Performance audit, Department of Health Services, Health Start Program

              A REPORT
TO THE
ARIZONA LEGISLATURE
Debra K. Davenport
Auditor General
Department of
Health Services
Health Start Program
Performance Audit Division
December • 2002
REPORT NO. 02 – 11
Performance Audit
The Auditor General is appointed by the Joint Legislative Audit Committee, a bipartisan committee composed of five
senators and five representatives. Her mission is to provide independent and impartial information and specific
recommendations to improve the operations of state and local government entities. To this end, she provides financial
audits and accounting services to the State and political subdivisions, investigates possible misuse of public monies, and
conducts performance audits of school districts, state agencies, and the programs they administer.
The Joint Legislative Audit Committee
Representative Roberta L. Voss, Chair Senator Ken Bennett, Vice Chair
Representative Robert Blendu Senator Herb Guenther
Representative Gabrielle Giffords Senator Dean Martin
Representative Barbara Leff Senator Peter Rios
Representative James Sedillo Senator Tom Smith
Representative James Weiers (ex-officio) Senator Randall Gnant (ex-officio)
Audit Staff
Dot Reinhard, Manager and Contact Person
Channin DeHaan, Team leader Terri Place
Copies of the Auditor General’s reports are free.
You may request them by contacting us at:
Office of the Auditor General
2910 N. 44th Street, Suite 410 • Phoenix, AZ 85018 • (602) 553-0333
Additionally, many of our reports can be found in electronic format at:
www.auditorgen.state.az.us
2910 NORTH 44 th STREET • SUITE 410 • PHOENIX, ARIZONA 85018 • (602) 553 -0333 • FAX (602) 553 -0051
DEBRA K. DAVENPORT, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL WILLIAM THOMSON
DEPUTY AUDITOR GENERAL
December 23, 2002
Members of the Arizona Legislature
The Honorable Jane Dee Hull, Governor
Ms. Catherine R. Eden, Ph.D., Director
Department of Health Services
Transmitted herewith is a report of the Auditor General, An Evaluation of the Health Start
program. This evaluation was conducted pursuant to A.R.S. §41-1279.08. I am also
transmitting with this report a copy of the Report Highlights for this evaluation to provide a
quick summary for your convenience.
As outlined in its response, the Department of Health Services agrees with all of the findings
and plans to implement all of the recommendations.
My staff and I will be pleased to discuss or clarify items in the report.
This report will be released to the public on December 24, 2002.
Sincerely,
Debbie Davenport
Auditor General
Enclosure
The Office of the Auditor General has completed an evaluation of the Health Start
Program. The evaluation was conducted pursuant to the provisions of A.R.S. §41-
1279.08. This is the Auditor General’s fourth evaluation of the Health Start Program.1
This report includes information about the program and its statutory goals,
recommendations for improving its administration, and demographic information on
program participants.
Health Start is a community-based program that delivers health education and
referral services to pregnant and postpartum women and their families in
communities at risk for poor birth outcomes. Health Start is designed to increase the
number of women who receive timely and adequate prenatal care and to promote
primary healthcare for families. The program is required by statute to reduce the
incidence of babies born with a very low birth weight, improve early childhood health,
and increase awareness of the need for good nutrition, child developmental
assessments, and preventive healthcare.
The program is administered by the Arizona Department of Health Services, Office of
Women’s and Children’s Health, and is offered at 24 sites around the State through
15 contracted service providers. The Health Start program uses lay health workers to
provide services. Health Start providers recruit lay health workers from within the
community and trains them to provide education, support, and referrals to pregnant
and postpartum women and their families. The lay health worker visits participants in
their homes, and participants have the opportunity to attend prescheduled group
classes.
Legislation outlines several areas the evaluation is required to assess, including the
program’s effectiveness in meeting its goals, the level and scope of services, and
various characteristics of program participants. However, evaluators were unable to
assess the program’s effectiveness and can provide only limited information on
some program participants because of inaccurate and incomplete program data.
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1 Three previous evaluations were conducted on the Health Start pilot program in 1996 (Report No. 96-2), 1997 (Report
No. 97-1), and 1998 (Report No. 98-3), and Laws 2002, Chapter 245 eliminated the evaluation requirement for the Health
Start Program after December 31, 2002.
Office of the Auditor General
SUMMARY
Information on program goals (see pages 9 through 13)
Health Start has five statutory goals related to healthcare for women and children.
Although evaluators could not draw conclusions about the program’s progress in
achieving its goals because of incomplete data, where possible, evaluators used
program data and supplemented it with vital statistics records to develop information
on the program.
The program’s first statutory goal is to reduce the incidence of infants who are born
with a very low birth weight (less than 3 lbs., 5 oz.) and who require more than 72
hours in a neonatal intensive care unit (NICU). Using vital statistics records for
program participants for whom data was available, evaluators found that in 2000 and
2001, the very low birth weight rate was about 1 percent. Specifically, 2 of 327
participants in 2000 and 8 of 680 participants in 2001 delivered babies who weighed
less than 3 lbs., 5 oz. The state-wide rate for babies born at a very low weight was
1.2 percent in 2000 and 1.1 percent in 2001. However, because the program is
focused on serving women at risk of poor birth outcomes, program participants may
have different characteristics than the general population. Therefore, the program’s
progress toward reducing very low birth weight or other goals cannot be directly
measured against the general population. Instead, measuring the program’s impact
would require a comparison group of individuals with characteristics similar to the
program participants, and program data was not reliable enough to allow the
formation of a comparison group. Evaluators also used vital statistics reports to
establish that, for program participants for whom data was available, infant
admission rates to the NICU were 6 percent in 2000 and 4 percent in 2001. State-wide,
5.8 percent of babies born in 2000 and 5.7 percent of babies born in 2001 were
admitted to the NICU. However, because the vital statistics records do not include
information about the length of stay in the NICU, evaluators could not provide
information on this part of the goal. The Department did not develop a process for
collecting NICU information until July 2002.
Some information is also available about the program’s other statutory goals. Other
goal areas include increasing the number of women receiving prenatal care, and the
number of children appropriately immunized, as well as educating families on good
healthcare and nutrition. For program participants for whom data was available, over
60 percent entered prenatal care in the first trimester. For the program participants for
whom data was available, 74 percent reported that their children were appropriately
immunized. In 2001, Arizona’s state-wide immunization rate was 78 percent.
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State of Arizona
Program administration needs improvement (see pages
15 through 18)
The Department needs to make several improvements to help ensure the program
is effectively administered. First, the Department needs to ensure that the program’s
limited resources are used for those women most in need of services. Evaluators
found that providers are not using the required risk assessment tool to determine
each registered client’s risk level. However, providers need more guidance on how to
do this, such as how to weigh the risk factors in terms of importance or their impact
on eligibility. Second, the Department should more effectively monitor sites. The
Department did not conduct 4 of the 15 required annual site visits in 2002. Further,
the Department needs to develop a process for reviewing the quality of providers’
program data during its site visits. Finally, the Department needs to strengthen
current policies and procedures, or develop additional ones, to ensure contracted
service providers understand how to correctly implement the program. Areas that
need improved policies and procedures include postpartum enrollment, data quality
and entry, and in-kind contribution reporting.
Information on program participants and services (see
pages 19 through 23)
By statute, this evaluation must report information on program enrollment and
disenrollment, demographic information on program participants, and information on
the level and scope of program services. Because evaluators were unable to obtain
reliable data for all program sites, the numbers presented in this chapter are based
on those participants for whom data was available.
Data was available for over 3,300 women who registered for possible inclusion in
Health Start in 2000 and 2001. Over 2,100 of these women eventually enrolled in the
program. Most of the women who registered but did not enroll were not pregnant and
thus not eligible to participate in the program. Of those women who enrolled, the
overwhelming majority did so before they gave birth. In addition, most were relatively
young, Hispanic, unmarried, and enrolled in or applying for AHCCCS.
