A well-woman visit provides a critical opportunity to receive recommended clinical preventive services, including age-appropriate screenings, counseling, and immunizations, to support women's health across the life span. The annual well-woman visit is endorsed by the American College of Obstetrics and Gynecologists (ACOG), and is one of the preventive services required by the Affordable Care Act (ACA) to be covered by private insurance plans without cost sharing. NYS survey data show that women without health insurance are significantly less likely to report having a preventive visit in the past year, highlighting the importance of continuing to promote enrollment in affordable health insurance for all women.

For women of reproductive age (defined as ages 15-44 or 18-44 years, depending on the data source), well-women visits provide a key opportunity for provision of reproductive health care (see Intervention 1.1.2 below). New York State survey data demonstrate that women ages 18-44 years are significantly less likely to receive annual preventive medical visits than older women.

A recent review by the Women's and Children's Health Policy Center at Johns Hopkins University found strong evidence that patient reminders/invitations are effective in increasing use of preventive health care visits by women. Other interventions - including community-based group education, patient navigation supports, provider reminder/recall systems, provider education, designated clinics/extended hours, community-level media, and expansion of insurance coverage - also appear to be effective.

Both the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Family Physicians (AAFP) recommend that every health care visit should include a discussion of women's reproductive life plan and pregnancy intentions. For women who desire pregnancy, discussion should address pregnancy risk factors including chronic disease management, how to prepare for a healthy pregnancy, and optimal birth spacing. For women, who wish to delay or prevent pregnancy, discussion should address contraceptive options, and effective contraception should be provided. Reproductive life planning discussions and care should include adolescents.

Nearly half of all pregnancies in the United States are unplanned (either mistimed or not wanted), which underscores the importance of raising discussions about pregnancy planning and promoting women's health across the lifespan, regardless of pregnancy intentions. While over 70% of women ages 18-44 years report having a preventive medical visit in the past year, only 35% report that a health care provider had ever talked with them about ways to prepare for a healthy pregnancy.

The NYS Partnership for Maternal Health (PMH), established in 2015, brings together key organizational partners committed to decreasing maternal mortality and morbidity (see Goal 1.2). The PMH has focused on preconception health as an initial priority, with several provider education projects, including a 2016 Commissioner's letter, completed to date.

Maternal mortality - the death of a woman while pregnant or within six weeks of a pregnancy from causes related to her pregnancy - is a devastating outcome. While New York's maternal mortality rate has been declining, it remains higher than many other states, with dramatic racial disparities. The most recent complete review of maternal deaths for New York State identified embolism, hemorrhage, infection, cardiomyopathy, and hypertensive disorders as the leading causes of maternal deaths. Severe Maternal Morbidity (SMM), also referred to as "near misses", encompasses life threatening medical complications or the need for life-saving interventions during delivery-related hospitalizations. SMM is 50-100 times more common than maternal mortality, with similar racial and ethnic disparities. A study identifying and analyzing SMM cases in New York State was published in 2017 to expand knowledge of these events.

The New York State Department of Health (NYSDOH) conducts comprehensive maternal mortality surveillance activities. Linked birth and death records, hospital in-patient and emergency department data, and a hospital-based adverse event reporting system are used to identify maternal deaths. All identified deaths are reviewed using a standardized tool. Data are analyzed and aggregated for review, discussion, and action. A multidisciplinary committee reviews the findings and provides recommendations for prevention, improvements in medical care and management, and education. The NYS Partnership for Maternal Health, established in 2015, brings together key organizational partners committed to decreasing maternal mortality and morbidity through collaboration.

In 2018, as part of the state's comprehensive maternal mortality initiative (see Intervention 1.2.2), NYSDOH is implementing an enhanced process for maternal death reviews, developed in collaboration with the state's chapter of the American College of Obstetricians and Gynecologists (ACOG). A formal multidisciplinary Maternal Mortality Review Board will have an active role in reviewing maternal death cases to assess causes of death, factors leading to death, preventability, and opportunities for intervention. Findings will be translated into issue briefs, Grand Rounds, quality improvement projects, and reports.

