Minnesota’s Public Health System

1. Healthy OutcomesandSelf-SufficiencyforPregnant and Parenting Teens Receiving TANF Cash AssistanceinRamsey County, Minnesota

2. Minnesota’s Public Health System • Organized into 56 Community Health Boards • Nationally recognized because of unique organization, State-Local partnership, and innovations

3. Ramsey County • East side of the Minneapolis/St. Paul Twin Cities • Most densely populated county • Pop. 525,000 • Increasing numbers of Hmong, Somalian immigrants • 1 in 3 English as a Second Language learners in St. Paul

4. Saint Paul – Ramsey County Department of Public Health • 301 employees • Organized into “Sections” • Administration • Correctional Health • Enviornmental Health • Healthy Communities • Epidemiology, Policy, Planning and Preparedness • Preventive Health • Screening and Case Mangement • WIC • Healthy Families

5. Healthy Families Section • Adolescent Parent Program • Home visiting and case management for pregnant and parenting teens under 17 yrs • REACH Young Parents Program • Home visiting and case management for pregnant and parenting teens 17 – 19 yrs who have not completed high school

6. Home Visits to Pregnant/Parenting Teens In 2000, large influx of TANF $ from feds, through MN Dept. of Health, increased emphasis on self-sufficiency of adolescents along with promotion of healthy outcomes for families.

7. Teen Home Visiting Staff • Public Health Nurses (PHN) • Minimum of 4 yr nursing degrees with public health certification, some with masters degrees • Social Workers – • Licensed SW’s and LICSW • Health Education Program Assistants • Health para professionals with 2 year degrees • Nutritionist • 4 year degree

8. Home Visits to Pregnant/Parenting Teens • Services provided to both male and female teen parents • Information collected, nursing diagnosis determined, individualized plan of care developed • Implement or refer for interventions • Track outcomes

9. Home Visiting Services • Physical health assessment of mom, dad(if present) and child(ren) • Health histories, vital signs, and direct observations • Notify MD when needed for health concern • Ensure all family members are hooked up with a primary care clinic, dentist, and psychiatrist (if needed) • Ensure health insurance is active; all paperwork processed

10. Home Visiting Services con’t • Mental health • Assessments • Past/present domestic violence • Past/present abuse/neglect • Past/present symptoms or diagnoses • Past/present self-mutilation • Referrals for psych evals and medication • Referrals for counseling and support groups • Assist with obtaining county MH case manager

11. Home Visiting Services con’t • Child Health Assessments • Assess for growth and development norms established by national pediatric standards • Nutritional assessment • Past health history/dental history • Daily living routines • Elevated lead, PICA • Past or current risk of abuse/neglect • Parent/child attachment

12. Home Visiting Services con’t • Housing assessment and assistance • Safety issues • Home Safety Checklist tool • Financial situation, money management • History or risk of homelessness • Goals for living independent living

13. Home Visiting Services con’t • Cognition/educational needs • Past or present learning difficulties • Attitudes towards school • Initiate special ed assessments • Future educational/career goals

14. Home Visiting Services con’t • Pre-natal education, teaching and monitoring • Breastfeeding promotion and support • Previous pregnancy history • Current status • Feelings about pregnancy • Partner involvement • Nutrition, vital signs • Smoking or chemical use • Preparation for newborn • Meds or treatments ordered by MD

15. Home Visiting Services con’t • Post-partum education, teaching and monitoring • Assessment of physical status of mom and baby • Breastfeeding promotion and support • Post-partum depression identification and referral

16. Home Visiting Services con’t • Assess knowledge of community resources and support • Assist and support to access resources • Referrals, as appropriate

17. Home Visiting Services con’t • Womens health • Family health history • Personal health history • Previous pregnancy outcomes • Family planning • Chemical use • Mental/emotional/abuse history • Client’s assets Medical care Early Childhood years Insurance Support Systems Dental care Transportation WIC food program

18. Home Visiting Services con’t • Caretaking and parenting • Assess strengths and weaknesses • Parenting practices of client’s parent(s) • Risk of abuse/neglect to self or child • Attachment and interaction • Child’s behavior • Current discipline practices