Health Start policies require that participants receive an average of five prenatal and
seven family follow-up home visits from lay health workers. Data on the number of
visits was not reliable and therefore it was not possible to determine how well the
program was doing in meeting the required number of visits. However, during home
visits, lay health workers discuss educational topics with participants. Some of the
most common topics discussed include immunizations, emotions and feelings, and
prenatal care. Lay health workers are also required to assess each participant’s
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Office of the Auditor General
home for safety hazards and evaluate each child enrolled in the program for
developmental delays. The program uses the Arizona Safe Home/Safe Child
Assessment checklist and the Ages and Stages Questionnaire to conduct these
assessments. When participants have needs outside the scope of Health Start, lay
health workers refer them to other pertinent programs, such as AHCCCS.
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State of Arizona
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Office of the Auditor General
TABLE OF CONTENTS
continued
1
9
9
10
11
13
15
15
16
17
18
19
19
21
23
Introduction & Background
Finding 1: Information on program goals
Program has five statutory goals
Incidence of very low birth weight and stays in intensive care
Vital statistics and program data provide some information about
other goals
Recommendation
Finding 2: Program administration needs improvement
Providers need guidance on use of risk assessment tool
Monitoring efforts are insufficient
Additional program policies needed
Recommendations
Finding 3: Information on program participants and services
Enrollment and participant characteristics
Program services
Recommendation
Agency Response
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State of Arizona
TABLE OF CONTENTS
concluded
Tables:
1 Schedule of Providers, Service Areas, and Amounts Distributed
Years Ended June 30, 2000, 2001, and 2002 (Unaudited)
2 Providers’ Progress Toward Immunization Goal
January 1, 2000 through December 31, 2001
3 Enrollment Results for Registered Women
Years Ended December 31, 2000, and 2001
4 Characteristics of Health Start Participants
Years Ended December 31, 2000, and 2001
5 Percentage of Women in Program by Race and Ethnicity
Years Ended December 31, 2000, and 2001
Figures:
1 Trimester Prenatal Care Began
Years Ended December 31, 2000, and 2001
2 Percentage of Participants by Number of Prenatal Visits
Years Ended December 31, 2000, and 2001
3 Reasons and Percentage for Disenrolling
Years Ended December 31, 2000, and 2001
2
12
20
21
21
11
12
20
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Office of the Auditor General
INTRODUCTION
& BACKGROUND
The Office of the Auditor General has completed an evaluation of the Health Start
Program administered by the Arizona Department of Health Services. The evaluation
was conducted pursuant to the provisions of A.R.S. §41-1279.08. This is the fourth
Auditor General evaluation of the Health Start Program.1 This report includes
information about the program and its statutory goals, recommendations for
improving its administration, and demographic information on program participants.
Program description
The Legislature established Health Start as a state pilot program in 1994. Health Start
is a community-based program that serves primarily pregnant women and their
families by providing participants with health educational materials and classes, and
referrals to healthcare providers and other community or governmental services.
Health Start is designed to increase the number of women who receive timely and
adequate prenatal care and to promote primary healthcare for families in order to
reduce the incidence of babies born at a very low birth weight, improve early
childhood health, and increase awareness of the need for good nutrition,
developmental assessments, and preventive healthcare.
The program is administered by the Arizona Department of Health Services, Office of
Women’s and Children’s Health, and is offered at 24 sites around the State through
15 contracted service providers (see Table 1, page 2). The Health Start program uses
lay health workers to provide services to communities considered high risk for poor
birth outcomes, such as those with a high rate of babies born at a very low birth
weight. Health Start providers recruit lay health workers from within the community
and train them to provide education, support, and referrals to pregnant and
postpartum women and their families. The lay health worker visits participants in their
homes, and participants have the opportunity to attend prescheduled group classes.
The lay health worker also works with the contractor’s program coordinator, a nurse,
and a social worker to ensure that participants receive needed care and services.
The program is
designed to increase
the number of women
receiving appropriate
prenatal care.
1 Three previous evaluations were conducted on the Health Start pilot program in 1996 (Report No. 96-2), 1997 (Report
No. 97-1), and 1998 (Report No. 98-3), and Laws 2002, Chapter 245 eliminated the evaluation requirement for the Health
Start Program after December 31, 2002.
The program uses lay
health workers to
provide services.
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State of Arizona
Amounts Distributed
Provider Service Area 2000 2001 2002
County Health Departments
Apache Round Valley, St. Johns,
Springerville, and the
Apache reservation $ 60,000 $ 60,032
Cochise Douglas, Sierra Vista, Bisbee,
and Willcox 70,000 71,997
Coconino Page and surrounding areas,
and the Navajo reservation $ 21,350 51,725 51,875
Gila Globe and surrounding areas 9,270 28,865
Mohave Kingman, Bullhead City, and
Lake Havasu 34,395 55,940
Pima Tucson, Green Valley, and
surrounding rural areas 30,820 100,000 89,438
Pinal Coolidge, Eloy, Stanfield, and
Gila Bend 67,000 66,369
Yavapai Prescott, Chino Valley, Prescott
Valley, and Cottonwood 130,930 170,000 115,720
Yuma Yuma, Sommerton, San Luis, and
Wellton 85,273 110,000 97,729
Community Health Centers/
Behavioral Health Centers
Centro de Amistad, Inc. Guadalupe 69,640 101,925 87,625
Clinica Adelante, Inc. El Mirage and Surprise 25,700 47,325 53,025
Mariposa Community Health
Center Nogales, Elgin, and Patagonia 80,683 115,000 85,000
Mountain Park Community
Health Center
South Phoenix 34,110
Native American Community
Health Center Phoenix-area Native Americans 44,286 53,175
North Country Community
Health Center
Flagstaff, Leupp, and the Navajo
reservation 79,088 84,455
Tempe Community Action
Agency, Inc. Tempe and South Scottsdale 82,050 80,000
Total $478,506 $1,142,064 $1,081,245
Source: Auditor General staff analysis of information provided by the Arizona Department of Health
Services and Health Start staff.
Schedule of Providers, Service Areas, and Amounts Distributed
Years Ended June 30, 2000, 2001, and 2002
(Unaudited)
Table 1
During the first meeting with a woman, the lay health worker finds out whether the
woman is pregnant. If she is pregnant, the lay health worker screens the woman for
risk factors for poor birth outcomes, such as high blood pressure, smoking,
homelessness, previous low-weight birth, and previous miscarriage. Though the
program primarily targets pregnant women and their families for enrollment, women
are eligible to enroll during the postpartum period as well. Reasons given by the
program manager for postpartum enrollment include poor maternal or infant health.
Participants may continue in the program until their child is 2 years old.
Previous evaluation and program changes
Various aspects of the Health Start program have changed since the previous
evaluation. The most recent evaluation of Health Start (Report No. 98-3) indicated
that the program appeared to be meeting its goals regarding prenatal care and
babies born at a low birth weight, but some birth outcomes showed no improvement.
For example, the rate of babies born at a low birth weight for participants was lower
than for a comparison group of mothers and infants not participating in the program
(4.8 percent compared with 6.3 percent). However, participants’ babies were placed
in the NICU at rates similar to the comparison group. Therefore, the evaluation
recommended that, in addition to low birth weight, the Legislature consider using
other birth outcomes, such as a reduced need for care provided in neonatal intensive
care units, to measure the program’s success. The evaluation also included several
recommendations to improve the program’s cost-effectiveness, including reducing
the family follow-up period to 2 years or less; allowing services to be provided
through group classes, as well as home visits; and requiring all providers to meet
their obligation to provide participants with an average of five prenatal visits or be
eliminated from subsequent contracts.
Following that evaluation in 1999, the Legislature authorized Health Start as a
permanent program and made several changes to the program. Statutory goals now
require the program to reduce the incidence of babies born with a very low birth rate
(under 3 lbs., 5 oz.,) and needing more than 72 hours in a NICU instead of requiring
the program to reduce the incidence of babies born with a low birth weight (under 5
lbs., 8 oz.). Other changes include reducing the length of time a participant may
continue in the program during family followup from 4 years after the child’s birth to
2 years, allowing postpartum enrollment and offering prescheduled group education
classes.