In April 2018, New York State launched a comprehensive initiative to target maternal mortality and reduce racial disparities in maternal health outcomes. Building on the state's established maternal mortality review process, this initiative encompasses a range of approaches to reducing maternal deaths and racial disparities, including:

• Creating a state Task Force on Maternal Mortality and Disparate Racial Outcomes

• Establishing a Maternal Mortality Review Board, building on the Department of Health's current maternal mortality review committee;

• Launching a Best Practice Summit with hospitals and obstetric providers;

• Piloting expansion of Medicaid coverage for doulas;

• Supporting Centering Pregnancy demonstration projects;

• Requiring Continuing Medical Education (CME) and curriculum development for health care practitioners and trainees;

• Expanding the New York State Perinatal Quality Collaborative (NYSPQC) clinical quality improvement activities; and,

• Convening a series of Commissioner listening sessions with women across the state.

These strategic activities should build on the rich array of existing clinical, community, and policy initiatives in the state. It is essential that a wide range of partners - including clinical providers and institutions, community-based organizations and leaders, and community members - be engaged in these efforts.

Approximately 55% of pregnancies in New York State are unintended (not wanted or mistimed). Reducing unintended pregnancies is a fundamental public health approach to reducing maternal mortality and morbidity. Use of effective contraceptives is key to reducing unintended pregnancy. Long acting reversible contraceptives (LARC), which include Intrauterine Devices (IUDs) and subdermal hormonal implants, are the most effective reversible methods available. Patient and provider knowledge, contraceptive coverage, and acquisition costs and logistics are all important factors to address use of effective contraception.

Over the past several years, several national and New York State initiatives have focused on: provider reimbursement for postpartum LARC insertion and LARC acquisition costs; provider education and training; integration of reproductive life planning in well-woman care; and, enhanced consumer outreach and pregnancy prevention education by Community Health Workers through the state's Maternal Infant Community Health Collaboratives (MICHC) program.

Depression is the most common morbidity among postpartum women, affecting 10-20% of women during or within 12 months of pregnancy. Depression has implications for the well-being of the entire family and the development of infants and children. Legislation enacted for NYS in 2014 requires hospitals to educate patients about maternal depression and requires insurers to cover postpartum depression screening regardless of which health care provider performs the screening, when depression screening is a covered benefit.

The United States Preventive Services Task Force recommends screening for depression in pregnant and postpartum women. For screening to be effective, systems must be in place to ensure accurate diagnosis and effective treatment and follow-up for women with positive screening results. The USPSTF review identified a range of systems to support screening follow-up, from having designated nurses to implement protocols for facilitated referrals to more intensive systems that include: staff and clinician training (1- or 2-day workshops); clinician manuals; monthly training lectures; academic detailing; materials for clinicians, staff, and patients; an initial visit with a nurse specialist for assessment, education, and discussion of patient preferences and goals; a visit with a trained nurse specialist for follow-up assessment and ongoing support for medication adherence; a visit with a trained therapist for cognitive behavioral therapy (CBT); and a reduced copayment for patients referred for psychotherapy. Multidisciplinary team-based primary care that includes self management support and care coordination has been shown to be effective in management of depression, as detailed in recommendations from the Community Preventive Services Task Force (CPSTF).

In a multi-year prenatal care quality improvement project conducted by the NYSDOH with Medicaid prenatal care providers, documentation of depression screening increased from 63% to 85% at initial prenatal visit and from 51% to 84% at postpartum visits (2009 to 2014 data) - although use of standardized screening tools was much lower. PRAMS data, which are based on an annual survey of a representative sample of women giving birth in New York State, show that approximately 76% of women report being asked about depression symptoms at their postpartum visit (2016 survey). While these data are encouraging, more efforts are needed to increase screening and strengthen supports and services for women with postpartum depression. A variety of collaborative initiatives have been implemented and are in progress to address this key issue, including updates to Medicaid coverage and reimbursement, the First 1000 Days on Medicaid initiative, the Healthy Steps program led by NYS Office of Mental Health, and the Early Childhood Comprehensive Systems (ECCS) Impact initiative led by NYS Council on Children and Families.

