Chapter 6: State and Federal Grants, Budgets and Accountability
This chapter offers basic information about managing the Maternal and Child Health Block Grant, such as the strategic planning process of the Title V application, accountability, performance measures, budgets and helpful tips from Title V leaders who have "been there, done that."
Comprehensive Needs Assessment
If you don't know where you are, you won't know where to go next…a needs assessment is a great starting point. - Joan Wightkin, administrator, MCH Program, Louisiana
A comprehensive needs assessment is recognized as a good public health practice and is a common feature of programs throughout the field. For the MCH Block Grant, it is required every five years although it is actually best thought of as a continuous and on-going activity. This process gives you an opportunity to take a fresh look at the needs as well as the accomplishments of the block grant, including program evaluation results, data, measures of health status for MCH populations, priorities and collaborations with other key programs. It also documents the basis for selecting the state negotiated performance measures that are designed to address the new priorities.
Because it takes time to conduct a comprehensive needs assessment, do not wait until the year it is due to start the process. Obtain a copy of the Maternal and Child Health Services Title V Block Grant Program Guidance and Forms for the Title V Application/Annual Report. Study the chapter that describes the needs assessment process before initiating any planning activities. It provides an excellent overview of strategic planning and spells out the steps in the process. You can look to other literature and resources to elaborate on any of the steps in the planning process. The needs assessment should serve to inform the MCH Block Grant plan development. One good source is the book, Needs Assessment in Public Health: A Practical Guide for Students and Professionals, authored by two MCH veterans, Donna Petersen and Greg Alexander.
Make a master plan for conducting a comprehensive needs assessment. Begin by reading the Guidance and make a list of the major steps you will have to complete. Make a listing of the workforce and fiscal resources you have available to complete this task. Start well in advance — preferably two years before the needs assessment is due. Make a master calendar for completing the needs assessment. Start with the date the needs assessment is due to MCHB and work backward until you have all steps in the process assigned both a deadline and a responsible staff member(s). If you have a staff member with expertise in conducting needs assessment, either designate that person as being "in charge" of the entire process, or ask for her guidance. Look at what work has been done in the past and all comments from the federal block grant reviewers about the strengths and weaknesses of the previous assessment.
Talk with your assigned MCHB project officer to obtain further information about comparable states that can serve as examples of how to carry out a comprehensive needs assessment. Talk with your AMCHP peers for additional tips on how they overcame problems or obstacles.
Checklist for Conducting Needs Assessment
- Study the guidance and make a list of tasks to be completed
- Put one person in charge of the needs assessment
- Make a master plan
- Discuss with MCHB project officer; obtain technical assistance if needed
- Gather existing documents (e.g., last needs assessment, data updates, studies, reports, program evaluations, SLAITS data, etc.)
- Assign every task to someone to complete by deadline
- Develop a calendar of key assignments and due dates
- Hold a stakeholders meeting for all interested parties to review master plan; periodic meetings thereafter for steering needs assessment activities
- Conduct environmental scan
- Use CAST-5
- Obtain new data and analyses
- Use consultants as needed
- Read draft report from front to back; edit
- Share draft with stakeholders; conduct process to develop list of needs and priorities based on needs assessment findings
- Share final needs assessment report, including listing of needs and priorities, widely - with state agency leadership, "sister" agencies, advocacy groups, legislature, governor's office, etc.
- Celebrate a job well done!
Convene a meeting of all staff, family advisors and coordinating programs (both within and outside your agency). Review the master plan with this ad hoc committee and use their advice in refining the plan for the needs assessment. This group can become a "steering committee" for the needs assessment and be convened periodically to provide status updates and problem solve. In some states, the MCH Block Grant advisory committee could serve this function. In other states, the steering committee may actually assume some of the responsibilities for carrying out the needs assessment. Remember that the more you decentralize the needs assessment process, the more you are going to need a single person to be on top of the process, someone to know who is doing what and when assignments are due.