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Office of the Auditor General
In 1999, the Legislature
authorized Health Start
as a permanent
program.
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State of Arizona
Appropriations and contracted service providers
The Health Start Program’s revenue source has shifted from the State’s General
Fund to the Tobacco Litigation Settlement Fund. Specifically, the program received
$700,000 and $1.2 million from the State’s General Fund during fiscal years 2000 and
2001, respectively. However, in fiscal year 2002, the program received $1.2 million
from the Tobacco Litigation Settlement Fund, in accordance with Proposition 204. 1
The Department is allocated three full-time employee positions to administer and
oversee the program and currently has two positions filled. Health Start provides
services through various contracted service providers, which include county health
departments and community health centers (see Table 1, page 2). In fiscal year 2000,
the Department had eight providers located in six counties. For fiscal years 2001 and
2002, the Department expanded to 15 providers operating in 12 counties. Providers
are paid for services such as registering a participant in the program, providing
prenatal home visits, or conducting group educational classes. Providers bill the
Department on a monthly basis for these services based on fees determined at the
time the contract is established. As shown in Table 1 (see page 2), $500,936 was
distributed to Health Start providers in fiscal year 2000; $1,142,558 in fiscal year
2001; and $1,065,779 in fiscal year 2002.
Additionally, the Department currently contracts with Scientific Technologies, Inc. to
provide computer program development and maintenance services for the Health
Start client database. In fiscal year 2000, the Department contracted with Diversified
Consulting Services to provide a database dictionary, reports, and training for the
Health Start database, and in fiscal year 2001, the Department contracted with
Community Resource Associates to plan program-wide trainings and meetings such
as the annual coordinators’ meeting.
Evaluation scope and limitation
Evaluators are unable to report fully on the statutorily required evaluation
components. Problems with the accuracy and completeness of information in the
Health Start database limited evaluators’ ability to assess and provide information on
each of the statutory components.
Evaluation scope is set by statute—A.R.S. §41-1279.08 B and C require the
evaluation to examine and report on several items, including the program’s
effectiveness, the level and scope of services, the criteria used to establish eligibility,
and the number and demographic characteristics of program participants. In
addition, the evaluation must provide information on program costs, including the
Fifteen contracted
service providers,
including county health
departments, provide
services in 12 of
Arizona’s 15 counties.
1 Originally the fiscal year 2002 program revenues included a $1.2 million appropriation from the General Fund and $2.2
million from the Tobacco Litigation Settlement Fund. However, the December 2001 budget reconciliation act eliminated
the General Fund appropriation. In addition, because of budget constraints and no further expected Proposition 204
allocations, the Department chose to restrict the program’s funding level to $1.2 million annually through fiscal year 2004.
average cost per participant and revenues and expenditures. For this report,
evaluators focused on obtaining information primarily for calendar years 2000 and
2001.
Problems with data affected all areas of the assessment—Data quality
problems limited evaluators’ ability to assess and provide information on each
statutorily required area. Evaluators received a download of the Department’s
database and compared the information in this download to information in client files
and vital statistics records. Evaluators found problems with both the accuracy and
completeness of the database information. For example, several of the fields were
determined to be inaccurate because database records and file records did not
match, or unreliable because no file records existed to confirm the accuracy of the
database records. Data completeness problems included information in file records
but not in the database and records in the database that had no identifying client
information, such as a name or date of birth, to allow evaluators to determine whether
the records were valid. Additionally, at Yavapai County Health Department, data
problems were so extensive—including women being matched to babies they did
not give birth to—that the entire data set had to be excluded.
Evaluators were able to assess and report on each of the required statutory areas to
the following degree:
􀁺􇩉 Information on the number and characteristics of program participants—
Information on the characteristics of all program participants cannot be provided
because one site’s data had to be excluded, and the records of approximately
300 other participants had to be eliminated due to missing identifying
information. Therefore, this evaluation provides information for only those
participants for whom complete data exists in calendar years 2000 and 2001
(see Finding 3, pages 19 through 23).
􀁺􇩉 Information on contractors and program service providers and revenues
and expenditures—Information on contractors and revenues and expenditures
can be provided because there are other data sources for this information (see
Introduction and Background, pages 1 through 8).
􀁺􇩉 Information on the number and characteristics of enrollment and
disenrollment and information from participants on the reasons for each—
For the reasons already explained, this evaluation provides information for only
those participants for whom complete data exists in calendar years 2000 and
2001 (see Finding 3, pages 19 through 23).
􀁺􇩉 Information on the average cost for each participant in the program—This
amount cannot be determined because the incompleteness of the database
could potentially inflate the cost per participant.
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Office of the Auditor General
􀁺􇩉 Information concerning the progress of program participants in achieving
goals and objectives—Conclusions cannot be drawn about the program’s
success in achieving its goals because the data is not complete, and some
fields are not accurate enough to use. Problems with completeness prevented
evaluators from developing a similar nonparticipant group with which
participants’ outcomes could be compared. Therefore, the prenatal care and
birth outcomes are reported for only those participants for whom vital statistics
data exists in calendar years 2000 and 2001. Immunizations and awareness of
the need for good nutrition, developmental assessments, and preventive
healthcare are reported using the available program data (see Finding 1, pages
9 through 13).
􀁺􇩉 Information on any long-term savings associated with the program—A
dollar estimate of the program’s long-term savings cannot be provided, but the
Department has made some changes that were intended to increase the
program’s cost-effectiveness. To estimate any savings, as was done in the
Auditor General’s 1998 evaluation, complete information on program
expenditures as well as the participants and services received is needed. While
adequate information on program expenditures exists, information on
participants and the number of prenatal and family followup visits is incomplete
and unreliable.
However, as recommended in the 1998 evaluation, the Department has made
changes that were intended to increase the program’s cost-effectiveness.
Specifically, changes include offering group education classes and reducing the
family follow-up period from 4 to 2 years. In addition, the program has made the
family follow-up period more focused by scheduling visits when immunizations
are due and developmental assessments should be completed.
􀁺􇩒 Recommendations regarding program administration and informational
materials distributed through the program—Evaluators provide program
administration recommendations (see Finding 2, pages 15 through 18) and one
recommendation regarding information materials (see Finding 3, pages 19
through 23).
This report presents findings and recommendations in the following areas:
􀁺􇩔 The Department needs to collect complete and reliable data on and report its
progress in meeting its five statutory goals.
􀁺􇩔 The Department should use its risk assessment tool to determine program
eligibility, improve its monitoring efforts, and enhance its policies and
procedures for such areas as postpartum enrollment.
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State of Arizona
􀁺􇩄 Demographic and enrollment information on program participants for whom
data exists, and the need to require providers to use the Arizona Family
Resource Guide or seek Department approval for substitute guides.
Methods
Evaluators used a variety of methods to conduct this review, including developing
data from other sources that would shed light on the program’s participants and the
degree to which the program’s goals were met. The methods used included the
following:
􀁺􇩔 To obtain general information about the program, evaluators reviewed Arizona
Revised Statutes; literature on research and programs aimed at improving birth
outcomes for at-risk populations, and program materials, such as Health Start
policy and procedure manuals.
􀁺􇩔 To determine the number and demographic characteristics of program
participants and the number and characteristics of participants who enroll and
disenroll from the program and reasons for each, evaluators analyzed Health
Start program data, collected from January 2000 through December 2001, for
the participants for whom reliable data was available.
􀁺􇩔 To determine birth outcomes of women enrolled in the Health Start program for
whom data was available, evaluators analyzed Arizona vital statistics data
collected from January 1, 2000, through December 31, 2001. In addition, this
information was used to validate the completeness and accuracy of the Health
Start database (see Scope Limitation, pages 4 through 7).
􀁺􇩔 To determine the unique aspects of each site’s provision of Health Start services,
such as the characteristics of the families served, the types of services provided,
and special needs of families not served but targeted in outreach services, and
to determine whether Health Start administrative procedures were carried out as
contracted, evaluators reviewed contract documents, conducted site visits, and
interviewed program coordinators and lay health care workers. Evaluators
conducted site visits and interviews with contractor staff at 14 of the 15 sites. The
Mohave County Health Department was not visited because the program
coordinator’s position was vacant during the period when site visits were
conducted.