There is strong evidence that very high risk infants - such as those with very low birth weight (VLBW) or extreme prematurity - are significantly more likely to survive and thrive when born in facilities with Level III Neonatal Intensive Care Units equipped to handle high-risk newborns. For decades the American Academy of Pediatrics and others have recommended that VLBW and very preterm infants be delivered at hospitals with Level III/IV NICU facilities, designated based on uniform standards and organized within a statewide regionalized system of perinatal care. More recently, there has been renewed attention on the importance of standards and systems for regionalized maternal care to ensure that high risk women receive care in facilities prepared to provide the required level of care to reduce maternal morbidity and mortality.

The New York State Department of Health oversees a regionalized perinatal system in which every birthing hospital and birthing center in the state is designated at one of four levels based on the level of perinatal care it provides to women and newborns. Regional systems of Level I-III hospitals are led by Regional Perinatal Centers that provide or coordinate maternal-fetal and newborn transfers of high risk patients from affiliate hospitals and birthing centers, and are responsible for support, education, consultation, and improvement in quality of care in their regional affiliates. A comprehensive process to update standards of care and designations, including incorporating midwife-led birthing centers in the system, is in progress. The New York State Perinatal Quality Collaborative (NYSPQC) initiative engages birthing hospitals and centers and other partners to translate evidence-based guidelines to clinical practice to improve outcomes for both mothers and infants.

A recent review by the Women's and Children's Health Policy Center at Johns Hopkins University found that population-based systems level approaches - such as statewide policies and guidelines- are an important component of interventions to increase risk-appropriate perinatal care. Adding a hospital component - such as ongoing education of hospital staff and clinical providers - to these systems interventions appears to increase their effectiveness. New York's systems-building and quality improvement approaches are consistent with this evidence base and serve as a strong foundation for continued work in this area.

Home visiting programs are a cornerstone of public health efforts to support pregnant and parenting families. An extensive body of research demonstrates that evidence-based home visiting programs improve numerous short- and long-term outcomes for mothers, infants, and families. As part of the national Maternal and Infant Early Childhood Home Visiting (MIECHV) program, the Home Visiting Evidence of Effectiveness (HomVee) project conducts ongoing in-depth analysis of research findings to identify evidence-based home visiting program models. In New York, MIECHV grant funds have supported the expansion of two specific evidence-based home visiting models: Nurse Family Partnership (NFP) and Healthy Families New York (HFNY). These complement other evidence-based programs operating in New York communities, including Early Head Start, Parents as Teachers, and Home Instruction for Parents of Preschool Youngers (HIPPY), as well as other traditional and emerging service models that include community outreach, home visit, and family support elements such as public health nursing, community health workers, and doulas.

Under New York State's MIECHV initiative, local home visiting programs have been engaged in a variety of efforts to build capacity and improve effectiveness in key areas, including: increasing referrals, client enrollment, and retention; extending the duration of breastfeeding; and increasing home visitors' knowledge and skills related to key topics such as intimate partner violence, substance use, mental health, smoking cessation, self-care, and post-partum/interconception care. Additionally, several local programs are working with the state to pilot the development of local coordinated intake and referral systems in communities with multiple home visiting programs.

Sudden Unexpected Infant Deaths (SUID) - a classification that includes Sudden Infant Death Syndrome (SIDS), accidental suffocation and strangulation in bed, and sleep-related deaths of unknown cause - are the leading cause of infant death after the first month of life and one of the leading causes of infant death overall. Because infants placed to sleep on their sides or stomachs (prone) are at increased risk of SIDS, the American Academy of Pediatrics and other public health organizations have long recommended that infants be placed to sleep on their backs. In 2011, these recommendations were expanded to address other risk factors for sleep-related deaths by promoting safe sleep environments, breastfeeding, and avoiding smoke exposure.

