenings and providing support and education on development, infant and home safety, and health prevention/ promotion. You will attend regular team meetings, case conferences, and conduct clinical home visits.

Neighborhood Ministries is an Equal Opportunity Employer.

Position Qualifications:

• BSN is required.

• Registered nurse license through the Arizona State Board of Nursing or license-eligible.

• Experience in Maternal/Child health, Pediatrics, Community Health, and/or Home Visiting is required.

• Bilingual (English/Spanish) is preferred.

Job Summary: Responsible for the provision, direction, supervision and evaluation of medical social services to clients in the home environment, in accordance with agency policies and procedures, applicable health standards, governmental laws and regulations. Proactively meet the needs of and assist the client in the achievement of individualized and measurable outcomes.

Social Work Consultant

Position Qualifications:

• Master’s Degree from a school accredited by the Council on Social Work Education of Social Work with a current license.

• Excellent organization and communication skills.

• Minimum of one year’ social work experience in a public health care setting.

• Excellent interpersonal and analytical skill.

Responsibilities/essential functions: The person in this position must be able to perform the following essential job functions with or without reasonable accommodations.

• Instruct, treat, observe and evaluate clients with significant social and emotional situations affecting their health status.

• Use special skills and judgment to resolve adverse social and emotional responses connected with the illness.

• Report any changes in client's condition and response to treatment to supervisor and the Nurse Consultant.

• Instruct and counsel the client and family in treating and coping with the social and emotional responses to illness.

• Provide ongoing assessment of needs.

• Participate in discharge planning.

• Participate in care coordination activities and act as resource to other team members in identification and resolution of client needs.

• Use appropriate community resources.

• Participate in staff meetings.

• Provide support and guidance to the Community Health Worker.

• Work collaboratively with the Nurse Consultant.

6.2.1.3.4. Complete and submit Attachment H – Key/Essential Personnel.

Attachment H was provided, but the information was not clear. Need clarification on the

CHWs.

The Lead CHW will dedicate 50% of her time to the Health Start Program and the other 50% to the SNAP and

Triple P Program. The two CHWs to be hired will dedicate 100% of their time to the Health Start Program. The

Program Director will dedicate 50% of her time to the Health Start Program and the remaining 50% to her other existing responsibilities to the Parenting Por Vida Program and other duties as assigned.