􀁺􇩔 To evaluate the effectiveness of program administration and monitoring,
evaluators interviewed Department staff and reviewed key documents.
Documents included contract documents such as the solicitation of proposals
and contract awards; program administration documents such as annual site
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Office of the Auditor General
review evaluations and end-of-year performance summaries; and billing and
service monitoring documents.
Acknowledgements
The Auditor General and staff express appreciation to the director and staff of the
Department of Health Services and the Health Start Program for their cooperation
and assistance during this evaluation.
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State of Arizona
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Office of the Auditor General
FINDING 1
Babies born with very
low birth weight can
experience severe
health problems and
developmental delays.
1 Research on low birth weight and very low birth weight referenced in this chapter includes: Iyasu, S., Tomashek, K., and
Barfield, W. “Infant Mortality and Low Birth Weight Among Black and White Infants—United States, 1980-2000.” Morbidity
and Mortality Weekly 51(27), July 12, 2002: 589-592; Andrulis, D.P., Duchon, L.M., and Reid, H.M., Healthy Cities, Healthy
Suburbs: Progress in Meeting Healthy People Goals for the Nation’s 100 Largest Cities and Their Suburbs. SUNY
Downstate Medical Center, Aug. 2002; and Hack, M., Klein, N.K., and Taylor, H.G. “Long-Term Developmental Outcomes
of Low Birth Weight Infants.” The Future of Children (5)1, Spring 1995.
Information on program goals
Evaluators could not draw conclusions about Health Start’s progress in achieving its
five statutory goals because data on program participants was inaccurate and
incomplete. However, where possible, evaluators used program data and vital
statistics records to develop information about the program.
Program has five statutory goals
Health Start has five statutory goals related to healthcare for women and children.
These goals are in keeping with research that suggests a link between low birth
weight, infant mortality, developmental problems, and other childhood difficulties.1 In
addition, research shows that babies who are born with very low birth weight—less
than 3 lbs., 5 oz.—have more severe health problems and developmental delays.
The program’s statutory goals address these links by focusing on the following
results:
􀁺􇩒 Reducing the incidence of infants who are born with a very low birth weight (less
than 3 lbs., 5 oz.), and who require more than 72 hours in a NICU,
􀁺􇩉 Increasing prenatal care services to women;
􀁺􇩒 Reducing the incidence of children affected by childhood diseases;
􀁺􇩉 Increasing the number of children receiving age-appropriate immunizations by
age 2; and
􀁺􇩉 Increasing awareness by educating families on the importance of good
nutritional habits, developmental assessments, and preventive health care.
Incidence of very low birth weight and stays in intensive
care
The Department needs complete and reliable data to ensure that the program is
meeting the goal of reducing the incidence of very low birth weight and extended
stays in the NICU. Evaluators were able to develop data about very low birth weight for
some of the program participants, but because one site was excluded due to extensive
data problems and information on other sites was incomplete, the information was too
limited to allow determinations of how successful the program has been in meeting this
goal. Further, because the program is focused on serving women at risk of poor birth
outcomes, program participants may have different characteristics than the general
population. Therefore, the program’s progress toward reducing very low birth weight
or other goals cannot be directly measured against the general population. Instead,
measuring the program’s impact would require a comparison group of individuals with
characteristics similar to the program participants, and program data was not reliable
enough to allow the formation of a comparison group. More specifically:
􀁺􇩂 Babies with very low birth weights—Using vital statistics reports, evaluators
identified 327 babies born to participants in 2000 and 680 born to participants
in 2001. In each of these 2 years, the rate of babies born at a very low birth
weight among program participants in the vital statistics reports was about 1
percent (2 of 327 in 2000 and 8 of 680 in 2001). Nine of these 10 babies spent
time in the NICU. The statewide rate in 2000 was 1.2 percent, and in 2001 it was
1.1 percent.
􀁺􇩎 Newborn babies spending time in intensive care—Vital statistics data identifies
whether babies were admitted to the NICU, but not how long they stayed. Among
program participants identified in the vital statistics reports, admission rates to the
NICU were 6 percent for 2000 (19 of 327) and 4 percent for 2001 (26 of 680).
Statewide, 5.8 percent of babies born in 2000 and 5.7 percent of babies born in
2001 were admitted to the NICU. Because vital statistics information does not
include information about the length of stay in the NICU, evaluators could not
provide information about the program on this aspect of its statutory goal.
Without complete and reliable data, program administrators cannot provide
meaningful information about the extent to which the program is meeting its desired
outcome in this area. The Department needs to take steps to collect complete and
reliable data and report data on both parts of this goal. The Department did not
develop a process for collecting this information until July 2002.
page10
State of Arizona
page11
Office of the Auditor General
Vital statistics and program data provide some
information about other goals
Some information is also available about the other four program goals set forth in
statute. Evaluators used vital statistic records to report information on the goal related
to prenatal care and used available program information on immunizations and
education. For the program participants for whom data was available, evaluators
found that over 60 percent of mothers entered prenatal care in the first trimester, and
that participants report that nearly three-quarters of their children had appropriate
immunizations for their ages. In addition, the available data indicates that
immunizations are among the most common educational topics discussed.
Access to prenatal care—Health Start is statutorily required to increase prenatal
care services to women. The Department has set more specific goals that 95 percent
of participants will receive (1) prenatal care in their first trimester and (2) at least five
doctor visits during their pregnancies. Using vital statistics records, evaluators were
able to develop information for some
Health Start participants related to
these goals. Over 60 percent of the
Health Start participants identified in
vital statistics records received
prenatal care during their first trimester
of pregnancy (see Figure 1) in both
2000 and 2001, and nearly 90 percent
received 5 or more doctor visits (see
Figure 2, page 12). Although these
amounts are not at the levels called for
in the Department’s program goals, on
average, participants who entered
prenatal care in the first trimester
received 13 doctor visits, as
recommended by the American
College of Obstetricians and
Gynecologists. In the 1998 evaluation,
62 percent of participants received
prenatal care in their first trimester and
on average received 10.2 doctor visits.
Several barriers, which are difficult for
program participants and lay health
workers to overcome, may influence
the Department’s success in
increasing access to prenatal care.
0%
10%
20%
30%
40%
50%
60%
70%
2000 2001
1st trimester 2nd trimester 3rd trimester
63%
22%
10%
62%
29%
6%
Figure 1 Trimester Prenatal Care Began1
Years Ended December 31, 2000, and 2001
1 In both 2000 and 2001, 2 percent of the cases in vital statistics
indicated that the participant did not receive any prenatal care. In
addition, 2 percent of cases each year could not be located in vital
statistics records.
Source: Auditor General staff analysis of 2000 and 2001 Arizona
Vital Statistics for Health Start participants. Data does not
include all Health Start participants because Health Start
data is incomplete.
page12
State of Arizona
Program coordinators and lay health workers described
barriers such as the following:
􀁺􇩓 Some participants at Centro de Amistad in
Guadalupe do not have phones and cannot call
their doctor’s office to make an appointment.
􀁺􇩐 Participants in Springerville and Eagar in Apache
County must travel 50 miles to get to the nearest
hospital with an obstetrics department and some
must rely on AHCCCS taxis to get them to the
hospital when they go into labor.
􀁺􇩐 Participants in Cochise County face a shortage of
medical care because the hospital in Bisbee
closed, the Dougals hospital’s maternity ward
closed, and there are no
obstetricians/gynecologists in Douglas.
Lay health workers take several steps to help ensure that
participants overcome such barriers and receive the
recommended amount of prenatal care. They
1 Three percent of the participants are missing information ion
prenatal visits invital statistics in both 2000 and 2001
Source: Auditor General staff analysis of 2000 and 2001 Arizona
Vital Statistics for Health Start participants. Data is
incompelete. It does not include all Health Start
participants.