A recent review by the Women's and Children's Health Policy Center at Johns Hopkins University found that national campaigns and interventions targeting caregivers, health care providers, and hospital levels appear to be effective at increasing exclusive back sleeping position in infants. There is less evidence to support interventions targeting only caregivers, health care providers, or child care providers alone. Researchers also noted substantial variation in following safe sleep recommendations by race and ethnicity, highlighting the need for interventions to consider these differences. A variety of efforts to promote safe sleep and reduce sleep-related mortality have been completed or are underway in New York State, including community awareness campaigns and materials and several hospitals- and community-based quality improvement projects.

Use of opioids among reproductive age women, including during pregnancy, has increased dramatically in recent years, paralleling the national and state opioid crisis. The rate of infants born with neonatal abstinence syndrome (withdrawal from opioids) increased by over 100% from 2008 to 2014, to nearly 6 infants per 1,000 delivery hospitalizations. Addressing the opioid epidemic is a public health priority in NYS. In 2014, the state established the Heroin and Opioid Task Force and enacted Combat Heroin legislation, establishing a multi-faceted response with a focus on prevention, harm reduction, treatment, recovery, and law enforcement. A collaborative approach is essential to addressing this complex issue. Several initiatives are in place and in process at the state level, including efforts focused specifically on pregnant women and families.

Local health departments, hospitals, health centers, insurers (including Medicaid Managed Care), businesses, CBOs and other stakeholders should collaboratively work to ensure increase awareness, availability and accessibility of culturally competent lactation consultants, and breastfeeding support prenatally and postpartum. This includes ensuring that culturally competent, professional lactation consultants (e.g., IBCLCs); peer support (e.g., WIC); and formal breastfeeding education is available in the local area, and that information and resources on accessing support and contacts is up-to-date and accessible.

Local health departments, health centers, insurers, businesses, CBOs and other stakeholders should work with hospitals to implement recommended maternity care practices and policies, and support hospitals in becoming certified as Baby Friendly. The goal is to increase the percent of mothers and newborns who are exposed to recommended maternity care practices, and the percent of infants born in Baby Friendly Hospitals.

Local health departments, hospitals, health centers, insurers (including Medicaid Managed Care), businesses, CBOs and other stakeholders should work to promote early skin-to-skin contact by educating women and their families of the benefits of skin-to-skin contact. Hospitals and health centers can ensure that providers and staff are knowledgeable and informed, and their policies, practices, and staff support skin-to-skin contact between mother and newborn immediately following birth (until the first breastfeeding is completed), and the first six hours.

Local health departments, hospitals, health centers, insurers, businesses, CBOs and other stakeholders should work with primary care practices to support staff education and training, provide guidance in developing policies and procedures that are consistent with recommended guidelines, and that practices meet the criteria to become designated as a NYS Breastfeeding Friendly Practice. The goal is to increase the number of designated practices, and the number of patients who are supported and receive primary care in a Breastfeeding Friendly Practice.

Local health departments, hospitals, health centers, insurers (including Medicaid Managed Care), businesses, and other stakeholders should establish partnerships with community-based organizations (i.e., trained community health workers, doulas and other peer support) to provide prenatal breastfeeding education, assistance, support, and facilitate coordination to community resources, and continuity of care post-discharge.

Local health departments, hospitals, health centers, insurers, businesses, CBOs and other stakeholders should ensure their worksite has fully implemented the NY Nursing Mothers in the Workplace Act (NY Labor Law 206-c) and can work to assist other worksites to implement this Labor Law and adopt and implement policies and recommended multi-component worksite breastfeeding support programs. At the county or regional level, several health departments are working together to develop interventions to support local worksites, including educational materials, assessment tools, and guidelines to designate worksites as Breastfeeding Friendly.

Local health departments, hospitals, health centers, insurers, businesses, CBOs and other stakeholders should work to assist child care providers support breastfeeding families. This includes encouraging and supporting child care providers to receive training and education to support breastfeeding families, helping facilities develop breastfeeding friendly policies and working with day care centers and homes to meet the criteria to become designated as breastfeeding friendly.

Local health departments, hospitals, health centers, insurers, businesses, CBOs and other stakeholders should work together to support and establish breastfeeding support groups in faith-based, community-based or health care organizations in communities. Support groups should provide access to lactation consultants (IBCLCs), other lactation professionals and peer support (pregnant and/or breastfeeding), their families, and other support persons).

