12/03/13
LHJ:
Sample Sacramento
Deliverable Form E – 5-Year Action Plans
(For further instructions see separate document titled “Action Plan Guidelines”)
MCAH SOW Goal 3_: Improve infant health
Problem Category
From Deliverable Form B of your Title V Needs Assessment - SIDS/SUID; Perinatal Substance Use
Problem Statement(s)
From Deliverable Form B of your Title V Needs Assessment -Black infants are having a higher rate of SIDS due to lack of knowledge
about SIDS risks and unsafe sleep practices
Pregnant white women have an increased rate of Perinatal Substance Use (PSU) due to lack of knowledge about the harm to the fetus
from alcohol use
Five Year Local Goal(s)
(Develop one or more five year local goal(s) that state the desired results of your interventions) - SIDS/SUID -Reduce the number of
presumed unexpected infant deaths by promoting infant safe sleep and Sudden Infant Death Syndrome (SIDS) risk reduction education
activities to the community with a focus on Black families
PSU - Increase the proportion of primary care providers who screen all pregnant and postpartum women for perinatal substance use;
increase community knowledge regarding the harmful effects to the baby from PSU
Risk/Contributing Factors
(List LHJ-specific contributing factors using a problem analysis) – SIDS/SUID - Unsafe infant sleep environments, prone/side sleep
positioning, exposure to substance use in utero or early infancy, lack of knowledge of SIDS, lack of regular prenatal care, prematurity,
low birth weight
PSU -Lack of education on effects of substance use during pregnancy, stress (external/internal), unhealthy relationships, lack of social
skills, poor health, domestic violence, mental health issues, low self-esteem, social acceptance of alcohol use
Best Practice Strategies/
Interventions
(List best practice strategies and/or interventions to address your problems) – SIDS/SUID - Educate parents, caregivers, and health care
providers about ways to reduce the risk for SIDS and other sleep-related causes of infant death. Targeted outreach to MCAH population
and other public health programs and providers. Increase knowledge of parents of newborns and childcare providers, especially for
Black families
PSU - Integration of perinatal substance use screening into a range of clinical and community settings, such as Federally Qualified Health
Centers, community clinics, managed care plans, health departments; community health education campaigns
Intervention Population(s)
Short and/or Intermediate Objective(s)
(List the populations you will be focusing on for the next five years) – SIDS/SUID - MCAH and other public health programs and
providers, childcare providers and parents of newborns, focusing especially on the Black community
PSU - Pregnant and postpartum women, primary care providers, Obstetric providers, local government departments, non-profit
organizations serving women
Inputs, including
Community Partner
Local Health Jurisdictions (LHJ) Needs Assessment Timeline and Deliverables
Intervention Activities to Meet Objectives
Performance Measures
Short and/or Intermediate
Page 1 of 8
12/03/13
LHJ:
involvement
Fiscal Year 1- 2015-2016
SIDS/SUID
By June 30, 2016 [x/X] parents
of newborns will demonstrate
increased knowledge and
intention to follow infant safe
sleep practices and SIDS risk
reduction in [number] birth
hospitals, with a special focus
on Black families





Birth hospital
staff
Pediatric,
obstetric (OB)
and family
practice
providers
WIC pregnant
clients
MCAH and
public health
department
staff
Public health
nurses
Process Description and Measure(s)
including data source