7%
63%
26%
9%
62%
27%
0%
10%
20%
30%
40%
50%
60%
70%
2000 2001
Number of visits
Under 5 5 to 12 13 or more
Percentage of Participants
encourage participants to make and attend their doctor
visits and ask whether participants attended their last
doctor visit. At some sites, they help clients arrange
transportation or provide them access to telephones.
Lay health workers also sometimes attend participants’
doctor visits when requested by the participant to
provide translation.
Immunization rates—The Department uses
childhood immunizations as a way to measure its
progress on both increasing immunization rates and
decreasing childhood disease. The Department has
set a goal of having 90 percent of participating children
properly immunized. According to available program
data, nearly three-fourths of Health Start participants
reported to their lay health worker that their child was
properly immunized. The percentage of children
immunized varied somewhat by provider (see Table 2).
In 2001, Arizona’s state-wide immunization rate was 78
percent.
Figure 2 Percentage of Participants 1
by Number of Prenatal Visits
Years Ended December 31, 2000, and 2001
1 In both 2000 and 2001, 3 percent of the participants are missing
information on prenatal visits in vital statistics.
Source: Auditor General staff analysis of 2000 and 2001 Arizona
Vital Statistics for Health Start participants. Data does not
include all Health Start participants because Health Start
data is incomplete.
Number of visits
Percentage of
Children Immunized
Number of
Providers
90 to 100% 1
80-89 4
70-79 3
60-69 3
50-59 4
Total 15
1 The program-wide goal is to have at least 90 percent of participating children
appropriately immunized for their age.
Source: Auditor General staff analysis of data provided by the Department of
Health Services, Health Start Program. Data are incomplete and
unreliable. They do not include all Health Start participants.
Table 2 Providers’ Progress Toward
Immunization Goal 1
January 1, 2000 through December 31, 2001
1 The program-wide goal is to have at least 90 percent of
participating children appropriately immunized for their age.
Source: Auditor General staff analysis of data provided by the
Department of Health Services, Health Start Program.
Data is incomplete and unreliable. It does not include
all Health Start participants.
Awareness of the need for good nutrition, developmental
assessments, and preventive healthcare—The Department is statutorily
required to educate families on the importance of good nutritional habits,
developmental assessments, and preventive healthcare. Statute does not set forth a
more specific target in this regard, and unlike the goals described above, this goal
has no Department-assigned target. Using available program information on the
educational topics discussed during home visits, evaluators determined that
immunization was among the most frequently discussed educational topics. In
addition, the Department uses the Ages and Stages Questionnaire in order to help
lay health workers identify developmental delays (see Finding 3, pages 19 through
23 for more information on educational topics and assessment tools).
Recommendation
1. The Department should collect complete and reliable data and report progress
on its five statutory goals.
page13
Office of the Auditor General
page14
State of Arizona
page15
Office of the Auditor General
Program administration needs improvement
The Department needs to make several improvements to help ensure the program
is effectively administered. First, the Department should see that providers
adequately screen program applicants and admit only those women at risk of poor
birth outcomes. Second, the Department should improve its monitoring of providers,
including reviewing the quality of providers’ program data. Finally, the Department
needs to strengthen current policies and procedures, or develop additional ones to
provide guidance on postpartum enrollment, maintaining the quality of data on
program participants, and reporting required in-kind contributions.
Providers need guidance on use of risk assessment tool
To ensure the program’s limited resources are being used for the women most in
need of services, contracted service providers need additional guidance on
assessing each applicant’s degree of risk for having a poor birth outcome. A 1996
statute required the Department to develop a screening method to determine the
women most in need of program services. In response, the Department developed
a risk assessment checklist that included over 30 risk items such as high blood
pressure, smoking, homelessness, and previous poor birth outcomes, such as a
baby born at a low birth weight or a miscarriage. The lay health worker is to gather
information about a woman’s risks during the initial screening visit.
Risk assessment tool not being used as intended—The program still
does not use the risk assessment as originally intended. In 1998, the Auditor
General’s evaluation found that the tool was implemented in a way that resulted in
virtually everyone being screened into the program, including women who did not
appear to be at risk of poor birth outcomes. The 1998 evaluation recommended that
the Department refine the instrument to screen into the program only women with
risks of poor birth outcomes. The Department disagreed with the recommendation
because it believed the communities were selected to provide program services due
FINDING 2
to their high risk, and therefore, most of the women in the community would need
services.
This evaluation was unable to determine whether all women in the program were at
risk of poor birth outcomes because the data on risk assessments was found to be
unreliable. However, interviews with service providers found that the risk assessment
tool is not being used as a screening tool. For example, 10 sites reported that any
pregnant woman is eligible for the program, and two sites reported that AHCCCS
eligibility or financial need were sufficient risks for including a woman in the program.
Additional guidance needed—To ensure the program’s limited resources are
used for those women most in need, the risk assessment tool should be used to help
determine program eligibility. Although the Department disagreed with this
recommendation in the previous evaluation, program resources have not increased,
and most providers have waiting lists of clients they are unable to serve due to limited
funding. Therefore, the Department should require providers to use the risk
assessment tool to help determine program eligibility. However, to ensure the current
risk assessment tool can be used to determine eligibility, providers need additional
guidance on the purpose of the risk assessment tool and how to use it. Currently, the
program’s policies and procedures manual states that only 7 of the more than 30 risk
factors, such as heart problems, diabetes, or sexually transmitted disease,
automatically qualify a woman for enrollment. The manual does not provide
instructions for how to weigh any of the other risks in terms of importance or eligibility.
For example, the manual does not provide guidance on the minimum number of risks
needed for program entry.
Monitoring efforts are insufficient
The Department should improve its monitoring of the program by conducting an
annual site visit with each contracted provider and making the visits more thorough.
According to the program’s policies and procedures, the Department must conduct
an annual visit to each contracted service provider to monitor providers’ program
implementation and compliance. In fiscal year 2001, the Department conducted all
but one site visit. In fiscal year 2002, however, the Department visited only 11 of the
15 providers because of limited staff.
The Department needs to develop a process for reviewing the quality of the
provider’s program data during its site visits. Currently, the Department reports that
files are checked for items such as organization, use of correct forms, educational
topics covered, and the appropriateness of referrals made. However, the Department
does not verify any of the file information against the database to monitor data quality
or identify potential data entry problems. As discussed in the Introduction and
Background section of this report, evaluators identified numerous problems with data
page16
State of Arizona
Risk assessment tool is
not being used to
screen participants.
The Department should
conduct annual site
visits consistently and
thoroughly.
quality, which resulted in the inability to draw conclusions about the program
achieving its goals (see pages 1 through 8).
Additional program policies needed
The Department should also strengthen current policies or add additional policies to
ensure service providers have appropriate guidance on how to implement the
program. Evaluators identified several areas where new policies or stronger policies
are needed:
􀁺􇩐 Postpartum enrollment—The Department needs to strengthen its policies and
procedures guiding postpartum enrollment. In 1999, program legislation
changed to allow providers to enroll a woman and her child postpartum. The
Health Start policies and procedures manual states that “women who
experience difficulty after delivery” are eligible to enroll. However, the manual
does not define postpartum eligibility, or provide criteria to judge “difficulty after
delivery.” Currently, lay health workers use the same registration and risk
assessment form used for prenatal clients, yet the tool is not designed to assess
postpartum complications in women or infants. In addition, evaluators
determined that not all providers understand that women can be enrolled in the
program postpartum. For example, two providers do not enroll postpartum
women because it is “not a goal” of the program. Another provider told
evaluators that they were not aware that postpartum enrollment was allowed.
􀁺􇩄 Data quality and data entry—The Department needs to develop several policies
and procedures to guide data quality and entry. First, although the Department
requires providers to enter all their program data and ensure its accuracy and
completeness, most providers do not have formal data quality procedures in
place. Recently, the Department initiated the development of data quality
assurance standards for use by all providers; however, the standards are not yet
complete. Second, the Department needs to develop reliable data entry
procedures for postpartum enrollment clients. Although the Department has
been working to fix problems in this area, service providers indicate that they are
unable to correctly enter data for women who enroll in the program postpartum.