Supporting the healthy social-emotional development of children has emerged as a public health priority. Social-emotional development is foundational to children's development in other domains, school readiness and success, and lifelong health and well-being. Adverse childhood experiences (ACEs) including abuse and neglect, parental mental illness and addiction, family separation, and other traumatic experiences can have profound impact on children's development. ACEs are associated with significantly increased risk for a wide range of chronic health conditions and risk factors later in life - as well as adverse pregnancy outcomes such as preterm birth.

Strategies to increase individual foundational knowledge and skills for those working with children and families are a key element of building an effective capacity and response. A variety of state projects and national resources are available for individual practitioners and organizations to support this aspect of workforce development. Additional resources will be added as this emerging area of practice continues to grow.

As noted for Intervention 3.1.2, social-emotional development is foundational to children's development in other domains, school readiness and success, and lifelong health and well-being. Adverse childhood experiences (ACEs) including abuse and neglect, parental mental illness and addiction, family separation, and other traumatic experiences can have profound impact on children's development and are associated with significantly increased risk for a wide range of chronic health conditions and risk factors later in life - as well as adverse pregnancy outcomes such as preterm birth.

Collaborative strategies to promote positive development, build resiliency, and support safe, stable, and nurturing relationships and environments throughout childhood and adolescence have the potential to improve health outcomes across the life course. Integrating basic trauma-informed approaches and practices can help recognize and respond to the impact of trauma on individuals and communities. While intensive behavioral health and trauma-informed care interventions are beyond the scope of some service settings and programs, strategies to promote positive social-emotional development and fundamental trauma-informed approaches should be integrated across all programs serving children, youth, and families. (See also Intervention 3.1.1)

Early identification of developmental delays and disabilities is critical to the well-being of children and their families. Routine developmental screening at specified intervals, combined with ongoing developmental surveillance, is an integral component of children's health care. The American Academy of Pediatrics recommends that developmental screening using standardized tools be completed at the 9, 18, and 30 (or 24) month well-child visits, but screening rates have remained low. Based on the 2016 National Survey of Children's Health (NSCH), only 30.4% of children ages 9 to 35 months nationally, and 17.5% in New York State, received a parent-completed standardized developmental screening in the previous year. National data also reveal disparities in screening rates, with lower rates among black and Asian children, children living in poverty, and children whose parents have lower education. A study published in Pediatrics found that disparities in age at diagnosis for autism spectrum disorders (ASD) between white and Latino children may be due in part to lack of language-appropriate screenings, culturally appropriate materials for families, and access to developmental specialists.

A recent review by the Women's and Children's Health Policy Center at Johns Hopkins University found evidence that structured quality improvement activities (e.g., Plan-Do-Study-Act cycles) in health care settings appear to be effective. Quality improvement initiatives that include additional systems-level approaches - such as collaboration with health departments, insurance coding or payment changes, or involvement in larger systems-change initiatives or improvement partnerships - also appear to be effective. Other interventions, including health care provider training and home visiting programs may be effective, but because the number of published studies is limited, further evidence is needed to fully assess these.

Children with special health care needs (CSHCN) are those who have chronic physical, developmental, behavioral, or emotional conditions and require health and related services beyond that which generally is required by most children - nearly one in five children ages birth to 17 years in New York State. Families of children with special health care needs (CSHCN) face unique challenges and bring tremendous knowledge, experience, and strengths to the care of their children that is an asset to both individual and population-based public health efforts. Systems must be designed and implemented to meet the needs of families, and to engage them in meaningful roles as their children's most important caregivers.

The New York State Department of Health Children with Special Health Care Needs (CSHCN) Program recently completed a Systems Mapping project to engage families from across the state in identifying successes, gaps, and barriers to services for CSHCN, using tools and technical support from the Maternal Child Health Workforce Development Center at the University of North Carolina (UNC). Through this process, over 130 family members of CSHCN from all regions of the state and diverse demographics participated in facilitated discussions. The resulting qualitative data (system maps) will inform the future practices of the CSHCN Program.