PSU – Infant health
By June 30, 2016, determine
the number of primary care
providers who screen for
perinatal substance use (PSU)
and, of those who screen, the
number referring women who
screen positive for follow-up
care
PSU– Infant health
 CPSP providers
 Primary Care
Providers
 PSCs
 Behavioral
Health
 Social Services
 Alcohol and
Drug
Programs
 Nonprofit/
community
organizations
addressing
Sample Sacramento
SIDS coordinator/public health
professional outreaches to parents of
newborns to provide infant safe sleep
education and SIDS risk reduction in birth
hospitals, focusing on Black families
Develop and administer evaluation tools to
measure knowledge changes after
education and intention to follow infant
safe sleep practices and SIDS risk reduction
SIDS educational materials are located at
the State web site:
http://www.cdph.ca.gov/programs/SIDS/P
ages/default.aspx
And the California SIDS Program web site:
http://californiasids.cdph.ca.gov
Develop and implement a Continuous
Quality Improvement/Quality Assurance
(CQI/QA) process to monitor
implementation of policies/processes, a
regular feedback mechanism to continually
improve the process and evaluate the
impact
Provide technical assistance as needed
PSU– Infant health
Perform the following activities:
 Engage existing community
partners/collaboratives
 Develop and implement a survey of
primary care providers to determine
whether they screen none, all, or some
pregnant and postpartum women for PSU,
and refer women who screen positive for
follow-up care. Include questions about
policies implemented, referral processes,
barriers/ challenges, and willingness to
screen all pregnant and postpartum
women
 Identify the providers screening all or some
Local Health Jurisdictions (LHJ) Needs Assessment Timeline and Deliverables






Number of new parents
outreached about the infant
safe sleep practices and SIDS
risk reduction
Number of new parents
receiving education about
the infant safe sleep
practices and SIDS risk
reduction
Briefly describe evaluation
tool developed
Briefly describe barriers,
challenges, and
opportunities to improve
infant safe sleep
Briefly describe the CQI/QA
process developed
Brief description of technical
assistance provided
PSU– Infant health
Briefly describe or report:
 Collaborative relationships
that support PSU screening
all pregnant and postpartum
women
 Survey developed and
implemented
 Number of completed
surveys/Number of surveys
sent out
 Total number of primary care
providers caring for pregnant
and postpartum women
 Opportunities, barriers, and
Outcome Measure(s) including data
source



[Number] of new parents
demonstrating increased
knowledge and intention
to follow infant safe
sleep practices and SIDS
risk reduction/ the total
number of new parents
educated [X]
Briefly describe the
results of evaluation
Describe the outcomes
of the CQI/QA process
including methods of
measurements and
results
PSU– Infant health
Measures include:
 Number of providers
who screen all pregnant
and postpartum women
for PSU and refer positive
screens for followup/Number of providers
who treat pregnant and
postpartum women
 Number of providers
who screen some
pregnant and
postpartum women for
PSU and refer positive
Page 2 of 8
12/03/13
LHJ:
Short and/or Intermediate Objective(s)
Inputs, including
Community Partner
involvement
Intervention Activities to Meet Objectives


(this fiscal year the focus will
be on homeless shelters; the
second year the focus will be
on faith-based organizations






Homeless
shelters
MCAH and
public health
department
staff
Public health
nurses
BIH Program
Loaves and
Fishes
St. John’s
Shelter
Performance Measures
Short and/or Intermediate
Process Description and Measure(s)
including data source
PSU
Fiscal Year 2 – 2016-2017
SIDS/SUID
By June 30, [20xx], [x/X] all
homeless shelters will
demonstrate increased
knowledge and adopt infant
safe sleep and SIDS risk
reduction practices into
Sample Sacramento