􀁺􇩉 In-kind contributions—The Department needs to develop a policy for what
constitutes reportable in-kind contributions and require providers to submit
updated in-kind projections annually. Each contracted service provider is
required to supplement state monies with in-kind resources. Providers that are
awarded $60,000 or more annually must contribute resources valued between
20 to 26 percent of the state monies received, based on the amount of the
contract award.1 The Department’s contracts provide no guidance on what type
of in-kind contributions are allowable. Evaluators’ review of service providers’
page17
1 Providers that are awarded less than $60,000 annually are required to contribute only computer hardware and software,
and nurse and social worker assistance.
Office of the Auditor General
Data quality assurance
standards are needed.
page18
State of Arizona
estimated in-kind contributions found that providers report a variety of items,
including employee benefits, office furniture, and lice shampoo. Without a
specific policy on what constitutes reportable contributions, it is not clear if all of
these are allowable, and providers may measure program cost differently. In
addition, since the contract period began in 2001, the Department has not
required providers to update their budgets annually or revise in-kind projections
when award amounts are adjusted during the year. Without updated budgets,
the Department cannot ensure that providers’ in-kind contributions are
appropriate and that it has complete information on program costs.
Recommendations
1. To help ensure the program’s limited resources are being used for women most
in need of services, the Department should require providers to use the risk
assessment tool to help determine program eligibility.
2. The Department should provide additional instructions to contracted service
providers on the purpose of the risk assessment tool and how to use it to
measure program eligibility.
3. The Department should ensure that all site visits are conducted annually as
required.
4. The Department should develop a process for reviewing the quality of providers’
program data during its site visits.
5. The Department should:
a) Strengthen policies and procedures guiding postpartum enrollment.
b) Ensure data quality and entry, both by continuing its efforts to develop data
quality assurance standards and by developing additional procedures for
how to enter postpartum clients.
c) Develop a policy for what constitutes appropriate in-kind contributions and
require providers to update their budgets and in-kind contribution estimates
as award amounts change.
page19
Office of the Auditor General
Information on program participants and services
By statute, this evaluation must report information on program enrollment and
disenrollment, demographic information on program participants, and information on
the level and scope of program services. Because evaluators were unable to obtain
reliable data for all program participants (see scope limitation, pages 4 through 7) the
numbers presented in this finding are based on those participants for whom data
was available.
Enrollment and participant characteristics
In 2000 and 2001, Health Start enrolled over 2,100 women for whom data was
available. Nearly one-third of these women left before completing the program. Most
were relatively young, Hispanic, unmarried, and enrolled in AHCCCS.
Enrollment numbers and characteristics—Data was available for over 3,300
women who registered for possible inclusion in Health Start in 2000 and 2001. Over
2,100 of these women eventually enrolled in the program. The registrations were
done by lay health workers attempting to identify women in the community who might
be eligible for the program. These lay health workers canvass the community for
pregnant women or women who recently gave birth. Lay health workers also take
referrals from hospitals and clinics. Table 3 (see page 20) shows the number of
registered women who enrolled and who did not enroll in Health Start for both 2000
and 2001. Using program data, evaulators were able to determine that the majority
of women enrolled in the program before they gave birth. However, because the
Department does not collect specific data on whether a woman enrolls as a prenatal
or postpartum participant, evaluators could not determine an exact number for either
of these types of enrollment. Most of the women who registered but did not enroll
were not pregnant and thus not eligible to participate in the program.
Reasons for disenrollment—For those women for whom data was available,
about one-third of those who enrolled in Health Start in 2000 and 2001 left before
completing the program. As illustrated in Figure 3 (see page 20), most women who
FINDING 3
page20
State of Arizona
2000 2001
Enrolled 855 1,328
Not enrolled
Not pregnant 168 239
Declined enrollment 64 207
Other 5 10
Total 237 456
Moved
58%
Lost Pregnancy
14%
Dropped
13%
Self-withdrawn
10%
2000 2001
Moved
57%
Lost Pregnancy
7%
Dropped
17%
Self-withdrawn
15%
Other
4%
Other
5%
Table 3 Enrollment Results for Registered Women1
Years Ended December 31, 2000, and 2001
Figure 3 Reasons and Percentage for Disenrolling
Years Ended December 31, 2000, and 2001
1 Enrollment data is missing for 24 women in 2000 and 405 women in 2001.
Source: Auditor General staff analysis of data provided by the Department of Health
Services, Health Start Program. Data is incomplete and unreliable. It does not
include all Health Start participants.
Source: Auditor General staff analysis of data provided by the Department of Health Services,
Health Start Program. Data is incomplete and unreliable. It does not include all
Health Start participants.
left the program did so because they moved out of the site’s program area. Besides
moving, other reasons for disenrollments include pregnancy loss or being dropped
from the program by the lay health worker. Health Start policies state that a woman
should be dropped from the program if the lay health worker fails to make contact
after four attempts. In 2000 and 2001, 17 percent and 13 percent of women,
respectively, were dropped for this reason.
Characteristics of program partici-pants—
For those women for whom data was
available, most of those enrolled in Health Start
were relatively young and unmarried. While
education and income information on program
participants was determined to be unreliable,
the majority of participants were enrolled in or
applying for AHCCCS at the time they enrolled
(see Table 4).
Of the women for whom information about race
and ethnicity was available, most were
white/Hispanic (see Table 5). The next largest
categories were white/non-Hispanic, and Native
American. African-Americans have a high rate of
low-weight births and infant mortality, and they
represented 3 percent of the women for whom
data was available in 2000, and 2 percent in
2001.
Program services
Lay health workers provide services to
participants during prenatal home visits and
family follow-up visits, and Health Start policies
require that participants receive an average of
five prenatal and seven family follow-up home
visits from lay health workers. During these visits,
they provide education and information,
administer assessments, and provide referrals to
other pertinent programs, such as AHCCCS,
when participants have needs outside the scope
of Health Start.
Providing education and information—The Department gives the providers a
broad list of educational topics, and recommends that topics are discussed based
page21
Office of the Auditor General
2000 2001
Average age 23.9 years 23.9 years
Married 35% 33%
First child 42% 42%
Enrolled in AHCCCS 42% 45%
Applying for AHCCCS 19% 17%
Table 4 Characteristics of Health Start Participants
Years Ended December 31, 2000, and 2001
Source: Auditor General staff analysis of data provided by the
Department of Health Services, Health Start Program.
Data is incomplete and unreliable. It does not include all
Health Start participants.
2000 2001
White/Non-Hispanic 14% 17%
White/Hispanic 66 65
Native American 12 10
African-American 3 2
Asian <1 1
Other/unknown 5 5
Percentage of Women in Program1
by Race and Ethnicity
Years Ended December 31, 2000, and 2001
1 Numbers do not total 100 percent due to rounding.
Source: Auditor General staff analysis of data provided by the
Department of Health Services, Health Start program.
Data is incomplete and unreliable. It does not include all
Health Start participants.
Table 5
on client need. The providers gather materials and information that address the
needs and concerns of the women in their area, and the Department approves these
materials for use in the program. Because data on the number of visits was not
reliable, it is not possible to determine whether participants received the required
number of visits. However, of the visits for which data was available, some of the most
common educational topics discussed include immunizations, emotions and
feelings, and prenatal care.
In addition, statute requires the Department to distribute the Arizona Family Resource
Guide to hospitals state-wide for parents of newly born children, and the Department
requires lay health workers to give one to each of their clients. The guide, which is
available in both English and Spanish, contains toll-free phone numbers for public
and private health, education, and family services organizations in all 15 Arizona
counties. However, 6 of the 14 providers told evaluators that they do not find the
guide helpful because it is not community-based. In addition, two providers were not
even aware of the guide. While most providers continue to use the guide and some
supplement it with a local resource guide, four providers are not using the guide at
all. The Department should ensure that providers distribute the guide to all program
participants or require service providers to develop and seek departmental approval
for substitute guides.