Always do an environmental scan early in the process to determine what data, program evaluations and other information you have readily available. Identify what information will be more difficult to secure and determine the best method to obtain the information. For example, the data you need might be available from another program such as Medicaid or Vital Statistics. Or perhaps you will need to identify outside consultants to obtain the information you need. Consultants may bring skills such as forecasting or social marketing that are not already available on your staff. The "steering committee" members should be helpful here. If you are not knowledgeable about statistical analyses, ensure that you have someone with expertise to help you identify trends, determine significant changes over time, and deal with hard data issues, such as small incidence or small populations.
Build adequate time into the needs assessment calendar for an advisory group to review the resulting data, trends and other information. You may use a process such as the Delphi Method or the Nominal Group Process to generate a listing of key MCH issues and some version of voting for the top priorities. Consider sending out the list of key MCH issues to all major stakeholders (local health commissioners, families, clinic personnel, human service agency directors) throughout the state and ask them to prioritize the issues. The results can be the Title V priorities for the next five years. Use the new priorities to direct resources toward the block grant efforts by selecting 7-10 state negotiated performance measures. Recognize that political realities may demand that the block grant priorities be amended to reflect current political leadership or campaign promises. However, having prepared the priorities without considering political perspectives may enable you to "take the high road" and offer a persuasive argument for keeping the priorities because they were determined through a fair and inclusive process.
Combine all of the data and results obtained during the needs assessment process into a written summary that describes the findings, the methodology used, who was involved in the process (stakeholders and other partners), and what the results mean in terms of Title V services and the levels of the MCH pyramid. The guidance provides detailed information about what should be included in the needs assessment summary report. While the needs assessment summary is a document that is submitted to MCHB, it can also be useful to advocacy organizations, advisory committees and other agencies in your state. You may want to use it as a marketing tool for the Title V program.
Capacity Assessment for State Title V (CAST-5)
CAST-5 is a set of assessment and planning tools designed to examine state program's capacity to carry out core maternal and child health functions. They are very helpful tools to use during the needs assessment process and fit well into the second stage in the needs assessment process as described in the guidance. The tools can be used collectively for a comprehensive assessment of the Title V capacity needs, including opportunities for capacity development. Or they can be used individually to assess the specific, narrower scope of the programs.
CAST-5 is meant to answer the strategic planning questions, "What do we have?" and "What do we need to get the job done?" It helps state Title V programs determine what organizational, programmatic and management resources must be developed or enhanced to achieve the program's goals.
Use of CAST-5 is not required by MCHB, but it is recommended by AMCHP because it assures that the needs assessment takes into consideration resources currently available and those needing development. In addition, CAST-5 provides broad guidance on prioritizing program capacity needs and developing strategies for capacity development. CAST-5 is an initiative of AMCHP and the Johns Hopkins University Women's and Children's Health Policy Center, in partnership with the federal MCH
Obtaining data is critical to the success of the needs assessment and MCH Block Grant plan. Some states have comprehensive structures in place to collect and analyze public health data, while other states have not invested in a data infrastructure of this nature. Because of this wide variability across the states, MCHB has invested significant resources in data capabilities in recent years, such as the State Systems Development Initiative (SSDI) grants to improve specific data sources. Additionally, MCHB funded a national telephone survey database for the health status of children with special health care needs known as SLAITS (conducted by the National Center for Health Statistics). MCHB plans an expansion of SLAITS to secure information about the preventive and primary care health status of all children. The Child Health Survey is conducted every four years mid-way between the SLAITS survey. Data is usually available 1 year after the survey is closed. Results can be found at the MCHB website under the data section.
As you begin the needs assessment process, determine what data sources are available within the state, from MCHB or from other national resources, as well as the limitations of these data. Determine what you can do to improve the quality of data sources with available fiscal and human resources. For example, SLAITS undersamples certain populations by design, so you may want to purchase additional sampling for your jurisdiction to target undersampled groups. You should also identify what basic MCH data exists in your state from sources such as Vital Statistics (from birth and death certificates); research that identifies trends specific to your state or its subpopulations; service data from Title V, WIC, early intervention, public schools, Medicaid, mental health and others; national MCH data from MCHB's Title V Information System (TVIS); and program evaluations. The block grant requires that reliable data be used for the national performance and outcome measures.