Local Health Jurisdictions (LHJ) Needs Assessment Timeline and Deliverables
pregnant and postpartum women and
referring positive screens
Develop and implement a process to
ensure a high rate of survey completion
Research and identify validated PSU
screening tools. References include:
1) Local MCAH Jurisdiction Survey on
Prenatal Substance Use Screening Data
(Sept. 22, 2006), pp. 21-24
http://www.cdph.ca.gov/HealthInfo/healt
hyliving/childfamily/Documents/MO-PSULocalJurisdictionSurvey.pdf
2) Screening Instruments for Pregnant
Women and Women of Childbearing Age:
Substance Use, Mental Health and
Intimate Partner Violence (VA Dept. of
Behavioral Health and Developmental
Services, 2012)
http://www.dbhds.virginia.gov/documents
/scrn-Perinatal-InstrumentsChart.pdf
3) Perinatal Substance Use Screening in
California (Chasnoff et al, 2008), p. 12
http://www.cdph.ca.gov/HealthInfo/healt
hyliving/childfamily/Documents/MOChasnoffPerinatalSubstanceUseScreeningR
eport-10-24-08.pdf
SIDS Coordinators/Public Health
Professional develop a relationship with
homeless shelters
Provide infant safe sleep education and
SIDS risk reduction and ongoing technical
assistance
Observe safe sleep practices in shelters
Work with shelters to develop and
implement policies to promote infant safe
sleep and SIDS risk reduction practice
Evaluate safe sleep and SIDS risk reduction
practices implemented
Develop and implement a Continuous
Outcome Measure(s) including data
source
challenges to PSU screening
and referral for follow-up






Number of presentations
given to homeless shelters
Briefly describe what was
observed
Briefly describe the process
to implement infant safe
sleep and SIDS risk reduction
practices in shelters
List technical assistance
provided
Briefly describe the CQI/QA
process developed.


screens for followup/Number of providers
who treat pregnant and
postpartum women
Number of providers
with policies
implemented for PSU
screening
[Number] of homeless
shelters demonstrating
increased knowledge of
safe sleep practices and
SIDS risk reduction /total
number of shelters
informed about infant
safe sleep and SIDS risk
reduction practice [X]
Number of shelters
adopting infant safe
sleep practices and SIDS
risk reduction/ total
Page 3 of 8
12/03/13
LHJ:
Short and/or Intermediate Objective(s)
that are predominately
attended by Black families)
Inputs, including
Community Partner
involvement

Intervention Activities to Meet Objectives
Sample Sacramento
Performance Measures
Short and/or Intermediate
Process Description and Measure(s)
including data source
Outcome Measure(s) including data
source
Quality Improvement/Quality Assurance
(CQI/QA) process
Family Promise
of Sacramento


PSU – Infant health
By June 30, 2017, [x/X]
providers will screen all
pregnant and postpartum
women for Perinatal Substance
Use (PSU) and refer women
who screen positive for followup
(will conduct for 2 years to
reach all providers)
Fiscal Year 3 – 2017-2018
SIDS/SUID
By June 30, [20xx], [x/X] faithbased organizations that
predominately serve Black
families will demonstrate
increased knowledge and adopt
infant safe sleep and SIDS risk
reduction practices into
PSU – Infant health
 CPSP providers
 Primary Care
Providers
 PSCs
 Behavioral
Health
 Social Services
 Alcohol and
Drug
Programs
 Nonprofit/
community
organizations
addressing PSU
PSU – Infant health
Perform the following activities:
 Assist providers to identify, develop
protocols and implement the use of
validated PSU screening tools (e.g., CPSP
Initial Combined Assessment Form, 4 P’s,
etc.).
 Collaborate with other providers,
community organizations, and support
groups to establish a referral resource
network
 Develop and implement a Continuous
Quality Improvement/Quality Assurance
(CQI/QA)
 Engage existing community
partners/collaboratives
PSU – Infant health
 Number of primary care
providers who have
completed protocols
/Number of providers who
treat pregnant and
postpartum women
 Describe technical assistance
provided
 CQI/QA process developed





Faith-based
organizations
that
predominately
serve Black
families MCAH
Public health
department
staff
Public health


Local Health Jurisdictions (LHJ) Needs Assessment Timeline and Deliverables
SIDS Coordinators/Public Health
Professional develop a relationship with
faith-based organizations
Provide infant safe sleep education and
SIDS risk reduction and ongoing technical
assistance
Work with faith-based organizations to
develop and implement educational
programs to promote infant safe sleep and
SIDS risk reduction practice