19. Home Visiting Services, con’t • Clinical medical record kept for each client • For each category, client knowledge, behavior and status(KBS) is assessed • Interventions are implemented • KBS ratings are tracked for improvement

20. Minnesota’s Program for TANF Clients • Called MFIP (pronounced m-fip) Minnesota Family Investment Program • Workforce Solutions, a Ramsey County department, administers the MFIP employment services

21. Teen Parents on MFIP • More than 70% of teen parents end up on welfare at some point in their lives • More than 53% of MFIP families in Minnesota began with a birth to a teen mom • Only 41% of mothers who have children before age 18 ever complete high school

22. Minnesota’s Program for MFIP Clients Each client assigned a job counselor to provide Employment Services (ES) • Assists clients in obtaining self-sufficiency by developing “employment plan” • Teens develop a “school plan” in place of employment plan • Ensures clients follow mandates • Ability to sanction cash grant if out of compliance

23. Public Health Nurses(PHNs) as ES Counselors • Because of our positive outcomes, Workforce Solutions contracted with Public Health for ES services to teens • Prior to July ’03, home visiting program was voluntary • Only 1/3 of teens on MFIP received home visiting services, now all are mandated

24. PHNs as ES Counselors • Began July 2003 • Now have ability/responsibility to sanction and approve child care payments • ES chart added to clinical medical record • PHNs have matched caseloads with Financial Workers and Child Care Workers in other county departments • Unique collaboration with child support enforcement department

25. Evaluation combining PHN and ES Counselor Roles • Continue to track all outcomes including: • Client satisfaction • Health status of families • Graduation rates • Positive attachment to children • Housing stability • Children will have: • Well child exams • Health insurance • Up-to-date immunization • Normal growth and development • Reduction in unintentional injury

26. Evaluation combining PHN and ES Counselor Roles • Additional study of mandatory vs. voluntary participation and its effect on health and self-sufficiency outcomes • Saint Paul – Ramsey County Department of Public Health selected to be in CityMatch Data Institute to study MFIP Teen Program

27. Year One Results • MFIP Teens received more coordinated, consistent, intensive, and comprehensive services • Developed a unique collaboration with several county departments and the school district • Improved service delivery and efficiency of services

28. Year One Results • Increased communication between service providers-a cross department “team feeling” has occurred • All MFIP teens received a comprehensive assessment and increased services

29. Lessons Learned • It is a difficult balancing act between the dual roles of public health home visitor and MFIP enforcers • Holding clients accountable to MFIP rules(sanctioning) is difficult for staff who have served in a service provider role

30. Lessons Learned • More up front training to PHNs on the rules and regulations of MFIP was needed • A sanction review team was implemented for consultation, evaluation and consistency of practice • Nurses now tell clients that the committee made the sanction decision rather than the individual nurse who visits the home

31. Lessons Learned • Even during the implementation phase, continued emphasis needs to be placed on public health practice issues and support for staff

32. Implications for Practice • There may be safety concerns for home visitors who have the responsibility to sanction cash grants • Programs with mandatory enrollment/service requirements affect relationships • Continued emphasis on public health practice (as well as learning the new employment services counselor role) is vital

33. Implications for Practice • Matched caseloads among PHNs, financial workers, and child care workers are essential • Have representatives from front line public health staff involved in all aspects of program design and implementation

34. Implications for Practice • Successful public health strategies can be adapted for use by agencies and departments with differing missions • Decreasing the number of county staff involved with teens • improves communication, coordination, quality, and client satisfaction of services • promotes healthier outcomes

35. Implications for Practice • Relationship based services that hold teens accountable for the rules they need to follow in order to receive MFIP cash assistance promotes client responsibility • Comprehensive services delivered by a multi-disciplinary team increases positive outcomes

36. Contacts Sue Mitchell, MPH 651-266-2428 sue.mitchell@co.ramsey.mn.us Linda Wagner, PHN, MPH 651-766-4063 linda.Wagner@co.ramsey.mn.us