Throughout this systems mapping process and other ongoing needs assessments, parents and providers of CSHCN in New York State have emphasized the fragmentation of services for CSHCN, the complexity of finding providers and accessing the myriad of services needed, and disparities in care - with some families getting what they need for their children and others "going without". Parents are seeking better information about their child's diagnosis and service systems, and they want more connections to other families who have had similar experiences. Partnering with and supporting families who reflect the diversity of our communities is essential to improving these service systems and experiences.

Family engagement may help to improve the quality and efficiency of the health care and public health systems at all levels, from direct care to organizational design to policy. There are opportunities for parents to receive leadership training and participate in state and local advisory and workgroups through several core programs.

NYS Public Health Law requires all maternity hospitals and birthing centers to administer newborn hearing screening programs, which is consistent with national public health goals and guidelines for early detection of hearing loss. Infants are screened shortly after birth in the hospital or birthing facility. Infants that do not pass their initial screenings are referred for follow up, which may include a second screening and, when needed, a full diagnostic hearing assessment. Infants with hearing loss are referred to the NYS Early Intervention Program for appropriate intervention services. Providers at each step in this process are required to report screening and follow-up test results in the state's Early Hearing Detection and Intervention Information System (NYEHDI-IS). Timely follow up of infants with hearing loss is critical to optimizing their development. Documentation of follow up in NYEHDI-IS is essential to tracking progress and informing public health improvement efforts.

Over 97% of infants born in New York State in 2016, had a documented initial hearing screening after birth. Of those infants who failed this initial screening, only 37.5% had follow-up test results documented in the NYEHDI-IS system. Although this percentage has improved significantly from the baseline of 9% in 2014, there is still substantial need for improvement. For the past several years, the New York State Department of Health has been engaged in a variety of efforts to improve newborn hearing screening and follow up, including enhancements to the data system to make it more useful for providers, dissemination of data to hospitals and other partners to reinforce the need for reporting, and convening structured quality improvement collaboratives with health care providers and families to improve follow up services, including linkage to the Early Intervention Program. There is a need to build on these efforts and engage more partners to ensure that all babies who fail their initial hearing screening receive timely and appropriate follow up.

Care coordination is the purposeful organization of care activities and information sharing among patients and those involved in their care to improve efficiency, quality of care, health outcomes, and patient satisfaction. The Institute of Medicine has identified care coordination as a key strategy with the potential to improve the effectiveness, safety, and efficiency of the U.S. health care system, improving outcomes for patients, providers, and payers.

Children with special health care needs (CSHCN) may require specialty medical services across multiple providers and service settings. They may experience multiple transitions as they develop and "age out" of specific programs or services (e.g., from Early Intervention to Special Education, elementary to secondary school, pediatric to adult health care) and move across service and community settings (e.g., hospital to community, home to school).

Both formal care coordination/ care management services and more informal transition supports can be critical for CSHCN and their families to manage their health and family needs during key periods of change and over time. The 2016 National Survey of Children's Health found that about 73% of children age birth to 17 years in New York State who needed care coordination services received effective services, while about 15% of youth with special health care needs received services necessary to transition to adult health care.

The US Surgeon General's Reports have emphasized oral health as a critical aspect of overall individual and population health. Research demonstrates the large number of lost school and work hours attributed to oral health problems. Dental cavities (also called dental caries or tooth decay) are one of the most common chronic diseases of childhood.

Drinking fluoridated water keeps teeth strong and reduces cavities by about 25% in children and adults. By preventing cavities, community water fluoridation has been shown to save money for families and for the US health care system. Community water fluoridation is the most cost-effective way to deliver fluoride to people of all ages, education levels, and income levels who live in a community. Most water has some natural levels of fluoride, but usually not enough to prevent cavities. Community water systems can add the right amount of fluoride to the local drinking water to prevent cavities. Community water fluoridation is recommended by nearly all public health, medical, and dental organizations. It is recommended by the American Dental Association, American Academy of Pediatrics, US Public Health Service, World Health Organization, and the Community Preventive Services Task Force. Grant funds are available from the New York State Department of Health to support implementation and maintenance of fluoridation systems in communities.