Number of presentations
given to faith-based
organizations
Briefly describe what was
observed
Briefly describe the process
to assist faith-based
organizations to promote
infant safe sleep and SIDS
risk reduction practices
number of shelters
informed about infant
safe sleep and SIDS risk
reduction practice [X]
Briefly describe the
results of evaluation
Describe the outcomes
of the CQI/QA process
PSU – Infant health
 [Number] of providers
who have developed and
implemented
policies/procedures for
PSU screening in their
clinics/Number of
providers who treat
pregnant and
postpartum women
 Brief description of
provider protocol
 Brief description of
 Brief description of
referral resource
network
 Brief description of
outcomes of the CQI/QA
process
 [Number] of faith-based
organizations
demonstrating increased
knowledge of safe sleep
practices and SIDS risk
reduction /total number
of faith-based
organizations informed
about infant safe sleep
and SIDS risk reduction
Page 4 of 8
12/03/13
LHJ:
Short and/or Intermediate Objective(s)
(the focus will be on faithbased organizations that are
predominately attended by
Black families)
Inputs, including
Community Partner
involvement

nurses
BIH program
Intervention Activities to Meet Objectives
Sample Sacramento
Performance Measures
Short and/or Intermediate
Process Description and Measure(s)
including data source



Develop a process to measure knowledge
change and intent to implement SIDS
information
Evaluate safe sleep and SIDS risk reduction
programs implemented
Develop and implement a Continuous
Quality Improvement/Quality Assurance
(CQI/QA) process


List technical assistance
provided
Briefly describe the CQI/QA
process developed.
Outcome Measure(s) including data
source



PSU – Infant health
By June 30, 2018, [x/X]
providers will screen all
pregnant and postpartum
women for Perinatal Substance
Use (PSU) and refer women
who screen positive for followup
(second year of objective)
PSU – Infant health
 CPSP providers
 Primary Care
Providers
 PSCs
 Behavioral
Health
 Social Services
 Alcohol and
Drug
Programs
 Nonprofit/
community
organizations
addressing PSU
PSU – Infant health
Perform the following activities:
 Assist providers to identify, develop
protocols and implement the use of
validated PSU screening tools (e.g., CPSP
Initial Combined Assessment Form, 4 P’s,
etc.).
 Collaborate with other providers,
community organizations, and support
groups to establish a referral resource
network
 Develop and implement a Continuous
Quality Improvement/Quality Assurance
(CQI/QA)
 Engage existing community
partners/collaboratives
Local Health Jurisdictions (LHJ) Needs Assessment Timeline and Deliverables
PSU – Infant health
 Number of primary care
providers who have
completed protocols
/Number of providers who
treat pregnant and
postpartum women
 Describe technical assistance
provided
 CQI/QA process developed
practice [X]
Number of faith-based
organizations providing
education programs
about infant safe sleep
practices and SIDS risk
reduction/ total number
of faith-based
organizations informed
about infant safe sleep
and SIDS risk reduction
practice [X]
Briefly describe the
results of evaluation
Describe the outcomes
of the CQI/QA process
PSU – Infant health
 [Number] of providers
who have developed and
implemented
policies/procedures for
PSU screening in their
clinics/Number of
providers who treat
pregnant and
postpartum women
 Brief description of
provider protocol
 Brief description of
 Brief description of
referral resource
network
 Brief description of
outcomes of the CQI/QA
process
Page 5 of 8
12/03/13
LHJ:
Short and/or Intermediate Objective(s)
Fiscal Year 4 – 2018-2019
SIDS/SUID
By June 30, [20xx], [x/X]
childcare providers will
demonstrate increased
knowledge and adopt infant
safe sleep practice and SIDS risk
reduction in the childcare
center
Inputs, including
Community Partner
involvement




Childcare
providers
Local social
service
department for
licensing
childcare
providers
MCAH and
public health
department
staff
Public health
nurses
Intervention Activities to Meet Objectives