Administering assessments—In addition to providing education and
information, the Department requires lay health workers to assess the safety of the
participants’ homes and the development of the participants’ children. To do this, the
Department requires lay health workers to use the following assessment tools:
􀁺􇩔 The Arizona Safe Home/Safe Child Assessment—The checklist is designed to
prevent in-home, unintentional injury to children under age 5, and the lay health
worker administers it once during the prenatal period and again after the baby’s
birth, preferably within 2 months. If lay health workers detect a hazard, they must
reassess the client’s home within 30 days to ensure that the hazard was
eliminated.
􀁺􇩁 Ages and Stages Questionnaire—The Department implemented the Ages and
Stages Questionnaire in response to the Auditor General’s 1998
recommendation that the program should devote more time to educating
parents on child development. The questionnaire assesses a child’s
developmental milestones, and lay health workers administer it three times
during the family follow-up period. If any developmental delays are suspected,
the lay health worker refers the family to the Arizona Early Intervention Program
(AZEIP) or another appropriate agency for further evaluation.
Providing referrals to other programs and services—Lay health workers
provide referrals for clients to other services and programs from which they may
benefit. Lay health workers can provide referrals to shelters for women who are
page22
State of Arizona
Six providers do not
find the Arizona
Family Resource
Guide useful because
it does not contain
local phone numbers.
Common topics
discussed include
immunizations,
emotions/feelings, and
prenatal care.
subject to domestic abuse, refer teenage participants to the Teenage Pregnancy
Program, or refer new mothers to immunization clinics if a child needs
immunizations. Additionally, providers that serve Native American populations might
provide referrals to tribal chapters. Lay health workers can also help women apply to
AHCCCS if they are not already enrolled. However, because the data on the number
of referrals women received is unreliable, this information cannot be reported.
Recommendation
1. The Department should either require providers to use the Arizona Family
Resource Guide or to develop a Department-approved substitute.
page23
Office of the Auditor General
page24
State of Arizona
Office of the Auditor General
AGENCY RESPONSE
Office of the Director
JANE DEE HULL, GOVERNOR
CATHERINE R. EDEN, DIECTOR
1740 West Adams Street
Phoenix, AZ 85007-2670
Phone: (602) 542-1025
Fax: (602) 542-1062
Ms. Debra K. Davenport
Auditor General
Office of the Auditor General
2910 North 44th Street, Suite 410
Phoenix, Arizona 85004
Dear Ms. Davenport:
Thank you for giving us an opportunity to respond to your office’s evaluation of the
Health Start Program. We agree with the report and all of its findings. In addition, we
plan to implement all of the report’s recommendations.
We regret that data limitations hindered the audit team’s ability to definitively determine
program outcomes, and we are already working to improve our data collection efforts.
While we concur with the Auditor General that Health Start participant screening could
be further improved, it is important to note that the Health Start program operates in high-risk,
vulnerable communities. Site selection is based on a variety of indicators, such as:
low birth weights; percent of the population living below the federal poverty level; the
teen birth rate; the rate of uninsured births; the ratio of the population to available
community health providers; the infant mortality rate; and the rate of pregnant women
receiving less than five prenatal visits in each geographic area.
As a result of this site selection process, Health Start serves over sixty of the most
underserved and vulnerable communities in our state. Examples of communities served
by Health Start include:
· Guadalupe, where the federal poverty rate is 25.6 percent (compared to 14.2
percent statewide), and the percent of residents with less than a 9th grade
education is 38.8 percent;
· St. Johns, where the ratio of the population to health care providers is 8,091:1,
compared to 770:1 statewide;
· Kaibeto, where the percent of women receiving no prenatal care is nearly three
times the state average;
· Dateland, a rural Arizona community where no health care providers exist;
Debra K. Davenport
Page 2
· Communities lacking local hospitals, such as Hayden, Wickleman, Arivaca, Ash
Fork, and Bagdad.
In these high-risk communities, lay health care workers perform a variety of vital
services, such as:
· Conducting risk assessments, and tailoring services based on individual client
needs;
· Educating clients on prenatal care, breastfeeding, and nutrition;
· Monitoring clients for pregnancy danger signs and referring clients to medical
providers when necessary;
· Educating women about child safety issues, such as proper use of car seats;
· Coordinating client transportation to health care providers;
· Delivering food baskets or taking clients to appointments for other support
services such as WIC or employment services;
· Referring pregnant women lacking health insurance to KidsCare or AHCCCS;
· Educating and referring pregnant women or women with newborns to
immunization services.
Enclosed please find letters from community health and service providers and program
participants voicing their support for the Health Start program. Due to space limitations,
all such letters were not included.
Thank you for giving us an opportunity to respond to the report. We appreciate your
staff’s professionalism and responsiveness in conducting this evaluation.
Sincerely,
Catherine R. Eden
Director
CRE:KV:lls
Enclosure
White Mountain Specialty Care
Eagar Plaza
367 N. Main Street
P. O. Box 1076 • Springerville, AZ 85938
Thomas B. Bennett, D.O. Phone: (520) 333-3543
Obstetrics & Gynecology Fax: (520) 333-3545
To: Dr. Catherine R Eden December 4, 2002
Director of Arizona Department of Health Services
Regarding: Health Start necessity in rural Arizona
Our practice fully utilizes the Health Start program. Many of our patients require translation, transportation, and other Health Start
services. Being located in a rural area means that there is limited access for many of our patients to these types of services. Without
the help of Health Start we would be unable to offer adequate OB/Gyn care to most of our Spanish-speaking patients, meaning that
many of these patients would end up going without any OB care, resulting in unnecessary perinatal morbidity and mortality along
with the associated costs. Our patients currently have to travel one hour each way to attend Lamaze classes in another county.
Health Start is now in the process of incorporating Prenatal/Lamaze classes in our area.
We cannot emphasize enough how very important Health Start is to our practice, the taxpayers of Arizona, and especially to our
patients. If you should have any questions or concerns, please feel free to contact us at the number listed below.
Sincerely,
Dr. Thomas B.Bennett OB/GYN
White Mountain Specialty Care
Phone # (928) 333-3543
Fax# (928) 333-3545
YUMA REGIONAL MEDICAL CENTER
December 5, 2002
Catherine R. Eden, Director
AZ Department of Health Services
Ms. Eden,
I am writing this letter to support the Health Start Program. The community of Yuma County needs this wonderful program.
With our diverse population and our towns so far spread apart, we need the promatoras to travel to the clients, because there
is a problem with transportation. The individual attention given to these pregnant women is very important. The caring ways
and role modeling that the ladies provide to the clients is a great way to provide education and information about services in
Yuma County.
I teach several types of childbirth classes and other related subjects here at Yuma Regional Medical Center. However, the
people in the outlying communities live too far to travel (45 minutes) to the center of town for the classes. The Health Start
Program meets the needs of those people. Also, we currently do not offer classes in Spanish. I am very grateful for the
promotoras for their hard work. The Health Start program is a bridge in the gap of services for this and other outlying
communities.
I would love to see this program continue and grow to meet the needs of this growing area. If you have any questions please
feel free to call me at: (928)336-7058.
Thank you very much.
Sincerely,
Donna M. Gradias, CCE
Childbirth Education Coordinator
Yuma Regional Medical Center
Caring for the growing needs of our communities
2400 South Avenue A Yuma, Arizona 85364 (520) 344-2000 fax: (520) 344-0404
Yavapai County Health Department
“Yavapai County Health Department will provide leadership, information, and services that
contribute to Improving the health of Yavapai County residents."
December 11, 2002
Catherine R. Eden
Director, Arizona Department of Health Services
Dear Dr. Eden,
We are very proud of the impact the Health Start Program in Yavapai County is having on our clients and on our conummities. Our
team of Health Start workers are gifted women who are mothers and native Spanish speakers. They are able to promote genuine
communication because they are able to talk with their clients in Spanish and then translate questions and information to and for
medical professionals and other resource people.
Health Start workers provide and explain handouts and information in both English and Spanish. They are able to encourage and
demonstrate skills and techniques one-on-one. They live in the communities they serve, so they have connections and credibility in
their communities. They are good mentors and role models for the pregnant women and new mothers they visit in their homes.