Access to oral (dental) health care is critical to maintain oral health throughout the life course. Early dental visits teach children that oral health is important and improve children's positive attitudes about oral health professionals and dental visits. Pregnant women who receive dental care are more likely to take their children to get oral health care, and untreated maternal dental caries may increase the odds of her children developing cavities. Children should be taught proper oral hygiene, including daily teeth brushing, at an early age.

Preventive dentistry encompasses several practices to keep teeth healthy and prevent cavities, gum disease, enamel wear, and tooth loss. It includes personal oral hygiene practices (including daily tooth brushing), dental cleanings, the application of sealants, and fluoride supplementation. To maintain optimal oral health, the American Dental Association (ADA) recommends visits to the dentist at regular intervals determined by a dentist. The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride, and that primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption. The Community Preventive Services Task Force (CPSTF) recommends school-based programs to deliver dental sealants and prevent tooth decay among children (see also Intervention 3.3.1).

A recent review by the Women's and Children's Health Policy Center at Johns Hopkins University found evidence that school-based oral health services, preschool interventions (participation in Head Start), enrollment in public health insurance programs (Medicaid or CHIP/Child Health Plus), and Medicaid reforms (e.g., increased provider reimbursements, enhanced benefits, administrative changes, and health plan incentives) appear to be effective. Caregiver education/counseling, home visits, and outreach to recruit dental practices to provide care may be effective but there is currently insufficient evidence to assess their effectiveness. There is also insufficient evidence currently to assess the effectiveness of interventions to increase dental visits of women during pregnancy. Of note, this particular review did not look at other promising strategies to increase use of preventive oral health services such as integration of oral health in primary medical care settings, co-location of dental and medical services, enhanced patient outreach and reminder systems (which have been found effective in increasing use of other preventive health services), or delivery of oral health services through other community-based programs.

Integrating oral health messages and prevention strategies in other public health programs has the potential to increase awareness, knowledge, and preventive oral hygiene practices among children and their families. Home visiting programs, nutrition programs, child care, and other early care and education programs are examples of community-based programs that may have opportunities to reinforce oral health promotion.

The focus within public health increasingly is on addressing social determinants of health: the conditions in which people are born, grow, live, work, and age. Social factors such as food insecurity, homelessness, employment conditions, poverty, adverse neighborhood environments, inadequate health care, lack of educational opportunities, social exclusion, racism and discrimination, lack of social support, and gender-based inequities are important forces that influence MCH outcomes, both directly and through their impact on other individual risk factors. These social determinants help explain why rates of key indicators - such as infant mortality and maternal mortality - are worse in the United States compared to other countries. They also help to explain the persistent racial, economic, and other disparities we see across virtually all key indicators of maternal and child health.

A dedicated focus on social determinants of health across the life course is consistent with input received from youth, families, and service providers as part of New York's needs assessment activities over the past three years. Stakeholders repeatedly identified factors that influence their use of health care services: health insurance coverage, accessibility of health care, provider diversity and cultural competence, transportation, stigma and confidentiality concerns, language barriers, cost, inability to take time off from work, and competing life responsibilities (cite: Title V applications for 2017 and 2019). Additionally, stakeholders noted lack of social support, unsafe neighborhoods, lack of affordable housing, limited access to affordable, healthy food, and lack of opportunities for physical activity as key barriers to good health.

While these factors may be addressed in the context of other topic-specific interventions described throughout this plan, it is essential that public health organizations and practitioners partner with other sectors to address them directly as foundational influences on all aspects of health and well-being. For this reason, the stakeholder group contributing to this action plan endorsed the inclusion of this cross-cutting goal and intervention to underpin other sections of the plan.

Healthy People 2020 has emphasized the need to address social determinants of health by including a new goal to "create social and physical environments that promote good health for all" as one of the four overarching goals for the decade. Achieving this goal in New York State will require new approaches, partnerships, and collaborations across a wide range of sectors, at both the community and state level.