PSU – Infant Health
 CPSP providers
 Primary Care
Providers
 PSCs
 Behavioral
Health
 Social Services
 Alcohol and
Drug
Programs
 Nonprofit/
community
organizations
addressing PSU
Performance Measures
Short and/or Intermediate
Process Description and Measure(s)
including data source

PSU – Infant Health
By June 30, 2018, all pregnant
and postpartum women in
MCAH programs and presenting
at the Public Health
Department (PHD) will be
screened for Perinatal
Substance Use (PSU), and those
who screen positive will be
referred for appropriate followup care
Sample Sacramento
SIDS coordinator/public health
professional provides infant safe sleep
education and SIDS risk reduction to
childcare providers
Observes infant safe sleep practices and
SIDS risk reduction in childcare center
Provide technical assistance as needed
Work with childcare providers to promote
activities on infant safe sleep education
and SIDS risk reduction
Encourage childcare providers to share the
educational materials with parents to
promote the infant safe sleep education
and SIDS risk reduction
Evaluate implementation of safe sleep and
SIDS risk reduction practices in child care
providers
Develop and implement a Continuous
Quality Improvement/Quality Assurance
(CQI/QA) process
PSU – Infant Health
Perform the following activities:
 Develop and implement policies (or a
screening protocol) to screen all pregnant
and postpartum women in MCAH
Programs and presenting at the PHD for
PSU
 Refer women who screen positive for PSU
to the appropriate provider
 Develop and implement a Continuous
Quality Improvement/Quality Assurance
(CQI/QA) process
 Collaborate with providers, community
organizations, and support groups to
establish a referral resource network
Local Health Jurisdictions (LHJ) Needs Assessment Timeline and Deliverables






Number of presentations
given to childcare providers
Briefly describe what was
observed
Briefly describe key infant
safe sleep education and
SIDS risk reduction
accomplishments and
barriers
List technical assistance
provided
Number of parents receiving
infant safe sleep and SIDS
risk reduction information
from the childcare providers
Briefly describe the CQI/QA
process developed
PSU – Infant Health
Briefly describe or report:
 Resources and support
groups for PSU prevention
 Access to care issues
 Rationale for interventions,
recommendations and
strategies/policies developed
 Referral process developed
and implemented
 CQI/QA process developed
 Collaboratives/
partnerships formed
 Resource referral
list/brochure/website
Outcome Measure(s) including data
source




[Number] of childcare
providers demonstrating
increased knowledge
about the infant safe
sleep practices and SIDS
risk reduction/ the total
number of childcare
providers educated [X]
Number of childcare
providers who adopt
infant safe sleep
practices and SIDS risk
reduction/ the total
number of childcare
providers educated [X]
Briefly describe the
results of the evaluation
Describe the outcomes
of the CQI/QA process
PSU – Infant Health
Measures include:
 Number of pregnant and
postpartum women in
MCAH programs and
presenting at the PHD
who are screened for
PSU/All pregnant and
postpartum women in
MCAH programs and
presenting at the PHD
 Number of pregnant and
postpartum women in
MCAH programs and
presenting at the PHD
Page 6 of 8
12/03/13
LHJ:
Short and/or Intermediate Objective(s)
Inputs, including
Community Partner
involvement
Intervention Activities to Meet Objectives
Sample Sacramento
Performance Measures
Short and/or Intermediate
Process Description and Measure(s)
including data source

Outcome Measure(s) including data
source
Develop and implement processes that link
women who screen positive for PSU to
appropriate resources



Fiscal Year 5 – 2019-2020
SIDS/SUID
By June 30, [20xx], [x/X] CPSP
providers will provide correct
infant safe sleep and SIDS risk
reduction information to all
their pregnant and postpartum
women




CPSP providers
staff
OB and family
practice
providers
MCAH and
public health
department
staff
Public health
nurses