In a very large, rural county like Yavapai, many of the women are isolated and lack transportation. Periodic visits from Health Start
workers give these women an opportunity to ask questions and demonstrate their parenting skills in their own homes and at a time
when they are most receptive to sharing their experiences and learning new skills. Home visits over a period of time (through
pregnancy and until children are two) create connections and closeness between workers and their clients, so clients are able to share
joys and concerns, and workers know clients well enough to see changes that can indicate problems like depression or domestic
abuse.
Health Start workers are able to focus on prevention, encourage healthy nutrition, promote child safety, follow immunizations, and
spot concerns. We have had numerous situations where our presence over time enables moms (and sometimes dads) to follow
through with social and emotional care for themselves and their children, i.e. getting out of a bad living situation, acknowledging
mental health issues and accessing care, helping moms connect with their babies and other children.
This program is of high value to the families in our community. When individuals and families succeed, the community is successful
too!
Sincerely,
Elly Yost
Eileen Ruddell
Veronica Rollins
Genny Barker
Julia Naig
Robin Olson
Alice Vera
Jonnie Nava
Yavapai County Health Start Staff
PRESCOTT PRESCOTT VALLEY COTTONWOOD
930 Division Street 7501 E. Civic Circ le 10 South 6th St., Bldg. C
Prescott, AZ 86301-3868 Prescott Valley, AZ 86314 Cottonwood, AZ 96326
(928) 771-3515 Appointments (928) 771-3377 (928) 639-8138 Environmental Health
(928) 771-3122 Administration (928) 771-3379 FAX (928) 639-8130 Nursing
(928) 771-3369 FAX (928) 639-8179 FAX
Marcia Moran Jacobson, Director
Sandra G. Halldorson, Director of Nursing
Chris Sexton, E. H. Administrator
12/11/2002 10:52 520-432-9480 HEALTH DEPTMENT PAGE 02
COCHISE COUNTY HEALTH DEPARTMENT
December 4, 2002
Dr. Catherine R. Eden, Director
Arizona Department of Health Services
Dear Dr. Eden,
I am writing in support of the Health Start Program here in Cochise County. Because we are
geographically isolated, the Health Start Program bridges the gaps in our communities that have only
one birthing center. At the beginning of this year, 2002, the birthing centers in Bisbee and Douglas
closed their services due to high insurance rates. The community of Willcox has not had a birthing
center for quite some time and must travel to Tucson for services. The communities of Bisbee and
Douglas must travel to Sierra Vista. Thus the Health Start Program serves the communities of
Douglas, Sierra Vista and Willcox with five "Promotoras" (lay health workers) who help pregnant
women and teens get into early prenatal care to insure a healthy pregnancy outcome.
These Promotoras are all trained as lactation consultants and are able to present classes on prenatal
care and childbirth. Two are also Car Safety technicians. The aspect of being a home visitor program
gives the lay health workers a unique forum for education, referrals and personal insight to their clients
needs.
This program also serves as a vehicle to promote the Folic Acid Program, ADHS Child Health Block
Grant and Adolescent Maternal and Child Health Program.
I can further attest that because of Health Start other agencies welcome the collaboration to provide a
smooth continuum of support services for pregnant and post-partum families.
Sincerely,
Maureen Kappler RNC
Program Manager
Health Start
DIANE C. CARPER, DBA, CHE MAIN OFFICE
Director 1415 W. Melody Lane, Bldg A 500 S Hwy. 80 515 7th Street 4115 E. Foothills Dr. 450 S. Haskell
BISBEE, AZ 85803 BENSON, AZ 85602 DOUGLAS, AZ 85807 SIERRA VISTA, AZ 85635 WILLCOX, AZ 85¢43
(520) 432-9472 (520) 586-3696 (520) 384-7575 (520) 803-3900 (520) 384- 4662
FAX (520) 432- 9480 (520) 588-2051 (520) 384•5453 (520) 459-8195 (520) 384- 0309
TDD (520) 432- 9297
Apache County Health Department
Health Start Program
Don Foster, Director Lisa McCall, Program Coordinator
Box 697 219 S. Mtn. Avenue
St. Johns, AZ 85936 Springervllle, AZ 85938
(928) 337-7532 (928)333-0203
December 4, 2002
Arizona Department of Health Services
Catherine R. Eden, Director
2927 North 35th Avenue
Phoenix, Arizona 85017
Re: Importance of the Health Start Program in southern Apache County.
Dear Catherine R. Eden:
I would like to inform you of the vital role the Health Start program plays in southern Apache County.
The program does a tremendous job of linking pregnant women and mothers of infants to the care they
need through the use of lay health workers. These workers provide prenatal outreach and education,
translation services for Spanish-speaking women, limited transportation, and advocacy to interface
with public assistance programs for pregnant women. The lay health workers also provide
developmental screening, immunization education, ear safety seats and education for families with
infants up to two years old. No other agency in southern Apache County offers these services.
Southern Apache County, including Springerville, Eagar, St. Johns, Concho, Vernon, Alpine and
Sanders, has been identified as a HPSA and a MUA. The local hospital does not offer OB services.
With only one OB service provider and no pediatric healthcare provider in the area, the risks to
pregnant women and young infants are great. Health Start's lay health workers fill a void created by the
lack of providers by offering the services mentioned earlier.
If Health Start did not exist, the impact on our communities would be incredible. This year, the lay
health workers have provided an average of 103 client visits per month. These include registration
and risk assessment, prenatal, birth outcome and family follow up visits.
Sincerely,
Don Foster, RS, MPH
M A I N O F F I C E :
621 S. 5TH STREET
GLOBE, ARIZONA 85501
TELEPHONE: (520) 425-3189
FAX: (520) 425-0794
TDD: (520) 425-0839 (FOR THE HEARING IMPAIRED)
N O R T H E R N C O M P L E X :
107 W. FRONTIER SUITE A
PAYSON, ARIZONA 85541
TELEPHONE: (520) 4741210
FAX: (520) 4747069
GILA COUNTY HEALTH DEPARTMENT
1400 ASH STREET, GLOBE, ARIZONA 85501
December 4, 2002
Dr. Catherine R. Eden
Director, Arizona Department of Health Services
Phoenix, Arizona
Dear Dr. Eden:
The Health Start Program in Gila County is unique. There are no other programs available in
the community that is comparable in nature. This program has become an important source of
support and education for our clients and the community at large. Maternal and Child Health
needs assessment indicated that there was no method of follow up for women post partum.
There were no resources available for them after their six week post partum visit. This was a
serious gap in service that the Health Start Program has been able to fill.
Since its inception, this program has been a support system for pregnant women who have
had some unusual circumstances. We have had clients who were experiencing domestic
violence, clients who have had drug abuse issues, clients whose infants have had serious
diagnoses in utero, and a client who died from an overdose. We have received referrals from
Child Protective Services and from Probation as conditions of their involvement. (Gila County
does not have a Healthy Families Program, or any similar program. Health Start is their only
resource.) By using the Ages and Stages Questionnaire, we have been able to identify
children that needed to be referred to AZEIP at a very early age. Clients have verbally
reported that the SafeHome Check has made them realize what needs to be in place for
optimal safety for their infant/toddler. The local hospital sporadically provides prenatal classes.
Our program has been able to provide education for those families, who solely speak Spanish,
do not have availability to attend a class, or who require additional support.
The Health Start Program has provided much needed resource and support to our community
members. We hope to expand our program to include additional locations. The transition to
parenting one or more children can sometimes be difficult. This program enables our
community members to have an objective knowledgeable person to turn to during this time. If
you would like additional information regarding our program, please feel free to contact us.
Sincerely,
Carolyn M. Haro, BSW Jendean G. Sartain, RNC
MCH Program Director Director of Nursing
Gila County Health Department Gila County Health Department
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Criminal Investigations Division
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and Fingerprint Identification
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Sunset Factors
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Pilot Program
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Services Reporting
Requirements
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Commission
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and Kinship Care Pilot
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Performance Audit Division reports issued within the last 12 months
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HB2003 Children’s Behavioral Health Services Monies
Department of Health Services—Office of Long Term Care