Local Health Jurisdictions (LHJ) Needs Assessment Timeline and Deliverables
SIDS coordinator/public health
professional provides infant safe sleep and
SIDS risk reduction information to CPSP
providers
Provide infant safe sleep education and
SIDS risk reduction to CPSP providers staff
Work with providers to promote activities
on infant safe sleep education and SIDS
risk reduction
Encourage CPSP providers to develop and
implement protocols to provide infant safe
sleep and SIDS risk reduction information
to pregnant and postpartum women
Develop and implement a Continuous
Quality Improvement/Quality Assurance
(CQI/QA) process
Provide technical assistance as needed






Number of presentations
given to CPSP providers staff
Number of CPSP providers
staff demonstrating correct
knowledge on the infant safe
sleep practices and SIDS risk
reduction
Briefly describe the results of
evaluation
Briefly describe evaluation
tool developed
Briefly describe the process
to implement infant safe
sleep and SIDS risk reduction
practices in CPSP providers
Briefly describe the CQI/QA
process developed



who screened positive
for PSU and were
referred for follow-up/All
pregnant and
postpartum women
screening positive for
PSU
Number of pregnant and
postpartum who
screened positive for PSU
and were referred to and
saw a provider/All
pregnant and
postpartum women who
screened positive and
were referred
Brief description of PSU
screening and referral
policies/protocol
Brief description of
outcomes of the CQI/QA
process
[Number] of CPSP
providers who provide
correct infant safe sleep
and SIDS risk reduction
information to all their
pregnant and
postpartum women/[X]
Briefly describe policies/
protocols adopted by
CPSP providers
Describe the outcomes
of the CQI/QA process
Page 7 of 8
12/03/13
Short and/or Intermediate Objective(s)
LHJ:
Inputs, including
Community Partner
involvement
Intervention Activities to Meet Objectives
Performance Measures
Short and/or Intermediate
Process Description and Measure(s)
including data source

PSU- Infant Health
By June 30, 2020, develop and
implement a community
awareness campaign targeting
women and men aged 15-44 [or
specific target population
within this group, e.g.
adolescents] aimed at
increasing awareness of the
adverse effects of PSU
PSU- Infant Health
 CPSP providers
 Primary Care
Providers
 Perinatal
Services
Coordinators
 Behavioral
Health
 Social Services
 Alcohol and
Drug
Programs
 Nonprofit/
community
organizations
addressing
PSU
Sample Sacramento
PSU- Infant Health
Perform the following activities:
 Convene task force to coordinate activities
for PSU awareness/prevention campaign
 Develop specific recommendations to
increase PSU prevention awareness
 Integrate recommendations into MCAH
program activities
 Develop a process to track and measure
awareness of PSU prevention
 Provide training and/or materials to health
department and community programs
 Develop a process to measure increased
awareness of the adverse effects of PSU
 Develop a process to measure knowledge
and intent to change behavior, such as
focus groups, survey, social media analysis.
 Develop a plan to evaluate the outcomes
of the campaign
 Promote PSU screening through webinars,
workshops, and presentations at
conferences/professional meetings
Local Health Jurisdictions (LHJ) Needs Assessment Timeline and Deliverables
Outcome Measure(s) including data
source
Brief description of technical
assistance provided
PSU- Infant Health
Briefly describe or report:
 Objectives, key activities,
timelines, evaluation
components, and barriers to
implementation of task force
recommendations
 Plan developed to evaluate
outcomes of the community
awareness campaign
 Increased awareness gained
as a result of the campaign
 Developed PSU prevention
messages
 Number of trainings and
attendees
 Community partners and
number of meetings held
PSU- Infant Health
Measures include:
 Describe community
awareness campaign
 Number of programs
including PSU prevention
in their work/Total
number of programs
 Number reporting
increased awareness of
adverse effects of
PSU/Total target
population
 List programs that have
added PSU prevention
information to their
curricula .
 Brief description of the
plan to evaluate the
effectiveness of the
campaign and any
outcomes
 Brief description of policy
changes, if any
Page 8 of 8